[Federal Register Volume 64, Number 88 (Friday, May 7, 1999)]
[Proposed Rules]
[Pages 24716-24854]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-11200]
[[Page 24715]]
_______________________________________________________________________
Part II
Department of Health and Human Services
_______________________________________________________________________
Health Care Financing Administration
_______________________________________________________________________
42 CFR Parts 412, 413, 483, and 485
Medicare Program; Changes to the Hospital Inpatient Prospective Payment
Systems and Fiscal Year 2000 Rates; Proposed Rule
Federal Register / Vol. 64, No. 88 / Friday, May 7, 1999 / Proposed
Rules
[[Page 24716]]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
42 CFR Parts 412, 413, 483, and 485
[HCFA-1053-P]
RIN 0938-AJ50
Medicare Program; Changes to the Hospital Inpatient Prospective
Payment Systems and Fiscal Year 2000 Rates
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Proposed rule.
-----------------------------------------------------------------------
SUMMARY: We are proposing to revise the Medicare hospital inpatient
prospective payment systems for operating costs and capital-related
costs to implement changes arising from our continuing experience with
the systems. In addition, in the addendum to this proposed rule, we are
describing proposed changes in the amounts and factors necessary to
determine 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, 1999. We also are setting
forth proposed rate-of-increase limits as well as proposed policy
changes for hospitals and hospital units excluded from the prospective
payment systems. Finally, we are proposing changes to the policies
governing payment to hospitals for the direct costs of graduate medical
education.
DATES: Comments will be considered if received at the appropriate
address, as provided below, no later than 5 p.m. on July 6, 1999.
ADDRESSES: Mail written comments (an original and three copies) to the
following address: Health Care Financing Administration, Department of
Health and Human Services, Attention: HCFA-1053-P P.O. Box 7517,
Baltimore, MD 21207.
If you prefer, you may deliver your written comments (an original
and three copies) to one of the following addresses:
Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW,
Washington, DC 20201, or
Room C5-11-03, Central Building, 7500 Security Boulevard, Baltimore, MD
21244-1850
FOR FURTHER INFORMATION CONTACT:
Steve Phillips, (410) 786-4531, Operating Prospective Payment, DRG, and
Wage Index Issues
Tzvi Hefter, (410) 786-4487, Capital Prospective Payment, Excluded
Hospitals, and Graduate Medical Education Issues
SUPPLEMENTARY INFORMATION:
Comments, Procedures, Availability of Copies, and Electronic Access
Because of staffing and resource limitations, we cannot accept
comments by facsimile (FAX) transmission. In commenting, please refer
to file code HCFA-1053-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 445-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; and
Health Care Financing Administration, Office of Information Services,
Security Standards Group, Division of HCFA Enterprise Standards, Room
N2-14-26, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
Attn: John Burke HCFA-1053-P.
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I. Background
A. Summary
Section 1886(d) of the Social Security Act (the Act) sets forth a
system of payment for the operating costs of acute care hospital
inpatient stays under Medicare Part A (Hospital Insurance) based on
prospectively set rates. Section 1886(g) of the Act requires the
Secretary to pay for the capital-related costs of hospital inpatient
stays under a prospective payment system. Under these prospective
payment systems, Medicare payment for hospital inpatient operating and
capital-related costs is made at predetermined, specific rates for each
hospital discharge. Discharges are classified according to a list of
diagnosis-related groups (DRGs).
Certain specialty hospitals are excluded from the prospective
payment systems. Under section 1886(d)(1)(B) of the Act, the following
hospitals and hospital units are excluded from the prospective payment
system: psychiatric hospitals or units, rehabilitation hospitals or
units, children's hospitals, long-term care hospitals, and cancer
hospitals. For these hospitals and units, Medicare payment for
operating costs is based on reasonable costs subject to a hospital-
specific annual limit.
Under section 1886(a)(4) of the Act, costs incurred in connection
with approved graduate medical education (GME) programs are excluded
from the operating costs of inpatient hospital services. Hospitals with
approved GME programs are paid for the direct costs of GME in
accordance with section 1886(h) of the Act; the amount of payment for
direct GME costs for a cost reporting period is based on the hospital's
number of residents in that period and the hospital's costs per
resident in a base year.
The regulations governing the hospital inpatient prospective
payment system are located in 42 CFR part 412. The regulations
governing excluded hospitals and hospital units are located in parts
412 and 413, and the GME regulations are located in part 413.
On July 31, 1998, we published a final rule in the Federal Register
(63 FR 40954) that implemented both statutory requirements and other
changes to the Medicare hospital inpatient prospective
[[Page 24717]]
payment systems for both operating costs and capital-related costs, as
well as changes addressing payment for excluded hospitals and payments
for GME costs. Generally, these changes were effective for discharges
occurring on or after October 1, 1998.
In addition, on February 25, 1999, we published in the Federal
Register (64 FR 9378) a final rule that implemented revised wage index
values, geographic adjustment factors, operating standardized amounts,
and capital Federal rates for hospitals subject to the inpatient
hospital prospective payment system. These changes are effective for
discharges occurring on or after March 1, 1999.
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. We also are proposing
changes concerning GME costs and excluded hospitals and units,
including critical access hospitals (CAHs). This proposed rule would be
effective for discharges occurring on or after October 1, 1999.
We note that the efforts that we are undertaking to make the
Medicare computer systems compliant on January 1, 2000, will not delay
our ability to make timely and updated payments to hospitals under the
FY 2000 prospective payment system final rule that will follow this
proposed rule. The following is a summary of the major changes that we
are proposing to make.
1. Proposed Changes to the DRG Reclassifications and Recalibrations of
Relative Weights
Section 1886(d)(4)(C) of the Act requires us to adjust the DRG
classifications and relative weights at least annually. In order to
avoid compromising our ability to process and pay hospital claims
during the period leading up to and immediately following January 1,
2000, we are not implementing any revisions to the International
Classification of Diseases, Ninth Revision, Clinical Modification (ICD-
9-CM) coding system. The changes that we are proposing to make relating
to DRG reclassifications and recalibrations for FY 2000 are set forth
in section II of is preamble.
2. Proposed Changes to the Hospital Wage Index
In section III of this preamble, we discuss proposed revisions to
the wage index and the annual update of the wage data. Specific issues
addressed in this section include the following:
The FY 2000 wage index update, using FY 1996 wage data.
The exclusion from the wage index of Part A physician wage
costs that are teaching-related, as well as resident and Part A
certified registered nurse anesthetist (CRNA) costs.
Revisions to the wage index based on hospital
redesignations.
3. Other Decisions and Proposed Changes to the Prospective Payment
System for Inpatient Operating and Graduate Medical Education Costs
In section IV of this preamble, we discuss several provisions of
the regulations in 42 CFR Parts 412 and 413 and set forth proposed
changes concerning the following:
Sole community hospitals.
Rural referral centers.
Indirect medical education adjustment.
Medicare Geographic Classification Review Board (MGCRB)
decisions.
Direct GME programs.
4. Proposed Changes to the Prospective Payment System for Capital-
Related Costs
In section V of this preamble, we discuss the special exceptions
process for certain eligible hospitals to receive additional payments
for major construction or renovation projects that began soon after the
start of the capital prospective payment system.
5. Proposed Changes for Hospitals and Hospital Units Excluded From the
Prospective Payment Systems
In section VI of this preamble, we discuss the following proposals
concerning excluded hospital and hospital units and CAHs:
Limits on and adjustments to the proposed target amounts
for FY 2000.
Changes in bed size or status of excluded hospitals or
hospital units.
Payment for services furnished at satellite hospital
locations.
Responsibility for care of patients in hospitals within
hospitals.
The allowable emergency response time for CAHs located in
frontier or other specifically defined remote areas.
Compliance with minimum data set requirements by CAHs with
swing bed approval.
6. 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 2000
prospective payment rates for operating costs and capital-related
costs. We also address update factors for determining the rate-of-
increase limits for cost reporting periods beginning in FY 2000 for
hospitals and hospital units excluded from the prospective payment
system.
7. Impact Analysis
In Appendix A, we set forth an analysis of the impact that the
proposed changes described in this proposed rule would have on affected
entities.
8. Capital Acquisition Model
Appendix B contains the technical appendix on the proposed FY 2000
capital cost model.
9. Report to Congress on the Update Factor for Hospitals under the
Prospective Payment System and Hospitals and Units Excluded From the
Prospective Payment System
Section 1886(e)(3)(B) of the Act requires the Secretary to report
to Congress on our initial estimate of a recommended update factor for
FY 2000 for both hospitals included in and hospitals excluded from the
prospective payment systems. This report is included as Appendix C to
this proposed rule.
10. Proposed Recommendation of Update Factor for Hospital Inpatient
Operating Costs
As required by sections 1886(e)(4) and (e)(5) of the Act, Appendix
D provides our recommendation of the appropriate percentage change for
FY 2000 for the following:
Large urban area and other area average standardized
amounts (and hospital-specific rates applicable to sole community and
Medicare-dependent, small rural hospitals) for hospital inpatient
services paid for under the prospective payment system for operating
costs.
Target rate-of-increase limits to the allowable operating
costs of hospital inpatient services furnished by hospitals and
hospital units excluded from the prospective payment system.
11. Discussion of Medicare Payment Advisory Commission Recommendations
Under section 1805(b) of the Act, the Medicare Payment Advisory
Commission (MedPAC) is required to submit a report to Congress, not
later than March 1 of each year, that reviews and makes recommendations
on Medicare payment policies. The March 1, 1999 report made several
recommendations concerning hospital inpatient payment policies. These
recommendations, and the action we are proposing to take with regard to
them
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(when an action is recommended) are discussed in detail in this
document. See section VII of this preamble for specific information.
For further information relating specifically to the MedPAC March 1
report or to obtain a copy of the report, contact MedPAC at (202) 653-
7220.
II. Proposed Changes to DRG Reclassifications and Recalibrations of
Relative Weights
A. Background
Under the prospective payment system, we pay for inpatient hospital
services on the basis of a rate per discharge that varies by the DRG to
which a beneficiary's stay is assigned. The formula used to calculate
payment for a specific case takes an individual hospital's payment rate
per case and multiplies it by the weight of the DRG to which the case
is assigned. Each DRG weight represents the average resources required
to care for cases in that particular DRG relative to the average
resources used to treat cases in all DRGs.
Congress recognized that it would be necessary to recalculate the
DRG relative weights periodically to account for changes in resource
consumption. Accordingly, section 1886(d)(4)(C) of the Act requires
that the Secretary adjust the DRG classifications and relative weights
at least annually. These adjustments are made to reflect changes in
treatment patterns, technology, and any other factors that may change
the relative use of hospital resources.
As discussed in more detail in section II.B.8 of this preamble, we
are not implementing any revisions to the ICD-9-CM codes. We have
undertaken, and continue to undertake, major efforts to ensure that all
of the Medicare computer systems are ready to function on January 1,
2000. If we were to implement changes to the ICD-9-CM codes on October
1, 1999, we would endanger the functioning of the Medicare computer
systems, and, specifically, we might compromise our ability to process
hospital bills. We can, however, reclassify existing codes into
different DRGs, if appropriate. The proposed changes to the DRG
classification system, and the proposed recalibration of the DRG
weights for discharges occurring on or after October 1, 1999, are
discussed below.
B. DRG Reclassification
1. General
Cases are classified into DRGs for payment under the prospective
payment system based on the principal diagnosis, up to eight additional
diagnoses, and up to six procedures performed during the stay, as well
as age, sex, and discharge status of the patient. The diagnosis and
procedure information is reported by the hospital using ICD-9-CM codes.
The Medicare fiscal intermediary enters the information into its claims
processing system and subjects it to a series of automated screens
called the Medicare Code Editor (MCE). These screens are designed to
identify cases that require further review before classification into a
DRG can be accomplished.
After screening through the MCE and any further development of the
claims, cases are classified by the GROUPER software program into the
appropriate DRG. The GROUPER program was developed as a means of
classifying each case into a DRG on the basis of the diagnosis and
procedure codes and demographic information (that is, sex, age, and
discharge status). It is used both to classify past cases in order to
measure relative hospital resource consumption to establish the DRG
weights and to classify current cases for purposes of determining
payment. The records for all Medicare hospital inpatient discharges are
maintained in the Medicare Provider Analysis and Review (MedPAR) file.
The data in this file are used to evaluate possible DRG classification
changes and to recalibrate the DRG weights.
Currently, cases are assigned to one of 499 DRGs in 25 major
diagnostic categories (MDCs). Most MDCs are based on a particular organ
system of the body (for example, MDC 6, Diseases and Disorders of the
Digestive System); however, some MDCs are not constructed on this basis
since they involve multiple organ systems (for example, MDC 22, Burns).
In general, cases are assigned to an MDC based on the principal
diagnosis, before assignment to a DRG. However, there are five DRGs to
which cases are directly assigned on the basis of procedure codes.
These are the DRGs for liver, bone marrow, and lung transplants (DRGs
480, 481, and 495, respectively) and the two DRGs for tracheostomies
(DRGs 482 and 483). Cases are assigned to these DRGs before
classification to an MDC.
Within most MDCs, cases are then divided into surgical DRGs (based
on a surgical hierarchy that orders individual procedures or groups of
procedures by resource intensity) and medical DRGs. Medical DRGs
generally are differentiated on the basis of diagnosis and age. Some
surgical and medical DRGs are further differentiated based on the
presence or absence of complications or comorbidities (CC).
Generally, GROUPER does not consider other procedures; that is,
nonsurgical procedures or minor surgical procedures generally not
performed in an operating room are not listed as operating room (OR)
procedures in the GROUPER decision tables. However, there are a few
non-OR procedures that do affect DRG assignment for certain principal
diagnoses, such as extracorporeal shock wave lithotripsy for patients
with a principal diagnosis of urinary stones.
The changes we are proposing to make to the DRG classification
system for FY 2000 and other decisions concerning DRGs are set forth
below.
2. MDC 15 (Newborns and Other Neonates with Conditions Originating in
the Perinatal Period)
Based on inquiries we have received, we reviewed the
appropriateness of including diagnosis codes V29.2 (Newborn observation
for suspected respiratory condition) and V29.3 (Newborn observation for
other genetic problem) in the list of allowable secondary diagnoses
under DRG 391 (Normal Newborn). Currently, when one of these codes is
the only secondary diagnosis for an otherwise healthy newborn, the case
is assigned to DRG 390 (Neonate with Other Significant Problems).
Diagnosis codes V29.2 and V29.3 are used to indicate that the
newborn was observed for a suspected condition but none was found.
Other newborn observation codes in this series (V29.0, V29.1, V29.8,
and V29.9) are included in the allowable secondary diagnoses under DRG
391. We believe that the presence of diagnosis code V29.2 or V29.3
should not exclude a newborn from being classified as normal.
Therefore, we are proposing to include diagnosis codes V29.2 and V29.3
in the list of allowable secondary diagnosis under DRG 391.
3. MDC 19 (Mental Diseases and Disorders)
We have received correspondence about the title of DRG 425, ``Acute
Adjustment Reaction and Disturbances of Psychosocial Dysfunction''
under MDC 19. The correspondents state that the use of the terms
``disturbances'' and ``dysfunction'' is redundant since the terms have
similar meanings. They suggested that we remove the term
``disturbances.''
We agree with the correspondents and are proposing to revise the
title of DRG 425 to read ``Acute Adjustment Reaction and Psychological
Dysfunction.''
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4. MDC 22 (Burns)
In the FY 1999 final prospective payment system rule that was
effective October 1, 1998 (63 FR 40957), we implemented an extensive
redesign of the DRGs for burns to more appropriately capture the
variation in resource use associated with different classes of burn
patients. The redesigned DRGs, 504 through 511, are split on such
factors as whether there is an extensive burn, a full-thickness burn,
or an inhalation injury, as well as other factors such as skin graft,
trauma, or presence of a CC. DRGs 504 and 505 are assigned to cases
with extensive third degree burns; that is, cases in which the burns
cover at least 20 percent of body surface area combined with a third
degree burn covering at least 10 percent of body surface area. DRGs 506
through 509 are assigned to all other cases with full-thickness burns
(that is, a third degree burn). Finally, DRGs 510 and 511 are assigned
to cases with nonextensive burns (that is, only first and second degree
burns).
After these DRGs went into effect on October 1, 1998, we were
contacted by several hospitals about our inclusion of the following
codes as full-thickness burns:
948.00 Body burn involving less than 10 percent of body surface,
third degree less than 10 percent or unspecified
948.10 Body burn involving 10 to 19 percent of body surface, third
degree less than 10 percent or unspecified
948.20 Body burn involving 20 to 29 percent of body surface, third
degree less than 10 percent or unspecified
948.30 Body burn involving 30 to 39 percent of body surface, third
degree less than 10 percent or unspecified
948.40 Body burn involving 40 to 49 percent of body surface, third
degree less than 10 percent or unspecified
948.50 Body burn involving 50 to 59 percent of body surface, third
degree less than 10 percent or unspecified
948.60 Body burn involving 60 to 69 percent of body surface, third
degree less than 10 percent or unspecified
948.70 Body burn involving 70 to 79 percent of body surface, third
degree less than 10 percent or unspecified
948.80 Body burn involving 80 to 89 percent of body surface, third
degree less than 10 percent or unspecified
948.90 Body burn involving 90 percent or more of body surface,
third degree less than 10 percent or unspecified
The hospitals are concerned that the use of the fifth digit ``0''
on codes 948.10 through 948.90 can capture cases in which there
actually is no third degree burn. The hospitals requested that we
consider removing from the full-thickness burn DRGs 506 through 509 all
codes in the 948 category with a fifth digit of ``0''.
We agree that the codes in category 948 with a fifth digit of ``0''
should not be assigned to DRGs 506 through 509 as full-thickness burns
since not all of these cases will have a third degree burn. Therefore,
we are proposing to remove these codes from DRGs 506 through 509 and to
add them to DRG 510 (Nonextensive Burns with CC or Significant Trauma)
and DRG 511 (Nonextensive Burns without CC or Significant Trauma).
If a case with a code of 948.10 is a full-thickness burn, this
information would be captured in the burn code for the site of the burn
(for example, 943.35 (Third degree burn of shoulder)) and the case
would be correctly assigned to a full-thickness burn DRG. Hospitals
have been instructed in Coding Clinic for ICD-9-CM, Fourth Quarter,
1994 (pages 22 through 28) to code the site of the burn first (940
through 947), when known. Codes from category 948 may be used as a
principal diagnosis only when the site of the burn is not specified.
Category 948 is used as an additional code to provide information on
the percentage of total body that is burned or to show the percentage
of burn that was third degree. When hospitals report codes properly,
full-thickness burns will be assigned to a code for burn of the
specific site (940 through 947). This site code also shows the degree
of the burn. Furthermore, for those rare cases where the site is not
provided, but it is known that 10 percent or more of the body has a
third degree burn, hospitals may report this information through the
use of category 948 with a fifth digit of ``1'' through ``9''. All of
these cases will be classified as full-thickness burns in DRGs 506
through 509. Therefore, our proposal to remove codes 948.1 through
948.9 with a fifth digit of ``0'' will not prevent cases from being
assigned to one of the full-thickness DRGs when there is a third degree
burn and the case is correctly coded.
5. 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 ``major cardiovascular procedures''
consists of two DRGs (DRGs 110 and 111). Consequently, in many cases,
the surgical hierarchy has an impact on more than one DRG. The
methodology for determining the most resource-intensive surgical class
involves weighting each DRG for frequency to determine the average
resources for each surgical class.
For example, assume surgical class A includes DRGs 1 and 2 and
surgical class B includes DRGs 3, 4, and 5. Assume also that the
average charge of DRG 1 is higher than that of DRG 3, but the average
charges of DRGs 4 and 5 are higher than the average charge of DRG 2. To
determine whether surgical class A should be higher or lower than
surgical class B in the surgical hierarchy, we would weight the average
charge of each DRG by frequency (that is, by the number of cases in the
DRG) to determine average resource consumption for the surgical class.
The surgical classes would then be ordered from the class with the
highest average resource utilization to that with the lowest, with the
exception of ``other OR procedures'' as discussed below.
This methodology may occasionally result in a case involving
multiple procedures being assigned to the lower-weighted DRG (in the
highest, most resource-intensive surgical class) of the available
alternatives. However, given that the logic underlying the surgical
hierarchy provides that the GROUPER searches for the procedure in the
most resource-intensive surgical class, this result is unavoidable.
We note that, notwithstanding the foregoing discussion, there are a
few instances when a surgical class with a lower average relative
weight is ordered above a surgical class with a higher average relative
weight. For example, the ``other OR procedures'' surgical class is
uniformly ordered last in the surgical hierarchy of each MDC in which
it occurs, regardless of the fact that the relative weight for the DRG
or
[[Page 24720]]
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 proposed revisions to the surgical hierarchy and
to reflect these changes in the proposed relative weights due to the
unavailability of revised GROUPER software at the time the proposed
rule is prepared. Rather, we simulate most major classification changes
to approximate the placement of cases under the proposed
reclassification and then determine the average charge for each DRG.
These average charges then serve as our best estimate of relative
resource use for each surgical class. We test the proposed surgical
hierarchy changes after the revised GROUPER is received and reflect the
final changes in the DRG relative weights in the final rule. Further,
as discussed in section II.C of this preamble, we anticipate that the
final recalibrated weights will be somewhat different from those
proposed, 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 propose to revise the surgical hierarchy for the
Pre-MDC DRGs and MDC 3 (Diseases and Disorders of the Ear, Nose, Mouth
and Throat) as follows:
In the Pre-MDC DRGs, we would reorder Lung Transplant (DRG
495) above Bone Marrow Transplant (DRG 481).
In MDC 3, we would reorder Tonsil and Adenoid Procedure
Except Tonsillectomy and/or Adenoidectomy Only (DRGs 57 and 58) above
Cleft Lip and Palate Repair (DRG 52).
6. Refinement of Complications and Comorbidities (CC) List
There is a standard list of diagnoses that are considered CCs. We
developed this list using physician panels to include those diagnoses
that, when present as a secondary condition, would be considered a
substantial complication or comorbidity. In previous years, we have
made changes to the standard list of CCs, either by adding new CCs or
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, 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 criteria
used for eliminating certain diagnoses from consideration as CCs were
intended to identify only the most obvious diagnoses that should not be
considered complications or comorbidities of another diagnosis. For
that reason, and in light of comments and questions on the CC list, we
have continued to review the remaining CCs to identify additional
exclusions and to remove diagnoses from the master list that have been
shown not to meet the definition of a CC. (See the September 30, 1988
final rule for the revision made for the discharges occurring in FY
1989 (53 FR 38485); the September 1, 1989 final rule for the FY 1990
revision (54 FR 36552); the September 4, 1990 final rule for the FY
1991 revision (55 FR 36126); the August 30, 1991 final rule for the FY
1992 revision (56 FR 43209); the September 1, 1992 final rule for the
FY 1993 revision (57 FR 39753); the September 1, 1993 final rule for
the FY 1994 revisions (58 FR 46278); the September 1, 1994 final rule
for the FY 1995 revisions (59 FR 45334); the September 1, 1995 final
rule for the FY 1996 revisions (60 FR 45782); the August 30, 1996 final
rule for the FY 1997 revisions (61 FR 46171); the August 29, 1997 final
rule for the FY 1998 revisions (62 FR 45966); and the July 31, 1998
final rule for the FY 1999 revisions (63 FR 40954)). We are not
proposing to add or delete any codes from the CC list.
In addition, as discussed in detail in section II.B.8 of this
preamble, because we are not making changes to the ICD-9-CM codes for
FY 2000, we do not need to modify the current list for new or deleted
codes. Therefore, there are no proposed revisions to the CC Exclusions
List for FY 2000.
7. Review of Procedure Codes in DRGs 468, 476, and 477
Each year, we review cases assigned to DRG 468 (Extensive OR
Procedure Unrelated to Principal Diagnosis), DRG 476 (Prostatic OR
Procedure Unrelated to Principal Diagnosis), and DRG 477 (Nonextensive
OR Procedure Unrelated to Principal Diagnosis) in order to determine
whether it would be appropriate to change the procedures assigned among
these DRGs.
DRGs 468, 476, and 477 are reserved for those cases in which none
of the OR procedures performed is related to the principal diagnosis.
These DRGs are intended to capture atypical cases, that is, those cases
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
[[Page 24721]]
60.18 Other diagnostic procedures on prostate and periprostatic
tissue
60.21 Transurethral prostatectomy
60.29 Other transurethral prostatectomy
60.61 Local excision of lesion of prostate
60.69 Prostatectomy NEC
60.81 Incision of periprostatic tissue
60.82 Excision of periprostatic tissue
60.93 Repair of prostate
60.94 Control of (postoperative) hemorrhage of prostate
60.95 Transurethral balloon dilation of the prostatic urethra
60.99 Other operations on prostate
All remaining OR procedures are assigned to DRGs 468 and 477, with
DRG 477 assigned to those discharges in which the only procedures
performed are nonextensive procedures that are unrelated to the
principal diagnosis. The original list of the ICD-9-CM procedure codes
for the procedures we consider nonextensive procedures, if performed
with an unrelated principal diagnosis, was published in Table 6C in
section IV. of the Addendum to the September 30, 1988 final rule (53 FR
38591). As part of the final rules published on September 4, 1990,
August 30, 1991, September 1, 1992, September 1, 1993, September 1,
1994, September 1, 1995, August 30, 1996, and August 29, 1997, we moved
several other procedures from DRG 468 to 477, and some procedures from
DRG 477 to 468. (See 55 FR 36135, 56 FR 43212, 57 FR 23625, 58 FR
46279, 59 FR 45336, 60 FR 45783, 61 FR 46173, and 62 FR 45981,
respectively.) No procedures were moved in FY 1999, as noted in the
July 31, 1998 final rule (63 FR 40962).
a. Adding Procedure Codes to MDCs. We annually conduct a review of
procedures producing DRG 468 or 477 assignments on the basis of volume
of cases in these DRGs with each procedure. Our medical consultants
then identify those procedures occurring in conjunction with certain
principal diagnoses with sufficient frequency to justify adding them to
one of the surgical DRGs for the MDC in which the diagnosis falls.
Based on this year's review, we identified several procedures that we
are proposing to move from DRG 468 to one of the surgical DRGs. We did
not identify any necessary changes in procedures under DRG 477 and are,
therefore, not proposing to move any procedures from DRG 477 to one of
the surgical DRGs.
First, we are proposing to move three codes from DRG 468 to MDC 1
(Diseases and Disorders of the Nervous System), all of which would be
assigned to DRGs 7 and 8 (Peripheral and Cranial Nerve and Other
Nervous System Procedure).\1\ Procedure code 38.7 (Interruption of the
vena cava) is sometimes performed in conjunction with treatment for the
principal diagnosis 434.11 (Cerebral embolism with infarction), which
is assigned to MDC 1. Under the current configuration, procedure code
38.7 is not assigned to MDC 1. Therefore when this procedure is
performed by a neurological condition, such as a cerebral embolism with
infarction, the discharge does not group to one of the surgical DRGs
within MDC 1. It is assigned instead to DRG 468 as an unrelated
procedure. Since our medical advisors tell us that procedure code 38.7
is appropriately performed for neurological conditions, we are
proposing to add it to DRGs 7 and 8.
---------------------------------------------------------------------------
\1\ A single title combined with two DRG numbers is used to
signify pairs. Generally, the first DRG is for cases with CC and the
second DRG is for cases without CC. If a third number is included,
it represents cases with patients who are age 0-17. Occasionally, a
pair of DRGs is split between age >17 and age 0-17.
---------------------------------------------------------------------------
Second, we are also proposing that procedure codes 83.92 (Insertion
or replacement of skeletal muscle stimulator) and 83.93 (Removal of
skeletal muscle stimulator) both be categorized with other procedures
on the nervous system. These procedures can be performed on patients
with a principal diagnosis in MDC 1, such as 344.00 (Quadriplegia
unspecified) or 344.31 (Monoplegia of lower limb, affecting dominant
side). Therefore, these two codes would also be assigned to DRGs 7 and
8.
Third, procedure code 39.50 (Angioplasty or atherectomy of
noncoronary vessel) is not currently assigned to MDC 4 (Diseases and
Disorders of the Respiratory System). This procedure can be performed
for patients who develop pulmonary embolism. The principal diagnosis
for pulmonary embolism is in MDC 4, and, to increase clinical
coherence, we propose to add procedure code 39.50 to that MDC in DRGs
76 and 77 (Other Respiratory System OR Procedures).
Fourth, insertion of totally implantable infusion pump (procedure
code 86.06) is not assigned to MDC 5 (Diseases and Disorders of the
Circulatory System) in the current DRG configuration. Infusion pumps
should be assigned to all MDCs where subcutaneous insertion of the pump
is appropriate. Procedure code 86.06 may be performed on patients with
a principal diagnosis in MDC 5 such as 451.83 (Phlebitis and
thrombophlebitis of the deep veins of other extremities). Therefore, we
are proposing to add procedure code 86.06 to DRG 120 (Other Circulatory
System OR Procedures) in MDC 5.
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 not proposing to move any procedures from DRG 468 to
DRGs 476 or 477, from DRG 476 to DRGs 468 or 477, or from DRG 477 to
DRGS 468 or 476.
8. Changes to the ICD-9-CM Coding System
As described in section II.B.1 of this preamble, the ICD-9-CM is a
coding system that is used for the reporting of diagnoses and
procedures performed on a patient. In September 1985, the ICD-9-CM
Coordination and Maintenance Committee was formed. This is a Federal
interdepartmental committee, co-chaired by the National Center for
Health Statistics (NCHS) and HCFA, that is charged with the mission of
maintaining and updating the ICD-9-CM system. That mission includes
approving coding changes, and developing errata, addenda, and other
modifications to the ICD-9-CM to reflect newly developed procedures and
technologies and newly identified diseases. The Committee is also
responsible for promoting the use of Federal and non-Federal
educational programs and other communication techniques with a view
toward standardizing coding applications and upgrading the quality of
the classification system.
The NCHS has lead responsibility for the ICD-9-CM diagnosis codes
included in the Tabular List and Alphabetic Index for Diseases, while
HCFA has lead responsibility for the ICD-9-CM procedure codes included
in the Tabular List and Alphabetic Index for Procedures.
The Committee encourages participation in the above process by
health-related organizations. In this regard, the Committee holds
public meetings for discussion of educational issues and proposed
coding changes. These meetings provide an opportunity for
representatives of recognized organizations in the coding field, such
as the American Health Information Management Association (AHIMA)
(formerly American Medical Record Association (AMRA)), the American
Hospital Association (AHA), and various physician specialty groups as
[[Page 24722]]
well as physicians, medical record administrators, health information
management professionals, and other members of the public to contribute
ideas on coding matters. After considering the opinions expressed at
the public meetings and in writing, the Committee formulates
recommendations, which then must be approved by the agencies.
The Committee presented proposals for coding changes for FY 2000 at
public meetings held on June 14 and November 2, 1998. Even though the
Committee conducted public meetings and considered approval of coding
changes for FY 2000 implementation, we are not implementing any changes
to ICD-9-CM codes for FY 2000. We have undertaken, and continue to
undertake, major efforts to ensure that all of the Medicare computer
systems are ready to function on January 1, 2000. If we were to make
system changes to capture additions, deletions, and modifications to
ICD-9-CM codes for FY 2000, we would endanger the functioning of the
Medicare computer systems, and, specifically, we might compromise our
ability to process hospital bills. Therefore, the code proposals
presented at the public meetings held on June 14 and November 2, 1998,
that (if approved) ordinarily would have been included as new codes for
October 1, 1999, will not be included in this proposed rule. These code
changes to ICD-9-CM will be considered for inclusion in the next annual
update for FY 2001. The initial meeting for consideration of coding
changes for implementation in FY 2001 will be held on May 13, 1999.
Copies of the minutes of the 1998 meetings can be obtained from the
HCFA Home Page at http://www.hcfa.gov/pubaffr.htm, under the ``What's
New'' listing. Paper copies of these minutes are no longer available
and the mailing list has been discontinued. We encourage commenters to
address suggestions on coding issues involving diagnosis codes to:
Donna Pickett, Co-Chairperson; ICD-9-CM Coordination and Maintenance
Committee; NCHS; Room 1100; 6525 Belcrest Road; Hyattsville, Maryland
20782. Comments may be sent by E-mail to: dfp4@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, Center for Health Plans and Providers,
Plan and Provider Purchasing Policy Group, Division of Acute Care; C4-
07-07; 7500 Security Boulevard; Baltimore, Maryland 21244-1850.
Comments may be sent by E-mail to: pbrooks@hcfa.gov.
9. Other Issue: Implantation of Muscle Stimulator
In the July 31, 1998 final rule, we responded to a comment on the
DRG assignment for implantation of a muscle stimulator (63 FR 40964).
In that document, we stated that we would readdress this issue after
reviewing the FY 1998 MedPAR file.
There is concern in the manufacturing industry that the current DRG
assignment for the implantation of a muscle stimulator and the
associated tendon transfer for quadriplegics is inappropriate. When the
procedures are performed during two separate admissions, the tendon
transfer (procedure code 82.56 (Other hand tendon transfer or
transplantation)) is assigned to DRGs 7 and 8 and the insertion of the
muscle stimulator (procedure code 83.92 (Insertion or replacement of
skeletal muscle stimulator)) is assigned to DRG 468. However, when both
procedures are performed in the same admission, the case is assigned to
DRGs 7 and 8.
As discussed in section II.B.7.a of this preamble, we are proposing
to assign code 83.92 to DRGs 7 and 8 in MDC 1. Therefore, if a case
involves either procedure code 82.56 or 83.92, or both procedure codes,
the case would be assigned to DRGs 7 and 8.
A presentation on one type of muscle stimulator was made by a
device manufacturer before the ICD-9-CM Coordination and Maintenance
Committee on November 2, 1998. The manufacturer strongly suggested that
a new code assignment be made for the procedure for insertion of this
stimulator and that it be placed in category 04.9 (Other operations on
cranial and peripheral nerves). However, based on comments received by
the Committee, there was an overwhelming response from the coding
community that a new code should not be created. The commenters believe
that these codes (82.56 and 83.92) adequately described the procedures
since the patient receives a tendon transfer in addition to the
skeletal muscle stimulator insertion. This is done so that the
quadriplegic patient can achieve some hand grasping ability where there
was none before. Some quadriplegic patients receive the tendon transfer
on one admission and the stimulator insertion on a subsequent
admission. Others have both procedures performed on the same admission.
Since the tendon transfer and stimulator insertion are being performed
on quadriplegic patients, a condition found in MDC 1, we propose to add
procedure codes 82.56 and 83.92 to DRGs 7 and 8.
C. Recalibration of DRG Weights
We are proposing to use the same basic methodology for the FY 2000
recalibration as we did for FY 1999. (See the July 31, 1998 final rule
(63 FR 40965).) That is, we would recalibrate the weights based on
charge data for Medicare discharges. However, we propose to use the
most current charge information available, the FY 1998 MedPAR file.
(For the FY 1999 recalibration, we used the FY 1997 MedPAR file.) The
MedPAR file is based on fully-coded diagnostic and surgical procedure
data for all Medicare inpatient hospital bills.
The proposed recalibrated DRG relative weights are constructed from
FY 1998 MedPAR data, based on bills received by HCFA through December
1998, from all hospitals subject to the prospective payment system and
short-term acute care hospitals in waiver States. The FY 1998 MedPAR
file includes data for approximately 11.2 million Medicare discharges.
The methodology used to calculate the proposed DRG relative weights
from the FY 1998 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.5, 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 and
disproportionate share payments, and, for hospitals in Alaska and
Hawaii, the applicable cost-of-living adjustment.
The average standardized charge per DRG was calculated by
summing the standardized charges for all cases in the DRG and dividing
that amount by the number of cases classified in the DRG.
We then eliminated statistical outliers, using the same
criteria 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
[[Page 24723]]
fraction of a case based on the ratio of its length of stay to the
geometric mean length of stay of the cases assigned to the DRG. That
is, a 5-day length of stay transfer case assigned to a DRG with a
geometric mean length of stay of 10 days is counted as 0.5 of a total
case.
We established the relative weight for heart and heart-
lung, liver, and lung transplants (DRGs 103, 480, and 495) in a manner
consistent with the methodology for all other DRGs except that the
transplant cases that were used to establish the weights were limited
to those Medicare-approved heart, heart-lung, liver, and lung
transplant centers that have cases in the FY 1998 MedPAR file.
(Medicare coverage for heart, heart-lung, liver, and lung transplants
is limited to those facilities that have received approval from HCFA as
transplant centers.)
Acquisition costs for kidney, heart, heart-lung, liver,
and lung transplants continue to be paid on a reasonable cost basis.
Unlike other excluded costs, the acquisition costs are concentrated in
specific DRGs (DRG 302 (Kidney Transplant); DRG 103 (Heart Transplant
for heart and heart-lung transplants); DRG 480 (Liver Transplant); and
DRG 495 (Lung Transplant)). Because these costs are paid separately
from the prospective payment rate, it is necessary to make an
adjustment to prevent the relative weights for these DRGs from
including the effect of the acquisition costs. Therefore, we subtracted
the acquisition charges from the total charges on each transplant bill
that showed acquisition charges before computing the average charge for
the DRG and before eliminating statistical outliers.
When we recalibrated the DRG weights for previous years, we set a
threshold of 10 cases as the minimum number of cases required to
compute a reasonable weight. We propose to use that same case threshold
in recalibrating the DRG weights for FY 2000. Using the FY 1998 MedPAR
data set, there are 39 DRGs that contain fewer than 10 cases. We
computed the weights for the 39 low-volume DRGs by adjusting the FY
1999 weights of these DRGs by the percentage change in the average
weight of the cases in the other DRGs.
The weights developed according to the methodology described above,
using the 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.
D. Use of Non-MedPAR Data for Reclassification and Recalibration of the
DRGs
1. Introduction
As in past years, in the DRG reclassification and recalibration
process for the FY 2000 proposed rule, we used the MedPAR file, which
consists of data for approximately 11 million Medicare discharges. In
the FY 1999 rulemaking process, we used the FY 1997 MedPAR file to
recalibrate DRGs and evaluate possible changes to DRG classifications;
for this FY 2000 proposed rule, we used the FY 1998 MedPAR file. The
Conference Report that accompanied the Balanced Budget Act of 1997
stated that ``in order to ensure that Medicare beneficiaries have
access to innovative new drug therapies, the conferees believe that
HCFA should consider, to the extent feasible, reliable, validated data
other than Medicare Provider Analysis and Review (MedPAR) data in
annually recalibrating and reclassifying the DRGs.'' (H. R. Conf. Rep.
No. 105-217 at 734 (1997)).
Consistent with that language, we considered non-MedPAR data both
in the rulemaking process for FY 1999 and in developing this proposed
rule. We received non-MedPAR data from entities on behalf of the
manufacturer of a specific drug, platelet inhibitors; the manufacturer
is seeking to obtain a new DRG assignment for cases involving platelet
inhibitors. The non-MedPAR data purported to show cases involving
platelet inhibitors. As discussed further below, we concluded it was
not feasible to use the non-MedPAR data submitted to us because, among
other things, we did not have information to verify that the cases
actually involved the drug, nor did we have information to verify that
the cases reflected a representative sample (and did not simply reflect
high cost cases).
Effective October 1, 1998, we implemented a code for platelet
inhibitors, but until we receive bills for Medicare discharges
occurring during FY 1999, the MedPAR data do not enable us to
distinguish between cases with platelet inhibitors and cases without
platelet inhibitors (63 FR 40963). Representatives of the
pharmaceutical company first presented us with non-MedPAR data during
the rulemaking process for FY 1999. The data was compiled by a health
information company, and purported to show, for cases from a sample of
hospitals, the average standardized charges (as calculated by the
health information company) for different classes of patients.
In the FY 1999 final rule, we stated a number of reasons why we
rejected the non-MedPAR data we had received. First, we could not
validate whether the data reflected Medicare beneficiaries. Second, the
data came from a limited number of hospitals (83) having an information
sharing contract with the health information company that compiled the
database; the company failed to provide us with information that would
enable us to verify whether the data reflected a representative sample
of hospitals or claims. Third, for over 90 percent of the cases, the
company failed to provide us with information on which hospital
furnished the treatment. This means that we could not validate the data
on standardized charges nor could we use the data to determine an
appropriate DRG weight for the DRG from which the cases would be
reclassified. For these reasons (and others), we concluded in the July
31, 1998 final rule that we could not use the data to change the DRG
assignment of cases involving platelet inhibitor drug therapy from DRG
112 (Percutaneous Cardiovascular Pacemaker Procedures) to DRG 116
(Other Permanent Cardiac Pacemaker Implant or PTCA with Coronary Artery
Stent Implant).
After publication of the July 31, 1998 final rule, we met and
corresponded on several occasions with the manufacturers, vendors, and
legal representatives of the pharmaceutical company in an effort to
resolve data issues. We reiterated that, among other things, we needed
to know for each case
[[Page 24724]]
the hospital that furnished the services. We have not received
information necessary to validate the data itself or its
representativeness.
We remain open to considering non-MedPAR data in the DRG
reclassification and recalibration process, but, consistent with the
Conference Report, as well as our longstanding policies, the data must
be ``reliable'' and ``validated.'' The July 31, 1998 final rule
reflects the major factors that we consider in evaluating whether data
are feasible, reliable, and validated, but we believe it might be
useful to discuss these issues in greater detail.
2. The DRG Reclassification and Recalibration Process
In order to understand whether it is feasible to use non-MedPAR
data, and whether the data are reliable and validated, it is critical
to understand the DRG recalibration and reclassification process. As
described earlier, one of the first steps in the annual DRG
recalibration is that the Medicare hospital inpatient claims (in the
MedPAR file) from the preceding Federal fiscal year are classified
using the DRG classification system (proposed or final) for the
upcoming year. Cases are classified into DRGs based on the principal
diagnosis, up to eight additional diagnoses, and up to six procedures
performed during the stay, as well as age, sex, and discharge status of
the patient. Each case is classified into one and only one DRG.
As the term suggests, the relative weight for each DRG reflects
relative resource use. The recalibration process requires data that
enable us to compare resource use across DRGs. As explained earlier, as
part of the recalibration process, we standardize the charges reflected
on each Medicare claim to remove the effects of area wage differences,
the IME adjustment, and the DSH adjustment; in order to standardize
charges, we need to know which hospital furnished the service. For each
DRG, we calculate the average of the standardized charges for the cases
classified to the DRG. To calculate DRG relative weights, we compare
average standardized charges across DRGs.
In evaluating whether it is appropriate to reclassify cases from
one DRG to another, we examine the average standardized charges for
those cases. The recalibration process and the reclassification process
are integrally related; to evaluate whether cases involving a certain
procedure should be reclassified, we need to have information that (1)
enables us to identify cases that involve the procedure and cases that
do not involve the procedure, and (2) enables us to determine
appropriate DRG relative weights if certain cases are reclassified.
3. Feasible, Reliable, Validated Data
As indicated earlier, the Conference Report reflected the
conferees' belief that, ``to the extent feasible,'' HCFA should
consider ``reliable, validated data'' in recalibrating and
reclassifying DRGs. The concepts of reliability and validation are
closely related. In order for us to use non-MedPAR data, the non-MedPAR
data must be reliable in and of itself in that the data must be
independently validated. When an entity submits non-MedPAR data, we
must be able to independently review the medical records and verify
that a particular procedure was performed for each of the cases that
purportedly involved the procedure. This verification requires the
identification of a particular Medicare beneficiary and the hospital
where the beneficiary was treated, as well as the dates involved.
Although it is unlikely that we would review 100 percent of thousands
of cases submitted for review, at a minimum, we must be able to
validate data through a random sampling methodology. We must also be
able to verify the charges that are reflected in the data.
Independent validation is particularly critical in part because the
non-MedPAR data might be submitted by (or on behalf of) entities that
have a financial interest in obtaining a new DRG assignment and in
obtaining the highest possible DRG relative weight. If we receive non-
MedPAR data that purport to reflect cases involving a certain procedure
and a certain level of charges, we must have some way to verify the
data.
Even if non-MedPAR data are reliable and verifiable, that does not
mean it is necessarily ``feasible'' to use the data for purposes of
recalibration and reclassification. In order to be feasible for these
purposes, the non-MedPAR data must enable us to appropriately measure
relative resource use across DRGs. It is critical that cases are
classified into one and only one DRG in the recalibration process, and
that we have information that enables us to standardize charges for
each case and determine appropriate DRG relative weights. Moreover, the
data must reflect a complete set of cases or, at a minimum, a
representative sample of hospitals and claims.
If cases are classified into more than one DRG (or into the
incorrect DRG) in the recalibration process, or if the non-MedPAR data
reflect an unrepresentative sample of cases, the measure of relative
resource would be distorted. For example, cases of percutaneous
transluminal coronary angioplasty (PTCA) treated with GPIIb/IIIa
platelet inhibitors (procedure code 99.20) are currently classified to
DRG 112. The drug manufacturer has provided us with information on the
average charges for a sample of cases that purportedly involve PTCA,
for the purpose of evaluating whether these cases should be moved to
the higher-weighted DRG 116. However, without adequate identification
of the cases to allow us to specifically identify all of the cases
treated with platelet inhibitors, the relative weight for DRG 112 would
reflect the costs of platelet inhibitor cases. This distortion would
result in excessive payments under DRG 112, and thus undermine the
integrity of the recalibration process.
Therefore, in order for the use of non-MedPAR data to be feasible,
generally we must be able to accurately and completely identify all of
the cases to be reclassified from one DRG to another. At a minimum, we
must have some mechanism for ensuring that DRG weights are not
inappropriately inflated (or deflated) to the extent that a DRG weight
reflects cases that would be reclassified to a different DRG.
In short, then, for use of non-MedPAR data to be feasible for
purposes of DRG recalibration and reclassification, the data must,
among other things (1) be independently verifiable, (2) reflect a
complete set of cases (or a representative sample of cases), and (3)
enable us to calculate appropriate DRG relative weights and ensure that
cases are classified to the ``correct'' DRG, and to one DRG only, in
the recalibration process.
Applying this analysis, the non-MEDPAR data we have received with
respect to platelet inhibitors are unreliable and its use is not
feasible. The health information company, on behalf of the
pharmaceutical company, has provided us with a sample of cases that
purported to reflect platelet inhibitors, and also purported to reflect
the standardized charges for those cases, but the company has failed to
provide us with information that would enable us to verify that the
cases actually involved platelet inhibitors or verify the level of
charges.
Moreover, the data are not useful for purposes of measuring
relative resource use. We have not received sufficient information to
verify whether the hospitals are representative of all hospitals in the
country and whether the non-MedPAR data reflects a representative
sample of all cases involving platelet inhibitors. Also, we have not
received sufficient information
[[Page 24725]]
to use the non-MedPAR data to calculate appropriate DRG relative
weights.
4. Submission of Data
Finally, in order for use of non-MEDPAR data to be feasible, we
must have sufficient time to evaluate and test the data. The time
necessary to do so depends upon the nature and quality of the data
submitted. Generally, however, a significant sample of the data should
be submitted by August 1, approximately 8 months prior to the
publication of the proposed rule, so that we can test the data and make
a preliminary assessment as to the feasibility of its use.
Subsequently, a complete database should be submitted no later than
December 1 for consideration in conjunction with the next year's
proposed rule.
5. How the Prospective Payment System Ensures Access to New
Technologies
As noted at the outset of this discussion, the Conference Report
that accompanied the BBA indicated that we should consider non-MEDPAR
data, to the extent feasible, ``in order to ensure that Medicare
beneficiaries have access to innovative new drug therapies.'' (H. R.
Conf. Rep. No. 105-217 at 734 (1997)) There seems to be a concern that,
if a new technology is introduced, and if the new technology is costly,
then Medicare would not make adequate payment if the new technology is
not immediately placed in a new DRG. This concern is unfounded. As
explained below, the Medicare hospital inpatient prospective payment
does ensure access to new drug therapies, and new technologies in
general.
First, to the extent a case involving a new technology is extremely
costly relative to the cases reflected in the DRG relative weight, the
hospital might qualify for outlier payments, additional payments over
and above the standard PPS payment.
Second, Medicare promotes access to new technologies by making
payments under the propsective payment system that are designed to
ensure that Medicare payments for a hospital's cases as a whole are
adequate. We establish DRGs based on factors such as clinical coherence
and resource utilization. Each diagnosis-related group encompasses a
variety of cases, reflecting a range of services and a range of
resources. Generally, then, each DRG reflects some higher cost cases
and some lower cost cases.
For some cases, the hospital's costs might be higher than the
payment under the propsective payment system; this does not mean that
the DRG classifications are ``inappropriate.'' For other cases, the
hospital's costs will be lower than the payment under the prospective
payment system. We believe that Medicare makes appropriate payments for
a hospital's cases as a whole.
Each year we examine the best data available to assess whether DRG
changes are appropriate and to recalibrate DRG relative weights. As we
have indicated on numerous occasions, it usually takes 2 years from the
time a procedure is assigned a code to collect the appropriate MedPAR
data and then make an assessment as to whether a DRG change is
appropriate. This timetable applies to reclassifications that would
lead to decreased payment as well as those that would increase payment.
In fact, the introduction of new technologies itself might lead to
either higher than average costs or lower costs.
Our ability to evaluate and implement potential DRG changes depends
on the availability of validated, representative data. We believe that
our policies ensure access to new technologies and are critical to the
integrity of the recalibration process. As explained above, we remain
open to using non-MedPAR data if the data are reliable and validated
and enable us to appropriately measure relative resource use.
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 under the Act, we
currently define hospital labor market areas based on the definitions
of Metropolitan Statistical Areas (MSAs), Primary MSAs (PMSAs), and New
England County Metropolitan Areas (NECMAs) issued by the Office of
Management and Budget (OMB). OMB also designates Consolidated MSAs
(CMSAs). A CMSA is a metropolitan area with a population of one million
or more, comprised of two or more PMSAs (identified by their separate
economic and social character). For purposes of the hospital wage
index, we use the PMSAs rather than CMSAs since they allow a more
precise breakdown of labor costs. If a metropolitan area is not
designated as part of a PMSA, we use the applicable MSA. Rural areas
are areas outside a designated MSA, PMSA, or NECMA.
We note that effective April 1, 1990, the term Metropolitan Area
(MA) replaced the term Metropolitan Statistical Area (MSA) (which had
been used since June 30, 1983) to describe the set of metropolitan
areas comprised of MSAs, PMSAs, and CMSAs. The terminology was changed
by OMB in the March 30, 1990 Federal Register to distinguish between
the individual metropolitan areas known as MSAs and the set of all
metropolitan areas (MSAs, PMSAs, and CMSAs) (55 FR 12154). For purposes
of the prospective payment system, we will continue to refer to these
areas as MSAs.
Beginning October 1, 1993, section 1886(d)(3)(E) of the Act
requires that we update the wage index annually. Furthermore, this
section provides that the Secretary base the update on a survey of
wages and wage-related costs of short-term, acute care hospitals. The
survey should measure, to the extent feasible, the earnings and paid
hours of employment by occupational category, and must exclude the
wages and wage-related costs incurred in furnishing skilled nursing
services. As discussed below in section III.F of this preamble, we also
take into account the geographic reclassification of hospitals in
accordance with sections 1886(d)(8)(B) and 1886(d)(10) of the Act when
calculating the wage index.
B. FY 2000 Wage Index Update
The proposed FY 2000 wage index values in section VI of the
Addendum to this proposed rule (effective for hospital discharges
occurring on or after October 1, 1999 and before October 1, 2000) are
based on the data collected from the Medicare cost reports submitted by
hospitals for cost reporting periods beginning in FY 1996 (the FY 1999
wage index was based on FY 1995 wage data).
We note that the FY 1999 wage index published in the July 31, 1998
final rule was further revised on February 25, 1999 (64 FR 9378) to
reflect approved revisions to the hospital wage data used to compute
the wage index. In that final rule, we implemented revised wage index
values, geographic adjustment factors, operating standardized amounts,
and capital Federal rates for hospitals subject to the inpatient
hospital prospective payment system. These changes are effective for
discharges occurring on or after March 1, 1999.
The proposed FY 2000 wage index includes the following categories
of data associated with costs paid under the
[[Page 24726]]
hospital inpatient prospective payment system (as well as outpatient
costs), which were also included in the FY 1999 wage index:
Salaries and hours from short-term, acute care hospitals.
Home office costs and hours.
Certain contract labor costs and hours.
Wage-related costs.
Consistent with the wage index methodology for FY 1999, the
proposed wage index for FY 2000 also continues to exclude the direct
and overhead salaries and hours for services not paid through the
inpatient prospective payment system such as skilled nursing facility
services, home health services, or other subprovider components that
are not subject to the prospective payment system.
We calculate a separate Puerto Rico-specific wage index and apply
it to the Puerto Rico standardized amount. (See 62 FR 45984 and 46041.)
This wage index is based solely on Puerto Rico's data. Finally, section
4410 of the BBA provides that, for discharges on or after October 1,
1997, the area wage index applicable to any hospital that is not
located in a rural area may not be less than the area wage index
applicable to hospitals located in rural areas in that State.
C. FY 2000 Wage Index Proposals
In the July 31, 1998 final rule, we reiterated our position that,
to the greatest degree possible, the hospital wage index should reflect
the wage costs associated with the areas of the hospital included under
the hospital inpatient prospective payment system (63 FR 40970). That
final rule contained a detailed discussion concerning the costs related
to teaching physicians, residents, and CRNAs, all of which are paid by
Medicare separately from the prospective payment system. For reasons
outlined in detail in that final rule, we decided not to remove those
costs from the calculation of the FY 1999 wage index, but to review
updated data and consider removing them in developing the FY 2000 wage
index.
In response to concerns within the hospital industry related to the
removal of these costs from the wage index calculation, the American
Hospital Association (AHA) convened a workgroup to develop a consensus
recommendation. The workgroup, which consisted of representatives from
national and state hospital associations, recommended that costs
related to teaching physicians, residents, and CRNAs should be phased
out of the wage index calculation over a 5-year period. As discussed in
more detail below, based upon our analysis of hospitals' FY 1996 wage
data, and consistent with the AHA workgroup's recommendation, we are
proposing to phase out these costs from the calculation of the wage
index over a 5-year period. The proposed FY 2000 wage index is based on
a blend of 80 percent of an average hourly wage including these costs,
and 20 percent of an average hourly wage excluding these costs.
1. Teaching Physician Costs
Before FY 1999, we included direct physician Part A costs and
excluded contract physician Part A costs from the wage index
calculation. Since some States prohibit hospitals from directly
employing physicians, hospitals in these States were unable to include
physician Part A costs because they were incurred under contract rather
than directly. Therefore, for cost reporting periods beginning in 1995,
we began separately collecting physician Part A costs (both direct and
contract) so we could evaluate how to best handle these costs in the
wage index calculation. Based on our analysis of the 1995 wage data, we
decided to include the contract physician salaries in the wage index
beginning with FY 1999.
In the July 31, 1998 final rule, in response to comments regarding
the inclusion in physician Part A costs of teaching physician costs for
which teaching hospitals are already compensated through the Medicare
GME payment, we stated that we would collect teaching physician data
``as expeditiously as possible in order to analyze whether it is
feasible to separate teaching physician costs from other physician Part
A costs'' (63 FR 40968). Excluding teaching physician costs from the
wage index calculation is consistent with our general policy to exclude
from that calculation those costs that are paid separately from the
prospective payment system.
Because the FY 1996 cost reports did not identify teaching
physician salaries and hours separately from physician Part A costs, we
instructed our fiscal intermediaries to collect, through a survey,
teaching physician costs and hours from the teaching hospitals they
service. Specifically, we requested collection of data on the costs and
hours related to teaching physicians that were included in Line 4
(salaried), Line 10 (contracted), Line 12 (home office and related
organizations), and Line 18 (wage-related costs) of the Worksheet S-3,
Part II. In our instructions accompanying the survey, we indicated that
these teaching-related costs are those payable under the per resident
amounts (Sec. 413.86) and reported on Worksheet A, Line 23 of the
hospital's cost report.
The survey data collected as of the last week of January 1999 are
included in the preliminary public use file made available on the
Internet on February 5, 1999. At that time, we had received completed
surveys for over one-half of teaching hospitals reporting physician
Part A costs on their Worksheet S-3, Part II (372 out of 700). In early
February 1999, we instructed intermediaries to review the survey data
for consistency with the Supplemental Worksheet A-8-2 of the hospitals'
cost reports. Supplemental Worksheet A-8-2 is used to apply the
reasonable compensation equivalency limits to the costs of provider-
based physicians, itemizing these costs by the corresponding line
number on Worksheet A.
When we notified the fiscal intermediaries (and the fiscal
intermediaries notified the hospitals) of the availability to review
the survey data on the Internet, we also established deadlines of March
5, 1999 for hospitals to request changes to the teaching survey data,
and April 5, 1999, for the fiscal intermediaries to submit the data to
HCRIS. The additional data collected from the hospitals through the
fiscal intermediaries by April 5 will be included in the final wage
data file released in May 1999.
Due to the extraordinary effort needed to collect these data and
the importance of accurately removing teaching physician costs, we will
consider requests from a hospital to revise its teaching survey data as
reflected on the final wage data file released in May 1999. (We are not
extending the deadline for requests for revisions to cost report data.)
Requests must be received by HCFA and the hospital's fiscal
intermediary no later than June 7, 1999, and must include all necessary
supporting documentation. As described above, these data were not
originally collected on the FY 1996 cost report. The deadlines
established under our annual process for editing and verifying the wage
data reflect the fact that hospitals prepare and submit their cost
reports at least 1 year, and generally more than 1 year, before the
deadline for requesting changes. Because the timeframe in which the
survey data were collected was considerably shorter, we have extended
the deadline for revising those data.
Since we published the July 31, 1998 final rule, we have received a
recommendation from the hospital industry concerning the methodology
that could be used to exclude physician
[[Page 24727]]
teaching-related costs from the wage index. The industry recommended
that we implement a 5-year phase-out of all physician Part A wage costs
that are teaching-related, as well as all resident and Part A CRNA
costs. In FY 2000, the first year of the phase-out, the applicable wage
index would be based on a blend of 80 percent of the current policy,
which would include all physician Part A costs, and 20 percent of the
new policy, which would exclude teaching physician Part A, resident,
and CRNA costs. The percentages would be adjusted 20 percent each year
until FY 2004, when all teaching physician, resident, and CRNA costs
would be eliminated from the wage index calculation.
The workgroup also recommended that if the teaching data collected
by the intermediaries are not accurate or reliable, HCFA would include
only 20 percent of reported physician Part A costs in the calculation,
based on the assumption that 80 percent of total physician Part A costs
are related to teaching physicians.
We appreciate the industry's willingness to work with us on this
issue and recommend a reasonable and practical solution. In developing
our proposed FY 2000 wage index, we have adopted most of the components
of this recommendation.
In developing the proposed FY 2000 wage index, we calculated the
teaching costs to be removed from the wage index as follow. If we had
complete survey data for a hospital, that amount was subtracted from
the amount reported on the Worksheet S-3 for physician Part A costs.
However, relying solely on the survey data would have resulted in the
removal of no teaching physician costs for many hospitals.
As noted above, the hospital industry recommended that if HCFA
believes the survey data are not reliable or accurate, it should remove
80 percent of the total physician Part A costs and hours. Although we
considered this option, we believe that removing 80 percent of the
total physician Part A costs and hours across the board would not
recognize the variations among hospitals in terms of the percentage of
their physician Part A costs consisting of teaching physician costs. Of
the hospitals for which we have survey data, teaching physician costs,
as reflected on the survey, amount to, on average, approximately 68
percent. If we adopted the recommended methodology, we would not only
negate the efforts of those hospitals and their fiscal intermediaries
that did complete the teaching physician survey, we would also actually
penalize hospitals that cooperated in completing the survey by removing
an amount in excess of actual teaching physician Part A costs they
reported.
Therefore, under our proposal, for any hospital that completed the
survey, we removed from the wage data the physician Part A teaching
costs and hours reported on the survey form. These data had been
verified by the fiscal intermediary before submission to HCFA. If we
did not have survey data for a teaching hospital as of February 22,
1999, we removed 80 percent of the hospital's reported total physician
Part A costs and hours for the proposed wage index. Based upon our
communications with fiscal intermediaries, we believe we will have a
substantially higher response rate for the survey data by the time we
calculate the final FY 2000 wage index values. As discussed above, we
have instructed the fiscal intermediaries to undertake a further
attempt to collect these data for those hospitals that initially did
not report survey data. We believe that since the average percentage of
teaching costs compared to total physician Part A costs is less than 80
percent, it would be an advantage to a hospital to complete the survey.
Although removing 80 percent from the amount reported on the
Worksheet S-3 for physician Part A costs allows an estimate of teaching
physician costs to be removed in the majority of cases in which survey
data are not available, there are instances in which a teaching
hospital did not report either survey data or any physician Part A
costs on its Worksheet S-3. We have identified 72 such teaching
hospitals in our database. For purposes of calculating the proposed FY
2000 wage index for these 72 hospitals, we subtracted the costs
reported on Line 23 of the Worksheet A, Column 1 (Resident and Other
Program Costs) from Line 1 of the Worksheet S-3. These costs (from Line
23, Column 1 of Worksheet A) are included in Line 1 of the Worksheet S-
3, which is the sum of Column 1, Worksheet A. They also represent costs
for which the hospital is paid through the per resident amount under
the direct GME payment. Therefore, we believe it is appropriate to
remove these costs from the wage index calculation in situations in
which hospitals have failed to otherwise identify their teaching
physician costs. To determine the hours to be removed, we divided the
costs reported on Line 23 of the Worksheet A, Column 1 by the national
average hourly wage for physician Part A costs based upon Line 4 of the
Worksheet S-3 (the national average hourly wage is $54.48). We have
indicated these 72 hospitals by an asterisk in Table 3C of this
proposed rule.
We invite comments as to whether the proposed method we have used
to remove teaching-related costs based on the amount included in Line
23, Column 1 of Worksheet A would be an appropriate method for removing
GME costs in the future (and perhaps other excluded area costs as
well). We are especially concerned that the earliest cost report on
which we will be able to make the necessary changes to capture the
separate reporting of teaching physician Part A costs would be cost
reports that would be submitted for cost reporting periods beginning
during FY 1998. Therefore, we are considering the potential for
subtracting the costs in Lines 20, 22, and 23 of Worksheet A from Line
1 of Worksheet S-3, Part II, in calculating the FY 2001 wage index. The
current Worksheet S-3 is not designed to net out of Line 1 costs that
are otherwise included in Column 1 of Worksheet A, but it would be
possible to use data from the Worksheet A in a manner similar to that
described above.
2. Resident and CRNA Part A Costs
The wage index presently includes salaries and wage-related costs
for residents in approved medical education programs and for CRNAs
employed by hospitals under the rural pass-through provision
(Sec. 412.113(c)). Because Medicare pays for these costs outside the
prospective payment system, removing these costs from the wage index
calculation would be consistent with our general policy to exclude
costs that are not paid through the prospective payment system.
However, because these costs were not separately identifiable before
the FY 1995 wage data, we could not remove them.
We began collecting the resident and CRNA wage data separately on
the FY 1995 cost report. However, there were data reporting problems
associated with these costs. For example, the original FY 1995 cost
report instructions for reporting resident costs on Line 6 of Worksheet
S-3, Part III, erroneously included teaching physician salaries and
other teaching program costs. Also, the FY 1995 Worksheet S-3 did not
provide for separate reporting of CRNA wage-related costs. These
problems were corrected in the reporting instructions for the FY 1996
cost report, and we are now proposing to remove CRNA and resident costs
over a 5-year period.
3. Transition Period
The proposed FY 2000 wage index is based on a blend of 80 percent
of
[[Page 24728]]
hospitals' average hourly wages without removing the costs and hours
associated with teaching physician Part A, residents, and CRNAs, and 20
percent of the average hourly wage after removing these costs and hours
from the wage index calculation. This methodology is consistent with
the recommendation of the industry workgroup for a 5-year phase-out of
these costs. The transition methodology is discussed in detail in
section III.E of this preamble.
D. Verification of Wage Data From the Medicare Cost Report
The data for the proposed FY 2000 wage index were obtained from
Worksheet S-3, Parts II and III of the FY 1996 Medicare cost reports.
The data file used to construct the proposed wage index includes FY
1996 data submitted to the Health Care Provider Cost Report Information
System (HCRIS) as of early February 1999. As in past years, we
performed an intensive review of the wage data, mostly through the use
of edits designed to identify aberrant data.
From mid-January to mid-February 1999, we asked our fiscal
intermediaries to revise or verify data elements that resulted in
specific edit failures. Some unresolved data elements are included in
the calculation of the proposed FY 2000 wage index pending their
resolution before calculation of the final FY 2000 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 April 5, 1999. We expect that all
unresolved data elements will be resolved by that date. The revised
data will be reflected in the final rule.
Also, as part of our editing process, we removed data for eight
hospitals that failed edits. For four of these hospitals, we were
unable to obtain sufficient documentation to verify or revise the data
because the hospitals are no longer participating in the Medicare
program or are in bankruptcy status. Two hospitals had negative average
hourly wages after allocating overhead to their excluded areas, and
were therefore removed from the calculation. The data from the
remaining two hospitals were removed because inclusion of their data
would have significantly distorted the wage index values. The data for
these hospitals will be included in the final wage index if we receive
corrected data that pass our edits. As a result, the proposed FY 2000
wage index is calculated based on FY 1996 wage data for 5,035
hospitals.
E. Computation of the Wage Index
The method used to compute the proposed FY 2000 wage index is as
follows:
Step 1--As noted above, we are proposing to base the FY 2000 wage
index on wage data reported on the FY 1996 Medicare cost reports. We
gathered data from each of the non-Federal, short-term, acute care
hospitals for which data were reported on the Worksheet S-3, Parts II
and III of the Medicare cost report for the hospital's cost reporting
period beginning on or after October 1, 1995 and before October 1,
1996. In addition, we included data from a few hospitals that had cost
reporting periods beginning in September 1995 and reported a cost
reporting period exceeding 52 weeks. These data were included because
no other data from these hospitals would be available for the cost
reporting period described above, and because particular labor market
areas might be affected due to the omission of these hospitals.
However, we generally describe these wage data as FY 1996 data.
Step 2--Salaries--The method used to compute a hospital's average
hourly wage is a blend of 80 percent of the hospital's average hourly
wage including all teaching physician Part A, resident, and CRNA costs,
and 20 percent of the hospital's average hourly wage after eliminating
all teaching physician, resident, and CRNA costs.
In calculating a hospital's average salaries plus wage-related
costs, including all teaching physician Part A, resident, and CRNA
costs, we subtracted from Line 1 (total salaries) the Part B salaries
reported on Lines 3 and 5, home office salaries reported on Line 7, and
excluded salaries reported on Lines 8 and 8.01 (that is, direct
salaries attributable to skilled nursing facility services, home health
services, and other subprovider components not subject to the
prospective payment system). We also subtracted from Line 1 the
salaries for which no hours were reported on Lines 2, 4, and 6. To
determine total salaries plus wage-related costs, we added to the net
hospital salaries the costs of contract labor for direct patient care,
certain top management, and physician Part A services (Lines 9 and 10),
home office salaries and wage-related costs reported by the hospital on
Lines 11 and 12, and nonexcluded area wage-related costs (Lines 13, 14,
16, 18, and 20). We note that contract labor and home office salaries
for which no corresponding hours are reported were not included.
We then calculated a hospital's salaries plus wage-related costs by
subtracting from total salaries the salaries plus wage-related costs
for teaching physicians (see section III.C.1 of this preamble for a
detail discussion of this policy), Part A CRNAs (Lines 2 and 16), and
residents (Lines 6 and 20).
Step 3--Hours--With the exception of wage-related costs, for which
there are no associated hours, we computed total hours using the same
methods as described for salaries in Step 2.
Step 4--For each hospital reporting both total overhead salaries
and total overhead hours greater than zero, we then allocated overhead
costs. First, we determined the ratio of excluded area hours (sum of
Lines 8 and 8.01 of Worksheet S-3, Part II) to revised total hours
(Line 1 minus Lines 3, 5, and 7 of Worksheet S-3, Part II). We then
computed the amounts of overhead salaries and hours to be allocated to
excluded areas by multiplying the above ratio by the total overhead
salaries and hours reported on Line 13 of Worksheet S-3, Part III.
Finally, we subtracted the computed overhead salaries and hours
associated with excluded areas from the total salaries and hours
derived in Steps 2 and 3.
Step 5--For each hospital, we adjusted the total salaries plus
wage-related costs to a common period to determine total adjusted
salaries plus wage-related costs. To make the wage adjustment, we
estimated the percentage change in the employment cost index (ECI) for
compensation for each 30-day increment from October 14, 1995 through
April 15, 1997 for private industry hospital workers from the Bureau of
Labor Statistics' Compensation and Working Conditions. We use the ECI
because it reflects the price increase associated with total
compensation (salaries plus fringes) rather than just the increase in
salaries. In addition, the ECI includes managers as well as other
hospital workers. This methodology to compute the monthly update
factors uses actual quarterly ECI data and assures that the update
factors match the actual quarterly and annual percent changes. The
factors used to adjust the hospital's data were based on the midpoint
of the cost reporting period, as indicated below.
Midpoint of Cost Reporting Period
------------------------------------------------------------------------
Adjustment
After Before factor
------------------------------------------------------------------------
10/14/95......................................... 11/15/95 1.023163
11/14/95......................................... 12/15/95 1.021153
12/14/95......................................... 01/15/96 1.019151
01/14/96......................................... 02/15/96 1.017157
02/14/96......................................... 03/15/96 1.015246
03/14/96......................................... 04/15/96 1.013489
[[Page 24729]]
04/14/96......................................... 05/15/96 1.011888
05/14/96......................................... 06/15/96 1.010428
06/14/96......................................... 07/15/96 1.009099
07/14/96......................................... 08/15/96 1.007900
08/14/96......................................... 09/15/96 1.006788
09/14/96......................................... 10/15/96 1.005719
10/14/96......................................... 11/15/96 1.004695
11/14/96......................................... 12/15/96 1.003653
12/14/96......................................... 01/15/97 1.002529
01/14/97......................................... 02/15/97 1.001325
02/14/97......................................... 03/15/97 1.000000
03/14/97......................................... 04/15/97 0.998514
------------------------------------------------------------------------
For example, the midpoint of a cost reporting period beginning
January 1, 1996 and ending December 31, 1996 is June 30, 1996. An
adjustment factor of 1.009099 would be applied to the wages of a
hospital with such a cost reporting period. In addition, for the data
for any cost reporting period that began in FY 1996 and covers a period
of less than 360 days or more than 370 days, we annualized the data to
reflect a 1-year cost report. Annualization is accomplished by dividing
the data by the number of days in the cost report and then multiplying
the results by 365.
Step 6--Each hospital was assigned to its appropriate urban or
rural labor market area before any reclassifications under sections
1886(d)(8)(B) or 1886(d)(10) of the Act. Within each urban or rural
labor market area, we added the total adjusted salaries plus wage-
related costs obtained in Step 5 for all hospitals in that area to
determine the total adjusted salaries plus wage-related costs for the
labor market area.
Step 7--We divided the total adjusted salaries plus wage-related
costs obtained under both methods in Step 6 by the sum of the
corresponding total hours (from Step 4) for all hospitals in each labor
market area to determine an average hourly wage for the area.
Because the proposed FY 2000 wage index is based on a blend of
average hourly wages, we then added 80 percent of the average hourly
wage calculated without removing teaching physician Part A, residents,
and CRNA costs, and 20 percent of the average hourly wage calculated
with these costs removed.
Step 8--We added the total adjusted salaries plus wage-related
costs obtained in Step 5 for all hospitals in the nation and then
divided the sum by the national sum of total hours from Step 4 to
arrive at a national average hourly wage (using the same blending
methodology described in Step 7). Using the data as described above,
the national average hourly wage is $20.9675.
Step 9--For each urban or rural labor market area, we calculated
the hospital wage index value by dividing the area average hourly wage
obtained in Step 7 by the national average hourly wage computed in Step
8.
Step 10--Following the process set forth above, we developed a
separate Puerto Rico-specific wage index for purposes of adjusting the
Puerto Rico standardized amounts. (The national Puerto Rico
standardized amount is adjusted by a wage index calculated for all
Puerto Rico labor market areas based on the national average hourly
wage as described above.) We added the total adjusted salaries plus
wage-related costs (as calculated in Step 5) for all hospitals in
Puerto Rico and divided the sum by the total hours for Puerto Rico (as
calculated in Step 4) to arrive at an overall average hourly wage of
$9.96607 for Puerto Rico. For each labor market area in Puerto Rico, we
calculated the hospital wage index value by dividing the area average
hourly wage (as calculated in Step 7) by the overall Puerto Rico
average hourly wage.
Step 11--Section 4410 of the BBA provides that, for discharges on
or after October 1, 1997, the area wage index applicable to any
hospital that is not located in a rural area may not be less than the
area wage index applicable to hospitals located in rural areas in that
State. Furthermore, this wage index floor is to be implemented in such
a manner as to assure that aggregate prospective payment system
payments are not greater or less than those that would have been made
in the year if this section did not apply. For FY 2000, this change
affects 185 hospitals in 39 MSAs. The MSAs affected by this provision
are identified in Table 4A by a footnote.
F. Revisions to the Wage Index Based on Hospital Redesignation
Under section 1886(d)(8)(B) of the Act, hospitals in certain rural
counties adjacent to one or more MSAs are considered to be located in
one of the adjacent MSAs if certain standards are met. Under section
1886(d)(10) of the Act, the Medicare Geographic Classification Review
Board (MGCRB) considers applications by hospitals for geographic
reclassification for purposes of payment under the prospective payment
system.
The methodology for determining the wage index values for
redesignated hospitals is applied jointly to the hospitals located in
those rural counties that were deemed urban under section 1886(d)(8)(B)
of the Act and those hospitals that were reclassified as a result of
the MGCRB decisions under section 1886(d)(10) of the Act. Section
1886(d)(8)(C) of the Act provides that the application of the wage
index to redesignated hospitals is dependent on the hypothetical impact
that the wage data from these hospitals would have on the wage index
value for the area to which they have been redesignated. Therefore, as
provided in section 1886(d)(8)(C) of the Act, the wage index values
were determined by considering the following:
If including the wage data for the redesignated hospitals
would reduce the wage index value for the area to which the hospitals
are redesignated by 1 percentage point or less, the area wage index
value determined exclusive of the wage data for the redesignated
hospitals applies to the redesignated hospitals.
If including the wage data for the redesignated hospitals
reduces the wage index value for the area to which the hospitals are
redesignated by more than 1 percentage point, the hospitals that are
redesignated are subject to that combined wage index value.
If including the wage data for the redesignated hospitals
increases the wage index value for the area to which the hospitals are
redesignated, both the area and the redesignated hospitals receive the
combined wage index value.
The wage index value for a redesignated urban or rural
hospital cannot be reduced below the wage index value for the rural
areas of the State in which the hospital is located.
Rural areas whose wage index values would be reduced by
excluding the wage data for hospitals that have been redesignated to
another area continue to have their wage index values calculated as if
no redesignation had occurred.
Rural areas whose wage index values increase as a result
of excluding the wage data for the hospitals that have been
redesignated to another area have their wage index values calculated
exclusive of the wage data of the redesignated hospitals.
The wage index value for an urban area is calculated
exclusive of the wage data for hospitals that have been reclassified to
another area. However, geographic reclassification may not reduce the
wage index value for an urban area below the statewide rural wage index
value.
We note that, except for those rural areas in which redesignation
would reduce the rural wage index value, the wage index value for each
area is computed exclusive of the wage data for hospitals that have
been redesignated from the area for purposes of their wage index. As a
result, several urban areas listed in Table 4A have no hospitals
[[Page 24730]]
remaining in the area. This is because all the hospitals originally in
these urban areas have been reclassified to another area by the MGCRB.
These areas with no remaining hospitals receive the prereclassified
wage index value. The prereclassified wage index value will apply as
long as the area remains empty.
The proposed revised wage index values for FY 2000 are shown in
Tables 4A, 4B, 4C, and 4F in the Addendum to this proposed rule.
Hospitals that are redesignated should use the wage index values shown
in Table 4C. Areas in Table 4C may have more than one wage index value
because the wage index value for a redesignated urban or rural hospital
cannot be reduced below the wage index value for the rural areas of the
State in which the hospital is located. When the wage index value of
the area to which a hospital is redesignated is lower than the wage
index value for the rural areas of the State in which the hospital is
located, the redesignated hospital receives the higher wage index
value, that is, the wage index value for the rural areas of the State
in which it is located, rather than the wage index value otherwise
applicable to the redesignated hospitals.
Tables 4D and 4E list the average hourly wage for each labor market
area, before the redesignation of hospitals, based on the FY 1996 wage
data. In addition, Table 3C in the Addendum to this proposed rule
includes the adjusted average hourly wage for each hospital based on
the preliminary FY 1996 data as of February 22, 1999. The MGCRB will
use the average hourly wage published in the final rule to evaluate a
hospital's application for reclassification for FY 2001, unless that
average hourly wage is later revised in accordance with the wage data
correction policy described in Sec. 412.63(w)(2). In such cases, the
MGCRB will use the most recent revised data used for purposes of the
hospital wage index. We note that in adjudicating these wage index
reclassification requests during FY 2000, the MGCRB will use the
average hourly wages for each hospital and labor market area that are
reflected in the final FY 2000 wage index.
At the time this proposed wage index was constructed, the MGCRB had
completed its review of FY 2000 reclassification requests. The proposed
FY 2000 wage index values incorporate all 441 hospitals redesignated
for purposes of the wage index (hospitals redesignated under section
1886(d)(8)(B) or 1886(d)(10) of the Act) for FY 2000. 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 following this proposed rule. The
changes may affect not only the wage index value for specific
geographic areas, but also the wage index value redesignated hospitals
receive, that is, whether they receive the wage index value for the
area to which they are redesignated, or a wage index value that
includes the data for both the hospitals already in the area and the
redesignated hospitals. Further, the wage index value for the area from
which the hospitals are redesignated may be affected.
Under Sec. 412.273, hospitals that have been reclassified by the
MGCRB 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 2000 must be received by the MGCRB by June 21, 1999. A
hospital that requests to withdraw its application may not later
request that the MGCRB decision be reinstated.
G. Requests for Wage Data Corrections
To allow hospitals time to evaluate the wage data used to construct
the proposed FY 2000 hospital wage index, we made available to the
public a data file containing the FY 1996 hospital wage data. As stated
in section II.D of this preamble, the data file used to construct the
proposed wage index includes FY 1996 data submitted to HCRIS as of
early February 1999. In a memorandum dated February 1, 1999, we
instructed all Medicare intermediaries to inform the prospective
payment hospitals that they serve of the availability of the wage data
file and the process and timeframe for requesting revisions. The wage
data file was made available February 5, 1999 through the Internet at
HCFA's home page (http://www.hcfa.gov). We also instructed the
intermediaries to advise hospitals of the availability of these data
either through their representative hospital organizations or directly
from HCFA. Additional details on ordering this data file are discussed
in section IX.A of this preamble, ``Requests for Data from the
Public.''
In addition, 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. It should be noted that the hospital
average hourly wages shown in Table 3C do not reflect any changes made
to a hospital's data after February 22, 1999. Changes approved by a
hospital's fiscal intermediary and forwarded to HCRIS by April 5, 1999
will be reflected on the final public use wage data file scheduled to
be made available May 7, 1999.
We believe hospitals have had ample time to ensure the accuracy of
their FY 1996 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 wage data file released
February 5, 1999, a hospital believed that its FY 1996 wage data were
incorrectly reported, the hospital was to submit corrections along with
complete, detailed supporting documentation to its intermediary by
March 5, 1999. Hospitals were notified of this deadline, and of all
other possible deadlines and requirements, through written
communications from their fiscal intermediaries in early February 1999.
Any wage data corrections to be reflected in the final wage index
must have been reviewed and verified by the intermediary and
transmitted to HCFA on or before April 5, 1999. (The deadline for
hospitals to request changes from their fiscal intermediaries was March
5, 1999.) These deadlines 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 August 1, 1999. We cannot guarantee that corrections
transmitted to HCFA after April 5, 1999 will be reflected in the final
wage index.
After reviewing requested changes submitted by hospitals,
intermediaries transmitted any revised cost reports to HCRIS and
forwarded a copy of the revised Worksheet S-3, Parts II and III to the
hospitals. In addition, fiscal intermediaries were to notify hospitals
of the changes or the reasons that changes were not accepted.
This procedure ensures 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
[[Page 24731]]
contact HCFA in an effort to resolve policy disputes. We note that the
April 5 deadline also applies to these requested changes. We will not
consider factual determinations at this time, as these should have been
resolved earlier in the process.
We have created the process described above to resolve all
substantive wage data correction disputes before we finalize the wage
data for the FY 2000 payment rates. Accordingly, hospitals that do not
meet the procedural deadlines set forth above will not be afforded a
later opportunity to submit wage data corrections or to dispute the
intermediary's decision with respect to requested changes.
The final wage data public use file will be released by May 7,
1999. Hospitals should examine both Table 3C of this proposed rule and
the May 7 final public use wage data file (which reflects revisions to
the data used to calculate the values in Table 3C) to verify the data
HCFA is using to calculate the wage index. Hospitals will have until
June 7, 1999 to submit requests to correct errors in the final wage
data due to data entry or tabulation errors by the intermediary or
HCFA. The correction requests that will be considered at that time will
be limited to errors in the entry or tabulation of the final wage data
that the hospital could not have known about before the release of the
final wage data public use file.
The final wage data file released on May 7, 1999 will contain the
wage data that will be used to construct the wage index values in the
final rule. As noted above in section III.C of this preamble, this file
will include hospitals' teaching survey data as well as cost report
data. As with the file made available in February 1999, HCFA will make
the final wage data file released in May 1999 available to hospital
associations and the public (on the Internet). However, with the
exception of the teaching survey data, this file 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 correction process described above (with the
March 5 deadline), 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 final file.
If, after reviewing the final file, 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 should outline
why the hospital believes an error exists and provide all supporting
information, including dates. These requests must be received by HCFA
and the intermediaries no later than June 7, 1999. Requests mailed to
HCFA should be sent to: Health Care Financing Administration; Center
for Health Plans and Providers; Attention: Stephen Phillips, Technical
Advisor; Division of Acute Care; C4-07-07; 7500 Security Boulevard;
Baltimore, MD 21244-1850. Each request must also be sent to the
hospital's fiscal intermediary. The intermediary will review requests
upon receipt and contact HCFA immediately to discuss its findings.
At this point in the process, changes to the hospital wage data
will be made only in those very limited situations involving an error
by the intermediary or HCFA that the hospital could not have known
about before its review of the final wage data file. (As noted above,
however, we are also allowing hospitals to request changes to their
teaching survey data. These requests must comply with all of the
documentation and deadline requirements as otherwise specified in this
proposed rule.) Specifically, neither the intermediary nor HCFA will
accept the following types of requests at this stage of the process:
Requests for wage data corrections that were submitted too
late to be included in the data transmitted to HCRIS on or before April
5, 1999.
Requests for correction of errors that were not, but could
have been, identified during the hospital's review of the February 1999
wage data file.
Requests to revisit factual determinations or policy
interpretations made by the intermediary or HCFA during the wage data
correction process.
Verified corrections to the wage index received timely (that is, by
June 7, 1999) will be incorporated into the final wage index to be
published by July 30, 1999 and effective October 1, 1999.
Again, we believe the wage data correction process described above
provides hospitals with sufficient opportunity to bring errors in their
wage data to the intermediary's attention. Moreover, because hospitals
will have access to the final wage data by early May 1999, they will
have the opportunity to detect any data entry or tabulation errors made
by the intermediary or HCFA before the development and publication of
the FY 2000 wage index by July 30, 1999 and the implementation of the
FY 2000 wage index on October 1, 1999. If hospitals avail themselves of
this opportunity, the wage index implemented on October 1 should be
free of these errors. Nevertheless, in the unlikely event that errors
should occur after that date, we retain the right to make midyear
changes to the wage index under very limited circumstances.
Specifically, in accordance with Sec. 412.63(w)(2), we may make
midyear corrections to the wage index only in those limited
circumstances in which a hospital can show (1) that the intermediary or
HCFA made an error in tabulating its data; and (2) that the hospital
could not have known about the error, or did not have an opportunity to
correct the error, before the beginning of FY 2000 (that is, by the
June 7, 1999 deadline). As indicated earlier, since a hospital 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.
In the September 1, 1994 Federal Register, we stated that we did
not believe that a ``formal appeals process'' regarding intermediary
decisions denying hospital requests for wage data revisions was
necessary, given the numerous opportunities provided to hospitals to
verify and revise their data (59 FR 45351). We continue to believe that
the process described above provides hospitals more than adequate
opportunity to ensure that their data are correct. Nevertheless, we
wish to clarify that, while there is no formal appeals process that
culminates before the publication of the final rule and that is
described above, hospitals may later seek formal review of denials of
requests for wage data revisions made as a result of that process.
Once the final wage index values are calculated and published in
the Federal Register, the last opportunity for a hospital to seek to
have its wage data revised is under the limited circumstances described
in Sec. 412.63(w)(2). As we noted in the September 1, 1995 Federal
Register, however, hospitals are entitled to appeal any denial of a
request for a wage data revision made as a result of HCFA's wage data
correction process to the Provider Reimbursement Review Board (PRRB),
consistent with the rules for PRRB appeals found at 42 CFR part 405,
Subpart R (60 FR 45795). As we also stated in the 1995 Federal
Register, and as the regulation at Sec. 412.63(w)(5) provides, any
subsequent reversal of a denial of a wage revision request that
[[Page 24732]]
results from a hospital's appeal to the PRRB or beyond will be given
effect by paying the hospital under a revised wage index that reflects
the revised wage data at issue. The revised wage data will not,
however, be used for purposes of revisiting past adjudications of
requests for geographic reclassification.
IV. Other Decisions and Proposed Changes to the Prospective Payment
System for Inpatient Operating Costs and Graduate Medical Education
Costs
A. Sole Community Hospitals (SCHs)(Sec. 412.92)
If a hospital is classified as a SCH because, by reason of certain
factors, it is the sole source of inpatient hospital services
reasonably available to Medicare beneficiaries in a geographic area,
the hospital is paid based on the highest of the following: the
applicable adjusted Federal rate; the updated hospital-specific rate
based on a 1982 base period; or the updated hospital-specific rate
based on a 1987 base period. Under our existing rules, urban hospitals
within 35 miles of another hospital cannot qualify as SCHs. Since 1983,
we have consistently defined an ``urban'' area for purposes of
determining if a hospital qualifies for SCH status as a MSA or NECMA as
defined by OMB.
In the past, we have considered and rejected two alternatives to
the MSA definitions of an urban area for SCH purposes. These
alternatives were the urbanized areas as defined by the Census Bureau
and the health facility planning areas (HFPAs) as used by the Health
Resource Services Administration. We have concluded that the MSA
definition continues to be the most appropriate geographic delimiter
available at this time. Therefore, we propose to continue to apply the
MSA definition of an urban area for SCH status purposes.
We propose to continue our current policy for several reasons.
First, as we have previously noted, since OMB considers local commuting
patterns in establishing urban definitions, we believe that residents
in urban areas have access to hospital services either by living in
close proximity to a hospital or by establishing a heavy commuting
pattern to an area in which a hospital is located (48 FR 39780,
September 1, 1983). We do not believe that either Census Bureau
urbanized areas or HFPAs take commuting patterns into account in the
way that OMB's MSAs do. We believe commuting patterns serve as an
important indicia of whether a hospital is the sole hospital reasonably
accessible by Medicare beneficiaries in an area.
In addition, we note that our use of MSAs to define urban areas for
SCH status purposes has direct statutory support. Section 1886(d)(2)(D)
of the Act specifically authorizes us to use OMB's MSA definition of
urban areas for purposes of calculating the prospective payment system
standardized amounts. SCH status represents an adjustment to the usual
prospective payment that a hospital would receive, and since that
prospective payment is based on the standardized amount, among other
factors, we believe it would be anomalous to employ one definition of
urban area for purposes of calculating the standardized amount and
another for purposes of determining if the hospital qualified as a SCH.
To do so would be to use one set of geographic delimiters in applying
the general rule (payment under the prospective payment system based on
the standardized amount) but a different set in determining exceptions
to the rule (payment under the prospective payment system adjusted to
take into account SCH status). We do not think this would be
appropriate. For this reason, also, we propose to continue to define
``urban'' for SCH purposes as meaning MSAs as defined by OMB, not as
meaning either Census Bureau urbanized areas or HFPAs.
B. Rural Referral Centers (Sec. 412.96)
Under the authority of section 1886(d)(5)(C)(i) of the Act,
Sec. 412.96 sets forth the criteria a hospital must meet in order to
receive special treatment under the prospective payment system as a
rural referral center. For discharges occurring before October 1, 1994,
rural referral centers received the benefit of payment based on the
other urban rather than the rural standardized amount. As of that date,
the other urban and rural standardized amounts were the same. However,
rural referral centers continue to receive special treatment under both
the disproportionate share hospital (DSH) payment adjustment and the
criteria for geographic reclassification.
One of the criteria under which a rural hospital may qualify as a
rural referral center is to have 275 or more beds available for use. A
rural hospital that does not meet the bed size criterion can qualify as
a rural referral center if the hospital meets two mandatory criteria
(specifying a minimum case-mix index and a minimum number of
discharges) and at least one of the three optional criteria (relating
to specialty composition of medical staff, source of inpatients, or
volume of referrals). With respect to the two mandatory criteria, a
hospital may be classified as a rural referral center if its--
Case-mix index is at least equal to the lower of the
median case-mix index for urban hospitals in its census region,
excluding hospitals with approved teaching programs, or the median
case-mix index for all urban hospitals nationally; and
Number of discharges is at least 5,000 discharges per year
or, if fewer, the median number of discharges for urban hospitals in
the census region in which the hospital is located. (The number of
discharges criterion for an osteopathic hospital is at least 3,000
discharges per year.)
1. Case-Mix Index
Section 412.96(c)(1) provides that HCFA will establish updated
national and regional case-mix index values in each year's annual
notice of prospective payment rates for purposes of determining rural
referral center status. The methodology we use to determine the
proposed national and regional case-mix index values is set forth in
regulations at Sec. 412.96(c)(1)(ii). The proposed national case-mix
index value 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 1998
(October 1, 1997 through September 30, 1998) and include bills posted
to HCFA's records through December 1998. Therefore, we are proposing
that, in addition to meeting other criteria, hospitals with fewer than
275 beds, if they are to qualify for initial rural referral center
status for cost reporting periods beginning on or after October 1,
1999, must have a case-mix index value for FY 1998 that is at least--
1.3438; or
The median case-mix index value for urban hospitals
(excluding hospitals with approved teaching programs as identified in
Sec. 412.105) calculated by HCFA for the census region in which the
hospital is located.
The median case-mix values by region are set forth in the following
table:
------------------------------------------------------------------------
Case-mix
Region index
value
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)...................... 1.2480
2. Middle Atlantic (PA, NJ, NY).............................. 1.2504
[[Page 24733]]
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)....... 1.3269
4. East North Central (IL, IN, MI, OH, WI)................... 1.2593
5. East South Central (AL, KY, MS, TN)....................... 1.2772
6. West North Central (IA, KS, MN, MO, NE, ND, SD)........... 1.1871
7. West South Central (AR, LA, OK, TX)....................... 1.3003
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)................. 1.3280
9. Pacific (AK, CA, HI, OR, WA).............................. 1.3277
------------------------------------------------------------------------
The preceding numbers will be revised in the final rule to the
extent required to reflect the updated FY 1998 MedPAR file, which will
contain data from additional bills received through March 31, 1999.
For the benefit of hospitals seeking to qualify as referral centers
or those wishing to know how their case-mix index value compares to the
criteria, we are publishing each hospital's FY 1998 case-mix index
value in Table 3C in section IV 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. 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 1997 (that is, October 1, 1996 through
September 30, 1997). That is the latest year for which we have complete
discharge data available.
Therefore, we are proposing that, in addition to meeting other
criteria, a hospital, if it is to qualify for initial rural referral
center status for cost reporting periods beginning on or after October
1, 1999, must have as the number of discharges for its cost reporting
period that began during FY 1998 a figure that is at least--
5,000; or
The median number of discharges for urban hospitals in the
census region in which the hospital is located, as indicated in the
following table.
------------------------------------------------------------------------
Number of
Region discharges
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)..................... 6672
2. Middle Atlantic (PA, NJ, NY)............................. 8635
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)...... 7753
4. East North Central (IL, IN, MI, OH, WI).................. 7390
5. East South Central (AL, KY, MS, TN)...................... 6741
6. West North Central (IA, KS, MN, MO, NE, ND, SD).......... 5662
7. West South Central (AR, LA, OK, TX)...................... 5344
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)................ 7993
9. Pacific (AK, CA, HI, OR, WA)............................. 5993
------------------------------------------------------------------------
We note that the number of discharges for hospitals in each census
region is greater than the national standard of 5,000 discharges.
Therefore, 5,000 discharges is the minimum criterion for all hospitals.
These numbers will be revised in the final rule based on the latest FY
1997 cost report data.
We reiterate that an osteopathic hospital, if it is to qualify for
rural referral center status for cost reporting periods beginning on or
after October 1, 1999, must have at least 3,000 discharges for its cost
reporting period that began during FY 1997.
C. Changes to the Indirect Medical Education Adjustment (Sec. 412.105)
Section 1886(d)(5)(B) of the Act provides that prospective payment
hospitals that have residents in an approved graduate medical education
(GME) program receive an additional payment to reflect the higher
indirect operating costs associated with GME. The regulations regarding
the calculation of this additional payment, known as the indirect
medical education (IME) adjustment, are located at Sec. 412.105.
In the August 29, 1997 final rule (62 FR 46029), we redesignated
the previous Sec. 412.105(g) as Sec. 412.105(f), and added a new
paragraph (g) to implement section 1886(d)(5)(B) of the Act as revised
by section 4621 of the Balanced Budget Act of 1997. However, when we
redesignated paragraph (g) as paragraph (f), we inadvertently did not
revise all of the relevant cross-references to reflect this
redesignation. Specifically, at Sec. 412.105(f)(1)(iii), there are
three cross-references to paragraph (g)(1)(ii). These cross-references
are incorrect in light of the redesignation of previous paragraph (g)
as paragraph (f). We are proposing to revise Sec. 412.105(f)(1)(iii) to
correct these cross-references.
D. Medicare Geographic Classification Review Board: Conforming Changes
Secs. 412.256 and 412.276
In the May 12, 1998 final rule (63 FR 26321), we revised the
regulations governing the timeframes for submittal of applications by
hospitals to the MGCRB for geographic reclassifications and for MGCRB
decisions to take into consideration the revised statutory publication
schedule for the annual prospective payment policies and rates (that
is, August 1 instead of September 1) implemented by the BBA. In making
those changes, we inadvertently omitted conforming changes to two other
sections of the regulations that also specify timeframes that are
affected by the change to an August 1 publication date--Secs. 412.256
and 412.276. We propose to revise Sec. 412.256(c)(2) to specify that at
the request of the hospital, the MGCRB may, for good cause, grant a
hospital that has submitted an application by September 1 (instead of
October 1) an extension beyond September 1 (instead of October 1) to
complete its application. In addition, we propose to revise
Sec. 412.276(a) to specify that the MGCRB notifies the parties in
writing, with a copy to HCFA, and issues a decision within 180 days
after the ``first day of the 13-month period preceding the Federal
fiscal year for which the hospital had filed a completed application''
for reclassification, to make the language consistent with the statute
and the May 1998 changes made to the application deadline in
Sec. 412.256(a)(2).
E. Payment for Direct Costs of Graduate Medical Education (Sec. 413.86)
Under section 1886(h) of the Act, Medicare pays hospitals for the
direct costs of graduate medical education (GME). The payments are
based on the number of residents trained by the hospital. The BBA
revised section 1886(h) of the Act to cap the number of residents that
hospitals may count for direct GME. We have issued rules to implement
the caps for GME (62 FR 46002, August 29, 1997; 63 FR 26327, May 12,
1998; and 63 FR 40986, July 31, 1998). Since the publication of these
rules we have received a number of questions relating to GME. In
addition, we have received information related to other aspects of our
GME policies. In response to these questions and information, we are
clarifying certain GME policies and also making some technical changes
to the regulations text. In addition, we are proposing certain changes
in GME policy.
[[Page 24734]]
1. Approved Geriatric Programs
Under sections 1886(h)(5)(F) and (G) of the Act and Sec. 413.86(g),
Medicare counts each resident within an initial residency period as a
1.0 full-time equivalent (FTE) for purposes of determining GME
payments. Each resident beyond the initial residency period is counted
as 0.5 full-time equivalent. Section 1886(h)(5)(F) of the Act extends
the initial residency period by up to 2 years if an individual is in a
geriatric or preventive medicine residency or fellowship. At
Sec. 413.86(b), we specify that an ``approved geriatric program'' is
``a fellowship program of one or more years in length that is approved
by the Accreditation Council for Graduate Medical Education (ACGME)
under the ACGME's criteria for geriatric fellowship programs.'' In
recent years, geriatric programs have been approved by other national
organizations. Consistent with the statute, we are proposing to clarify
the definition of approved geriatric programs at Sec. 413.86(b) to
include fellowship programs approved by the American Osteopathic
Association, the Commission on Dental Accreditation, and the Council on
Podiatric Medical Education. These organizations, in addition to ACGME,
are recognized by HCFA as the accrediting bodies for determining
approved educational activities. We also would make a conforming change
to Sec. 413.86(g)(1)(iii) to recognize approved geriatric programs
accredited by all national approving organizations.
2. Hospital Payment for Resident Training in Nonhospital Settings
Under sections 1886(d)(5)(B)(iv) and 1886(h)(4)(E) of the Act,
hospitals may count residents working in nonhospital sites for indirect
and direct medical education respectively if the hospital incurs ``all
or substantially all'' of these education costs. The requirements for
counting the time residents spend training in nonhospital settings are
addressed at Sec. 413.86(f)(4). Currently, the requirements for
hospital payment under this provision are that the resident spend his
or her time in patient care activities and that a written agreement
exist between the hospital and the nonhospital site. This written
agreement must indicate that the hospital will incur the cost of the
residents' salaries and fringe benefits while the residents are
training in the nonhospital site and that the hospital is providing
reasonable compensation to the nonhospital site for supervisory
teaching activities. In addition, the written agreement must indicate
the compensation the hospital is providing to the nonhospital site for
supervisory teaching activities.
Under the statute, the time residents spend at nonhospital sites
may be counted ``if the hospital incurs all, or substantially all, of
the costs of the training program in that setting.'' The existing
regulations text, however, is framed in terms of the hospital having an
agreement that it ``will incur'' the costs in the nonhospital setting.
We are proposing to make a technical change to the regulations text by
adding a new Sec. 413.86(f)(4)(iii), to clarify that in order to count
residents at a nonhospital site, the hospital must actually incur all
or substantially all of the costs for the training program, as defined
in Sec. 413.86(b), in the nonhospital site. This definition of all or
substantially all requires the hospital to incur the expenses of the
residents' salaries and fringe benefits (including travel and lodging
where applicable) and the portion of the cost of teaching physicians'
salaries and fringe benefits attributable to direct GME.
3. New Residency Programs
In the regulations we published on August 29, 1997 and May 12,
1998, we established special rules for adjusting the full-time
equivalent (FTE) resident caps for indirect and direct GME for new
medical residency programs. In general, the special rules allow for
adjustments to the caps based on a number of residents participating in
the program in its third year of existence. In Secs. 413.86(g)(6)(i)
and 413.86(g)(6)(ii), we set forth a methodology for adjusting hospital
FTE caps for new medical residency training programs established on or
after January 1, 1995. We are proposing the following clarifications,
technical changes, and policy changes:
a. In Sec. 413.86(g)(6)(i), we specify that, if a hospital had no
residents before January 1, 1995, the adjustments for new programs are
based on the highest number of residents in any program year during the
third year of the newly established program. However,
Sec. 413.86(g)(6)(ii) does not explicitly state the methodology for
adjusting caps for hospitals that did have residents in the most recent
cost reporting period ending before January 1, 1995. The adjustments of
the caps for programs established on or after January 1, 1995 and on or
before August 5, 1997, also are made based on the number of residents
in the third year of the new program. We are proposing to revise
Sec. 413.86(g)(6)(ii) to clarify that, for a hospital that did have
residents in the most recent cost reporting period ending on or before
December 31, 1996 (the proposed revised date described in section
IV.E.3.d. of this preamble), the adjustment is based on the highest
number of residents in any program year in the third year of the new
program.
b. Sections 413.86(g)(6)(i) and 413.86(g)(6)(ii) specify that the
adjustment to the cap is also based on the number of years in which
residents are expected to complete each program based on the minimum
accredited length for the type of program. We are proposing to add
language to clarify how to account for situations in which the
residents spend an entire program year (or years) at one hospital and
the remaining year (or years) of the program at another hospital. In
this situation, the adjustment to the FTE cap is based on the number of
years the residents are training at each hospital, not the minimum
accredited length for the type of program. If we were to use the
minimum accredited length for the program in this case, the total
adjustment to the cap might exceed the total accredited slots available
to the hospitals participating in the program. In the May 12, 1998
final rule (63 FR 26334), we specified that the adjustment to the FTE
cap may not exceed the number of accredited resident slots available.
c. It was brought to our attention that the regulations do not
explicitly address how to apply the cap during the first 3 years of a
new program before the adjustments to the cap are established. We are
proposing to clarify our policy on new residency programs by adding
language in Secs. 413.86(g)(6)(i) and 413.86(g)(6)(ii) to specify how
to determine the hospital's cap in the first 3 years of a new residency
program, before the implementation of the hospital's permanent
adjustment to its FTE cap effective beginning with the fourth year of
the program. We are proposing to specify that the cap may be adjusted
during each year of the first 3 years of the hospital's new residency
program, using the actual number of residents participating in the new
program. The adjustment may not exceed the number of accredited slots
available to the hospital for each program year.
d. As discussed above, on August 29, 1997, we implemented the
hospital-specific caps on the number of residents that a hospital can
count for purposes of GME payments in a final rule with comment period
(62 FR 46002). In both the May 12, 1998 and July 31, 1998 final rules
(63 FR 26327 and 63 FR 40954), we responded to comments we received on
this provision. We did not receive any comments about hospitals that
participated in residency training in the
[[Page 24735]]
past, had terminated their participation prior to the hospitals' cost
reporting period ending in calendar year 1996, and have now again begun
a new residency program. After publication of the July 31, 1998 final
rule, we were contacted by representatives of some hospitals that had a
resident cap of zero because they had temporarily terminated their GME
programs in the past and had no residents training during the cost
reporting period ending in 1996. Based on the existing regulations,
these hospitals have FTE caps of zero. There is no provision in the
existing regulations for making adjustments to the cap to allow these
hospitals to receive payment for indirect and direct GME for allopathic
and osteopathic residents.
To address this issue, we are proposing to revise
Sec. 413.86(g)(6)(i) to allow for an adjustment to a hospital's FTE cap
if the hospital had no allopathic and osteopathic residents in its cost
reporting period ending during calendar year 1996. This change would
allow all hospitals that did not participate in allopathic and
osteopathic resident training in the cost reporting period ending in
calendar year 1996 to receive adjustments to the indirect and direct
GME FTE caps for new residency programs. We believe it is appropriate
to revise the regulations to allow for payment during the first 3 years
of the new program and for an adjustment to the FTE cap 3 years after
these hospitals restart participation in residency training, similar to
the existing adjustment for hospitals that never participated in
residency training. We propose to revise Sec. 413.86(g)(6)(i) to allow
a hospital that has zero residents for the cost reporting period ending
during the calendar year 1996 to receive an adjustment. This change
would be effective for discharges occurring on or after October 1,
1999, for purposes of the IME adjustment and for cost reporting periods
beginning on or after October 1, 1999, for purposes of direct GME.
In addition, we are proposing to make a change in
Sec. 413.86(g)(6)(ii) to make the language similar to that in
Sec. 413.86(g)(6)(i) to specify that hospitals that did have residents
in the cost reporting period ending on or before December 31, 1996, are
allowed adjustments to the cap for new programs begun on or after
January 1, 1995, and on or before August 5, 1997. Currently,
Sec. 413.86(g)(6)(ii) refers to a hospital that did have residents in
its most recent cost reporting period ending on or before January 1,
1995. The regulation states that these hospitals also may qualify for
an adjustment to the caps, but only for medical residency programs
created on or after January 1, 1995, and on or before August 5, 1997.
Since we are proposing to revise Sec. 413.86(g)(6)(i) to indicate that
a hospital may qualify for an adjustment to the cap under that
paragraph if it did not have residents in the cost reporting period
ending during calendar year 1996, we are proposing to make a similar
change in Sec. 413.86(g)(6)(ii) to indicate that this paragraph
provides for an adjustment to the cap for hospitals that did have
residents in its most recent reporting period ending on or before
December 31, 1996. We are proposing this revision to make the language
of these two paragraphs consistent. Hospitals may qualify either under
Sec. 413.86(g)(6)(i) or Sec. 413.86(g)(6)(ii). For hospitals that
qualify under Sec. 413.86(g)(6)(i), the FTE caps are established 3
years after the hospital either begins or restarts participation in
residency training for programs that began on or after January 1, 1995.
However, for hospitals that qualify under Sec. 413.86(g)(6)(ii),
adjustments to the cap are limited to those programs that began on or
after January 1, 1995 and on or before August 5, 1997.
e. We are proposing to make technical changes to
Secs. 413.86(g)(6)(i) and 413.86(g)(6)(ii), which refer to whether a
hospital had residents in its most recent cost reporting period on or
before December 31, 1996. Instead of simply specifying ``residents,''
we are proposing to reference ``allopathic and osteopathic residents,''
because the FTE cap applies only to allopathic and osteopathy
residents. There is no FTE cap on the number of podiatry and dentistry
residents. Therefore, we are proposing to add the words ``allopathic
and osteopathic'' in Secs. 413.86(g)(6)(i) and 413.86(g)(6)(ii) before
the word ``resident''.
4. Adjustment to GME Caps for Certain Hospitals To Account for
Residents in New Medical Residency Training Programs
Section 4623 of the BBA amended section 1886(h) of the Act to
provide for ``special rules'' in applying FTE caps for medical
residency training programs established on or after January 1, 1995. In
the August 29, 1997 and May 12, 1998 final rules (62 FR 46002 and 63 FR
26327), we implemented special rules to account for residents in new
medical residency training programs. We are proposing to implement
another special rule to permit an adjustment to the FTE cap for a
hospital if the entire facility was under construction prior to August
5, 1997 (the date of enactment of the BBA) and if the hospital
sponsored a new medical residency training program but the residents
temporarily trained at another hospital.
Under current policies, if a new medical residency training was
established on or after January 1, 1995, a hospital may receive an
adjustment to its FTE cap to account for residents in the new program.
If the residents in the new program begin training in one hospital and
are subsequently ``transferred'' to another hospital, the second
hospital does not receive an adjustment to its FTE cap; if we made an
adjustment for the second hospital, then two hospitals would receive an
adjustment for the same resident.
We believe, however, that an adjustment for the second hospital
might be appropriate in certain limited circumstances. If the second
hospital sponsored a new medical residency training program but the
residents in the new program temporarily trained at the first hospital
because the second hospital was still being built, then we believe it
might be appropriate to permit an adjustment for the second hospital.
Otherwise, the second hospital's FTE cap would be zero, and the
hospital would not receive any GME or IME payments.
We are proposing to permit an adjustment under this policy only if
the second hospital (the sponsor of the new program) began construction
of its entire facility prior to the date of enactment of the BBA. Prior
to August 5, 1997, a hospital would not have had knowledge of the
provisions of the BBA and thus would not have known that a decision to
temporarily train residents at another hospital might have resulted in
the hospital being unable to receive GME and IME payments in the
future. In contrast, a hospital that began construction of an entirely
new facility on or after August 5, 1997 would have had notice of
changes in the law prior to making a decision to temporarily train
residents at another hospital.
Thus, we are proposing to add a new Sec. 413.86(g)(7) (existing
Sec. 413.86(g)(7) would be redesignated as Sec. 413.86(g)(9)) to
address application of the FTE caps with regard to a hospital that
began construction of an entire facility prior to August 5, 1997,
sponsored medical residency training programs, and temporarily trained
those residents at another hospital(s) until the new facility was
completed. For hospitals that meet these criteria, we propose that the
FTE caps will be determined in a manner similar to those hospitals that
qualify for an adjustment to the FTE cap under Sec. 413.86(g)(6)(i).
That is, the hospital's cap would equal the lesser of (a) the product
of the highest number of
[[Page 24736]]
residents in any program year during the third year of the first
program's existence for all new residency training programs at either
the newly constructed facility or the temporary training site and the
number of years in which residents are expected to complete the
programs based on the minimum accredited length for each type of
program; or (b) the number of accredited slots available for each year
of the program. If the medical residency training programs sponsored by
the newly constructed hospital have been in existence for 3 years or
more by the time the residents begin training at the newly constructed
hospital, the newly constructed hospital's cap would be the number of
residents training in the third year of the first of those programs
begun at the a temporary training site. If the medical residency
training programs sponsored by the newly constructed hospital have been
in existence for less than 3 years when the residents begin training at
the newly constructed hospital, the hospital's cap would be based on
the number of residents training at the newly constructed hospital in
the third year of the first of those programs (including the years at
the temporary training site). This provision would be effective for
portions of cost reporting periods occurring on or after October 1,
1999.
5. Temporary Adjustments to FTE Cap To Reflect Residents Affected by
Hospital Closure
In the May 12, 1998 prospective payment system final rule (63 FR
26330), we indicated that we would allow a temporary adjustment to a
hospital's resident cap under limited circumstances and if certain
criteria are met when a hospital assumes the training of additional
residents because of another hospital's closure. The temporary
adjustment to the FTE cap is available to the hospital only for the
period of time necessary to train those displaced residents. Once the
residents leave the hospital or complete their programs, the hospital
cap would be based solely on the statutory base year (with any
applicable adjustments for new medical residency training programs or
affiliated group arrangements).
Under current policies, we permit a temporary adjustment to the FTE
cap for a hospital only if it assumed additional medical residents from
a hospital that closed in the July 1996-June 1997 residency training
year. We are proposing to allow adjustments to address hospital
closures after this period. Thus, we would allow an adjustment for a
hospital if it takes on additional residents from a hospital that
closes at any time on or after July 1, 1996. This adjustment is
intended to account for residents who may have partially completed a
medical residency training program and would be unable to complete
their training without a residency position at another hospital.
We are proposing this change because hospitals have indicated a
reluctance to accept additional residents from a closed hospital
without a temporary adjustment to their caps. Therefore, we are
proposing to add a new Sec. 413.86(g)(8) to allow a temporary
adjustment to a hospital's FTE cap to reflect residents added because
of a hospital's closure at any time on or after July 1, 1996. We would
allow an adjustment to a hospital's FTE cap if the hospital meets the
following criteria: (a) the hospital is training additional residents
from a hospital that closed on or after July 1, 1996; and (b) the
hospital that is training the additional residents who are assumed from
the closed hospital submits a request to its fiscal intermediary at
least 60 days before the beginning of training of the residents for a
temporary adjustment to its FTE cap, documents that the hospital is
eligible for this temporary adjustment to its FTE cap by identifying
the residents who have come from the closed hospital and have caused
the hospital to exceed its cap, and specifies the length of time that
the adjustment is needed. After the displaced residents leave the
hospital's training program or complete their residency program, the
hospital's cap would be based solely on the statutory base year (with
any applicable adjustments for new medical residency training programs
or affiliated group arrangements).
6. Determining the Weighted Number of FTE Residents
Section 413.86(g)(1)(ii) states that for residency programs in
osteopathy, dentistry, and podiatry, the minimum requirement for
certification in a specialty or subspecialty is the minimum number of
years of formal training necessary to satisfy the requirements of the
appropriate approving body listed in Sec. 415.200(a). This reference is
incorrect. The correct section in which approving bodies for residency
programs are listed is Sec. 415.152. We propose to make this
correction.
Section 413.86(g)(1)(i) specifies that the initial residency period
is the minimum number of years of formal training necessary to satisfy
board eligibility in the particular specialty for which the resident is
training, as specified in the 1985-1986 Directory of Residency Training
Programs. Section 1886(h)(5)(G)(iii) of the Act allows the Secretary to
increase or decrease the initial residency period if the minimum number
of years of formal training specified in a later edition of the
directory is different from the period specified in the 1985-1986
Directory of Residency Training Programs. We are proposing to revise
the regulations text to state that the initial residency period is
determined using the most recently published edition of the Graduate
Medical Education Directory, not the 1985-1986 Directory.
7. Clarification of a Statement in the Preamble of the May 12, 1998
Final Rule Relating to Affiliated Groups
In the May 12, 1998 final rule (63 FR 26341), in the third column
of page 26341, in the sentence prior to section ``O. Payment to Managed
Care Plans for Graduate Medical Education,'' we stated, ``If the
combined FTE counts for the individual hospitals that are members of
the same affiliated group do not exceed the aggregate cap, we will pay
each hospital based on its FTE cap as adjusted per agreements.'' The
phrase ``do not exceed'' should have read ``exceed.'' Thus, the
sentence should have read, ``If the combined FTE counts for individual
hospitals that are members of the same affiliated group exceed the
aggregate cap, we will pay each hospital based on its FTE cap as
adjusted per agreements.'' We regret any confusion that resulted from
this misstatement.
V. Proposed Changes to the Prospective Payment System for Capital-
Related Costs: Special Exceptions Process
Section 1886(g) of the Act requires the Secretary to pay for
hospital capital-related costs ``in accordance with a prospective
payment system established by the Secretary.'' Under the statute, the
Secretary has broad authority in establishing and implementing the
capital prospective payment system. We initially implemented the
capital prospective payment system in an August 30, 1991 final rule (56
FR 43409), in which we established a 10-year transition period to
change the payment methodology for Medicare inpatient capital-related
costs from a reasonable cost-based methodology to a prospective
methodology (based fully on the Federal rate).
Generally, during the transition period, inpatient capital-related
costs will be paid on a per discharge basis, and the amount of payment
depends on the relationship between the hospital-specific rate and the
Federal rate during the hospital's base year. A hospital with
[[Page 24737]]
a base year hospital-specific rate less than the Federal rate will be
paid under the fully prospective payment methodology during the
transition period. This method is based on a dynamic blend percentage
of the hospital's hospital-specific rate and the applicable Federal
rate for each year during the transition period. A hospital with a base
period hospital-specific rate greater than the Federal rate will be
paid under the hold harmless payment methodology during the transition
period. A hospital paid under the hold harmless payment methodology
receives the higher of (1) a blended payment of 85 percent of
reasonable cost for old capital plus an amount for new capital based on
a portion of the Federal rate or (2) a payment based on 100 percent of
the adjusted Federal rate. The amount recognized as old capital is
generally limited to the allowable Medicare capital-related costs that
were in use for patient care as of December 31, 1990. Under limited
circumstances, capital-related costs for assets obligated prior to
December 31, 1990, but put in use for patient care after December 31,
1990 may also be recognized as old capital if certain conditions are
met. These costs are known as obligated capital costs. New capital
costs are generally defined as allowable Medicare capital-related costs
for assets put in use for patient care after December 31, 1990.
Beginning in FY 2001, at the conclusion of the transition period for
the capital prospective payment system, capital payments will be based
solely on the Federal rate for most hospitals.
In the August 30, 1991 final rule, we also established a capital
exceptions policy, which provides for exceptions payments during the
transition period (Sec. 412.348). We also indicated that we would
carefully monitor the impact of the capital prospective payment system
in order to determine whether some type of permanent exceptions process
was necessary and the circumstances under which additional payments
would be made.
In the Conference Report that accompanied the Omnibus Budget
Reconciliation Act (OBRA) of 1993 (Pub. L. 103-66), Congress addressed
obligated capital criteria for hospitals in States with a lengthy
certificate of need (CON) process. The language states, ``The conferees
note that in the proposed rule for fiscal year 1994 changes to the
hospital inpatient prospective payment system that was published in the
Federal Register on May 26, 1993, the Secretary indicated that
insufficient information was available to complete a systematic
evaluation of the obligated capital criteria for hospitals in states
with a lengthy Certificate-of-Need process in time to consider
appropriate changes during the fiscal year 1994 rulemaking process. The
conferees expect the Secretary to complete the assessment in time for
consideration in the fiscal year 1995 rulemaking process and that
appropriate changes in payment policy will be made to address the
problems of hospitals subject to a lengthy Certificate-of-Need review
process or subject to other circumstances which are not fully addressed
in the current rules. In addition, the conferees believe the Secretary
should evaluate whether current policies provide adequate protection to
sole community hospitals and hospitals that serve a disproportionate
share of low income patients.'' (H.R. Conf. Rep. No. 103-66, at 744
(1993)).
In the May 27, 1994 proposed hospital inpatient prospective payment
rule (59 FR 27744), we described our analysis of provisions related to
obligated capital for hospitals subject to lengthy CON processes and
proposed a change to the deadline for putting an asset into use for
patient care (Sec. 412.302(c)(2)(i)(D)). We proposed changing the
deadline from ``the earlier of'' September 30, 1996, or 4 years from
the date of CON approval to ``the later of'' September 30, 1996, or 4
years from the date of CON approval.
In addition, in the May 27, 1994 proposed rule, we noted that the
same hospitals that had asked for changes in the obligated capital
provisions had also recommended changes to the capital exceptions
policy, which would provide exceptions payments after the conclusion of
the capital prospective payment transition period. These hospitals had
asked that the minimum payment level for urban hospitals with at least
100 beds and a DSH percentage of at least 20.2 percent be guaranteed
through the rest of the transition and extended for at least 10 years
after the transition. We noted that we had tried to address the
concerns of these hospitals in developing the proposed special
exceptions process that was discussed in the same proposed rule.
In the September 1, 1994 final rule (59 FR 45376), we adopted the
proposed change to the deadline for putting an asset into use in the
obligated capital regulations (Sec. 412.348). We also implemented the
capital special exceptions process and adopted qualifying criteria for
the classes of eligible hospitals. The classes of eligible hospitals
include urban hospitals with a DSH percentage of 20.2 percent and at
least 100 beds and sole community hospitals.
Under the special exceptions provision at Sec. 412.348(g), an
additional payment may be made for up to 10 years beyond the end of the
capital prospective payment system transition period for eligible
hospitals that meet (1) a project need requirement, (2) a project size
requirement, and (3) in the case of certain urban hospitals, an excess
capacity test. In the September 1, 1994 final rule, we described the
special exceptions process as ``* * * narrowly defined, focusing on a
small group of hospitals who found themselves in a disadvantaged
position. The target hospitals were those who had an immediate and
imperative need to begin major renovations or replacements just after
the beginning of the capital prospective payment system. These
hospitals would not be eligible for protection under the old capital
and obligated capital provisions, and would not have been allowed any
time to accrue excess capital prospective payments to fund these
projects.'' (59 FR 45385)
In addition to sole community hospitals and urban hospitals with at
least 100 beds that have a DSH percentage of at least 20.2 percent,
hospitals eligible for special exceptions include urban hospitals with
at least 100 beds that receive at least 30 percent of their revenue
from State or local funds for indigent care, and hospitals with a
combined inpatient Medicare and Medicaid utilization of at least 70
percent.
To qualify for a special exceptions payment, a hospital must
satisfy a project need requirement as described at Sec. 412.348(g)(2)
and a project size requirement as described at Sec. 412.348(g)(5). For
hospitals in States with CON requirements, the project need requirement
is satisfied by obtaining a CON approval. For other hospitals, the
project need requirement is satisfied by meeting an age of assets test.
The project size requirement is satisfied if the hospital completes the
qualifying project between the period beginning on or after its first
cost reporting period beginning on or after October 1, 1991, and the
end of its last cost reporting period beginning before October 1, 2001,
and the project costs are (1) at least $200 million or (2) at least 100
percent of the hospital's operating cost during the first 12-month cost
reporting period beginning on or after October 1, 1991. The minimum
payment level under special exceptions for all qualifying hospitals is
70 percent of allowable capital-related costs. Special exception
payments are offset against positive Medicare capital and operating
margins.
[[Page 24738]]
When we established the special exceptions process, we selected the
hospital's cost reporting period beginning before October 1, 2001, as
the project completion date in order to limit cost-based exceptions
payments to a period of not more than 10 years beyond the end of the
transition to the fully Federal capital prospective payment system.
Because hospitals are eligible to receive special exceptions payments
for up to 10 years from the year in which they complete their project
(but for not more than 10 years after September 30, 2001, the end of
the capital prospective payment transition), if a project is completed
by September 30, 2001, exceptions payments could continue up to
September 30, 2011. In addition, we believed that for projects
completed after the September 30, 2001, hospitals would have had the
opportunity to reserve their prior years' capital prospective payment
system payments for financing projects.
In the July 31, 1998 final rule (63 FR 40999), we stated that a few
hospitals had expressed concern with the required completion date of
October 1, 2001, and other qualifying criteria for the special
exceptions payment. Therefore, we solicited certain information from
hospitals on major capital construction projects that might qualify for
the capital special exceptions payments so we could determine if any
changes in the special exceptions criteria or process were necessary.
Four hospitals responded timely with information on their major
capital construction projects. The hospitals submitted information
about their location, the cost of the project, the date that the
certificate of need approval was received, the start date of the
project, and the anticipated completion date.
Some hospitals suggested that we change the existing project
completion date criterion, that is, the criterion that the qualifying
projects must be completed between the hospital's first cost reporting
period beginning on or after October 1, 1991, and the end of its last
cost reporting period beginning before October 1, 2001. They proposed
that, as an alternative, a hospital be eligible for the special
exceptions payment if the hospital had received its CON approval for
the qualifying project by September 1, 1995, and had spent $750,000 or
10 percent of total project cost by that date, and that the project
completion date be changed to December 31, 2005 (which would be well
beyond the 10 years we have established for the capital prospective
payment system transition). However, other hospitals recommended that
we not institute a date by which a hospital must have received its CON
approval.
In addition, some hospitals have suggested other ways in which the
special exceptions process could be revised. Some of these hospitals
expressed concern about the project size requirement and stated that
small community-based institutions were unlikely to be able to support
debt in the range of $200 million.
We understand that a few hospitals may not meet the DSH percentage
requirement of at least 20.2 percent. Some of these hospitals suggested
lowering the qualifying percentage to 15 percent. They also suggested
changing the payment level for special exceptions from 70 percent to 85
percent and changing the requirement at Sec. 412.348(g)(8)(ii)(B) that
special exception payments be offset against positive Medicare
operating and capital margins. They suggested limiting the offset
provision to capital margins. In addition, some of these hospitals
suggested capping special exceptions payments that result from changes
to the current special exceptions process at $40 million annually.
While we have no specific proposal at this time to revise the
special exceptions process, we specifically invite comments from
hospitals and other interested parties on the suggestions and
recommendations discussed above. We note that, since the capital
special exceptions process is budget neutral, any liberalization of the
policy would require a commensurate reduction in the capital rate paid
to all hospitals. Even after the end of the capital prospective payment
system transition, we will continue to make an adjustment to the
capital Federal rate in a budget neutral manner to pay for exceptions,
as long as an exceptions policy is in force. Currently, the limited
special exceptions policy will allow for exceptions payments through
September 30, 2011.
We have little information about the impact of any of the
recommended changes, since no hospitals are currently being paid under
the special exceptions process. Until FY 2001, the special exceptions
provision pays either the same as the regular exceptions process or
less for high DSH and sole community hospitals. We will attempt to
obtain information on projects that may qualify for special exceptions
payments through our fiscal intermediaries during the comment period.
However, we are reluctant to place a significant data gathering burden
on fiscal intermediaries at this time because of their current workload
resulting from the major efforts to make the Medicare computer systems
compliant on January 1, 2000. Based on comments that we receive from
hospitals and any data received from the fiscal intermediaries, we may
address changes to the special exceptions criteria in the final rule,
or we may propose changes in the criteria in the FY 2001 hospital
inpatient prospective payment system proposed rule.
VI. Proposed Changes for Hospitals and Hospital Units Excluded From
the Prospective Payment System
A. Limits on and Adjustments to the Target Amounts for Excluded
Hospitals and Units (Secs. 413.40(b)(4) and (g))
1. Updated Caps
Section 1886(b)(3) of the Act (as amended by section 4414 of the
BBA) establishes caps on the target amounts for certain excluded
hospitals and units for cost reporting periods beginning on or after
October 1, 1997 through September 30, 2002. The caps on the target
amounts apply to the following three categories of excluded hospitals:
psychiatric hospitals and units, rehabilitation hospitals and units,
and long-term care hospitals.
A discussion of how the caps on the target amounts were calculated
can be found in the August 29, 1997 final rule with comment period (62
FR 46018); the May 12, 1998 final rule (63 FR 26344); and the July 31,
1998 final rule (64 FR 41000). For purposes of calculating the caps,
the statute requires us to calculate the 75th percentile of the target
amounts for each class of hospital (psychiatric, rehabilitation, or
long-term care) for cost reporting periods ending during FY 1996. The
resulting amounts are updated by the market basket percentage to the
applicable fiscal year.
The current estimate of the market basket increase for excluded
hospitals and units for FY 2000 is 2.6 percent. Accordingly, the
proposed caps on target amounts for cost reporting periods beginning in
FY 2000 are as follows:
Psychiatric hospitals and units: $11,067
Rehabilitation hospitals and units: $20,071
Long-term care hospitals: $39,596
2. New Excluded Hospitals and Units (Sec. 413.40(f))
a. Updated Caps for New Hospitals and Units. Section 1886(b)(7) of
the Act establishes a payment methodology for new psychiatric hospitals
and units, rehabilitation hospitals and units, and long-term care
hospitals. Under the statutory methodology, for a hospital that is
within a class of hospitals specified in the statute and that first
[[Page 24739]]
receives payments as a hospital or unit excluded from the prospective
payment system on or after October 1, 1997, the amount of payment will
be determined as follows. For the first two 12-month cost reporting
periods, the amount of payment is the lesser of (1) the operating costs
per case, or (2) 110 percent of the national median of target amounts
for the same class of hospitals for cost reporting periods ending
during FY 1996, updated to the first cost reporting period in which the
hospital receives payments and adjusted for differences in area wage
levels.
The proposed amounts included in the following table reflect the
updated 110 percent of the wage neutral national median target amounts
for each class of excluded hospitals and units for cost reporting
periods beginning during FY 2000. These figures are updates to the
final FY 1999 figures by the estimated market basket increase of 2.6
percent. For a new provider, the labor-related share of the target
amount is multiplied by the appropriate geographic area wage index and
added to the nonlabor-related share in order to determine the per case
limit on payment under the statutory payment methodology for new
providers.
------------------------------------------------------------------------
Labor- Nonlabor-
Class of excluded hospital or unit related related
share share
------------------------------------------------------------------------
Psychiatric....................................... $6,376 $2,536
Rehabilitation.................................... 12,537 4,984
Long-Term Care.................................... 16,158 6,424
------------------------------------------------------------------------
b. Multicampus Excluded Hospitals. Section 1886(b) of the Act, as
amended by the BBA, provides for caps on target amounts for certain
classes of excluded hospitals, and also provides a statutory payment
methodology for new excluded hospitals. A question has arisen regarding
the appropriate target amount to be used for an excluded hospital or
unit that was part of a multicampus hospital but alters its
organizational structure so that it is no longer part of that
multicampus hospital. The question was raised by long-term care
hospitals that are seeking alternate structures due to the application
of the cap on hospital-specific target amounts specified in
Sec. 413.40(c)(4)(iii).
In these cases, to determine the appropriate target amount, we must
determine whether the excluded hospital or unit established under the
organizational restructure is a new provider. Under Sec. 413.40(f)(1),
a new excluded hospital or unit is a provider of hospital inpatient
services that (1) has operated as the type of hospital or unit for
which HCFA granted it approval to participate in the Medicare program,
under present or previous ownership (or both), for less than 1 full
year; and (2) has provided the type of hospital inpatient services for
which HCFA granted it approval to participate for less than 2 full
years. For a new children's hospital, a 2-year exemption from the
application of the target amount is permitted (Sec. 413.40(f)(2)(i)).
For the first two 12-month cost reporting periods, a new psychiatric or
rehabilitation hospital or unit or a long-term care hospital receives
the lower of its new inpatient operating cost per case or 110 percent
of a national median of target amounts for the class of hospital,
updated and adjusted for area wages (Sec. 413.40(f)(2)(ii)).
If the entity that separated itself from the multicampus hospital
provides inpatient services of a different type than it had when it was
part of the multicampus hospital so that it qualifies as a different
class of excluded hospital or unit (for example, from long-term care to
rehabilitation), we would calculate a new target amount per discharge
for the newly created hospital or unit. However, if the entity does not
operate as a different class of hospital or unit, it does not meet the
criteria at Sec. 413.40(f)(1) to qualify as a new provider. Instead, if
the entity replaces a hospital or unit that had been excluded from the
prospective payment system (for example, the entity had previously been
a long-term care hospital before becoming part of the multicampus
hospital), the previously established hospital-specific target amount
for the hospital prior to becoming part of the multicampus hospital
would again be applicable. This is consistent with our current policy
for a hospital or unit excluded from the prospective payment system
that has periods in which the hospital or unit is not subject to the
target amount, as specified at Sec. 413.40(b)(1)(i). The target amount
established earlier for the hospital or unit is again applicable
despite intervening cost reporting periods during which the hospital or
unit was not subject to that target amount due to other provisions of
the law or regulations that applied while it was part of the
multicampus hospital. In contrast, we propose to revise
Sec. 413.40(b)(1)(iii) to specify that if the entity continues to
operate as the same class of hospital that is excluded from the
prospective payment system, but does not replace a provider that
existed prior to being part of a multicampus hospital (for example, a
newly created long-term care hospital became part of a multicampus
hospital and subsequently separates from the multicampus hospital to
operate separately), the base period for calculating a hospital-
specific target amount for the newly separated hospital is the first
cost reporting period of at least 12 months effective with the revised
Medicare certification.
3. Exceptions
The August 29, 1997 final rule with comment period (62 FR 46018)
specified that a hospital that has a hospital-specific target amount
that is capped at the 75th percentile of target amounts for hospitals
in the same class (psychiatric, rehabilitation, or long-term care)
would not be granted an adjustment payment (also referred to as an
exception payment) based solely on a comparison of its costs or patient
mix in its base year to its costs or patient mix in the payment year.
Since the hospital's target amount would not be determined based on its
own experience in a base year, any comparison of costs or patient mix
in its base year to costs or patient mix in the payment year would be
irrelevant.
In addition, the July 31, 1998 final rule (63 FR 41001) revised
Sec. 413.40(g)(1) to specify, under paragraph (g)(1)(iv), that in the
case of a psychiatric hospital or unit, rehabilitation hospital or
unit, or long-term care hospital, the amount of the adjustment payment
may not exceed the applicable limit amounts for hospitals of the same
class.
Similarly, for hospitals and units with a FY 1998 hospital-specific
revised target amount established under the rebasing provision at
Sec. 413.40(b)(1)(iv), in determining whether the hospital qualifies
for an adjustment and the amount of the adjustment, we compare the
hospital's operating costs to the average costs and statistics for the
cost reporting periods used to determine the FY 1998 revised target
amount. Since the rebased FY 1998 target amount is an average of three
cost reporting periods, as described in Sec. 413.40(b)(1)(iv),
comparisons of costs from the cost year to the FY 1998 cost period
would be inaccurate. Therefore, as specified in the August 29, 1997
final rule with comment period (62 FR 46018), a determination of
whether the hospital qualifies for an adjustment and the amount of an
adjustment is based on a comparison of the hospital's operating costs
and its costs used to calculate the FY 1998 rebased target amount.
The conditions that must be met to qualify for an adjustment remain
unchanged, as specified in Chapter 30 of the Provider Reimbursement
Manual. Making comparisons between the base year and the cost year
requires that each particular inpatient service be
[[Page 24740]]
compared. For example, to determine whether the hospital qualifies for
an adjustment and the amount of an adjustment for increased routine
services or an increase in a particular ancillary service, we compare
the costs incurred by the hospital in the cost year to the hospital's
routine services or ancillary services in the base year. Therefore, for
hospitals that have been rebased under the provisions of
Sec. 413.40(b)(1)(iv) and qualify for an adjustment under the
provisions of Sec. 413.40(g), the base year figures used for costs,
utilization, length-of-stay, etc., are determined based on the average
of the costs and utilization statistics from the same 3 cost reporting
years used in calculating the FY 1998 rebased target amount. While we
recognize that additional calculations are necessary to prepare an
adjustment payment request in this manner, we believe it is the most
equitable means of determining an adjustment payment. We also point out
that the averaging calculation for the various cost centers and
utilization statistics must only be performed the first year a provider
requests an adjustment after FY 1998, and thereafter those averaged
calculations may be utilized for subsequent years' adjustment requests.
Therefore, once these averages are calculated, the same values will
be used for determining the amount of any subsequent year adjustments.
We propose to revise Sec. 413.40(g)(1) to clarify these limitations
on the adjustment payments.
4. Development of Case-Mix Adjusted Prospective Payment System for
Rehabilitation Hospitals and Units
Section 4421 of the BBA added a new section 1886(j) to the Act
which mandates the phase-in of a case-mix adjusted prospective payment
system for inpatient rehabilitation services (freestanding hospitals
and units) for cost reporting periods beginning on or after October 1,
2000 and before October 1, 2002. The prospective payment system will be
fully implemented for cost reporting periods beginning on or after
October 1, 2002.
As provided in section 1886(j)(3)(A) of the Act, the prospective
payment rates will be based on the inpatient operating and capital
costs of rehabilitation facilities. Payments will be adjusted for case-
mix using patient classification groups, area wages, inflation, and
outlier and any other factors the Secretary determines necessary. We
will set prospective payment amounts so that total payments under the
system during FY 2001 and FY 2002 are projected to equal 98 percent of
the amount of payments that would have been made under the current
payment system. Outlier payments in a fiscal year may not be projected
or estimated to exceed 5 percent of the total payments based on the
rates for that fiscal year.
B. Changes in Bed Size or Status of Hospital Units Excluded Under the
Prospective Payment System
Existing regulations (Secs. 412.25(b) and (c)) specify that, for
purposes of payment to a psychiatric or rehabilitation unit that is
excluded from the prospective payment system, changes in the bed size
or the status of excluded hospital units will be recognized only at the
beginning of a cost reporting period. These regulations have been in
effect since the inception of the inpatient hospital prospective
payment system and were intended to simplify administration of the
exclusion provisions of the prospective payment systems by establishing
clear rules for the timing of changes in these excluded units.
Recently, a number of hospitals have suggested that we consider a
change in our policy to recognize, for purposes of exclusion from the
prospective payment system, reductions in number of beds in, or entire
closure of, units at any time during a cost reporting period. They
indicated that the bed capacity made available as a result of these
changes could be used, as they need them, to provide additional
services to meet patient needs in the acute care part of the hospital
that is paid under the prospective payment system.
We have evaluated the concerns of the hospitals and the effect on
the administration of the Medicare program and the health care of
beneficiaries of making these payment changes. As a result of this
evaluation, we believe it is reasonable to adopt a more flexible policy
on recognition of hospitals' changes in the use of their facilities.
However, we note that whenever a hospital establishes an excluded unit
within the hospital, our Medicare fiscal intermediary must be able to
determine costs of the unit separately from costs of the part of the
hospital paid under the prospective payment system. The proper
determination of costs ensures that the hospital is paid the correct
amount for services in each part of the facility, and that payments
under the prospective payment system do not duplicate payments made
under the rules applicable to excluded hospitals and units, or vice
versa. For this reason, we do not believe it would be appropriate to
recognize, for purposes of exclusion from the prospective payment
system, changes in the bed size or status of an excluded unit that are
so frequent that they interfere with the ability of the intermediary to
accurately determine costs.
Moreover, section 1886(d)(1)(B) of the Act authorizes exclusion
from the prospective payment system of specific types of hospitals and
units, but not of specific admissions or stays, such as admissions for
rehabilitation or psychiatric care, in a hospital paid under the
prospective payment system. Without limits on the frequency of changes
in excluded units for purposes of proper Medicare payment, there is the
potential for some hospitals to adjust the status or size of their
excluded units so frequently that the units would no longer be distinct
entities and the exclusion would effectively apply only to certain
types of care.
To provide more flexibility to hospitals while not recognizing
changes that undermine statutory requirements and principles, we
propose to revise Secs. 412.25(b) and (c) to provide that, for purposes
of exclusion from the prospective payment system, the number of beds
and square footage of an excluded unit may be decreased, or an excluded
unit may be closed in its entirety, at any time during a cost reporting
period under certain conditions. The hospital would be required to give
the fiscal intermediary and the HCFA Regional Office a 30-day advance
written notice of the intended change and to maintain all information
needed to accurately determine costs attributable to the excluded unit
and proper payments. However, any unit that is closed during a cost
reporting period could not be paid again as a unit excluded from the
prospective payment system until the start of the next cost reporting
period. If the number of beds or square footage of a unit excluded from
the prospective payment system is decreased during a cost reporting
period, that decrease would remain in effect for the remainder of that
period.
We note that the number of beds and square footage of the part of
the hospital paid under the prospective payment system may also be
affected by a change in the size or status of a unit that is excluded
from the prospective payment system. If the bed capacity and square
footage were previously part of the excluded unit and are then included
in the part of the hospital paid under the prospective payment system
and are used to treat acute patients rather than excluded unit
patients, the additional bed capacity and square footage would,
starting with the effective date of the change, be counted as part of
the
[[Page 24741]]
hospital paid under the prospective payment system. We would count the
bed capacity and square footage for purposes of calculating available
bed-days and the number of beds under Secs. 412.105 and 412.106,
relating to payments for the indirect costs of GME and service to a
disproportionate share of low-income patients. On the other hand, if
the bed capacity and square footage are taken out of service or added
to another Medicare provider, such as a distinct-part SNF, they would
not be counted as part of the hospital paid under the prospective
payment system.
C. Payment for Services Furnished at Satellite Hospital Locations
Under Medicare, each hospital is treated, for purposes of
certification, coverage, and payment, as a single institution. That is,
each entity that is approved to participate in Medicare as a
``hospital'' must separately comply with applicable health and safety
requirements as a condition of participation under regulations at Part
482, with provider agreement requirements specified in regulations at
Part 489, and with requirements relating to the scope of benefits under
Medicare Part A and B specified in parts 409 and 410. Our policies that
involve the movement of patients from one hospital to another, or from
outpatient to inpatient status at a same hospital, are premised on the
assumption that each hospital is organized and operated as a separate
institution.
Section 412.22(e) of the regulations permits an entity that is
located in the same building or in separate buildings on the same
campus as another hospital to be treated, for purposes of exclusion
under the prospective payment systems, as a ``hospital within a
hospital.'' This status is available, however, only when the entity
meets specific, stringent criteria designed to ensure that the
hospital-within-a-hospital is organized as a separate entity and
operates as a separate entity.
Recently, we have received several requests for approval of
``satellite'' arrangements, under which an existing hospital that is
excluded under the prospective payment system, and that is either a
freestanding hospital or a hospital-within-a-hospital under
Sec. 412.22(e), wishes to lease space in a building or on a campus
occupied by another hospital, and, in some cases, to have most or all
services to patients furnished by the other hospital under contractual
agreements, including arrangements permitted under section 1861(w)(1)
of the Act. In most cases, a hospital intends to have several of these
satellite locations so that the hospital would not exist at any single
location, but only as an aggregation of beds located at several sites.
Generally, the excluded hospital seeks to have the satellite facility
treated as if the satellite facility were ``part of'' the excluded
hospital.
The fundamental problem with satellite arrangements is that the
satellite facility might be ``part of'' the excluded hospital only on a
nominal basis (that is, only on paper). The satellite facility might
not operate as part of the excluded hospital, but instead might
effectively be a ``part of'' the hospital within which it is located,
or might effectively be its own separate entity. From a payment
perspective, if the satellite facility is effectively not part of the
excluded hospital, then Medicare would make inappropriately high
payments if Medicare treats the satellite facility as part of the
excluded hospital.
Perhaps most significantly, if Medicare treated the satellite
facility as part of the excluded hospital, the services in the
satellite facility might inappropriately be paid by Medicare on the
basis of reasonable costs (subject to limits) when they should be paid
on the basis of prospective payment. If the satellite facility operates
as ``part of'' the prospective payment system hospital in which it is
located, and not as part of the excluded hospital with which it is
affiliated, then the considerations underlying exclusion from the
prospective payment system do not apply to the services furnished in
satellite facilities. Thus, if the satellite facility is effectively
part of the prospective payment system hospital, then the services
should be paid under the prospective payment system.
Satellite arrangements can lead to inappropriate Medicare payments
in a number of ways. For example, an excluded long-term care hospital
might set up a satellite facility within an acute care hospital paid
under the prospective payment system. Such a configuration could make
it relatively easy for the prospective payment hospital to discharge a
patient prematurely to the excluded long-term care hospital satellite
location that is in its building or on its campus. The result could be
inappropriate duplication of payment, in that the prospective payment
system hospital would receive full payment under the DRG system even if
it did not complete the acute treatment of the patient, and the
hospital excluded under the prospective payment systems would receive
payment for some services that should have been furnished in the
prospective payment system hospital and paid under the prospective
payment system. While the discharge and transfer regulations at
Sec. 412.4 provide disincentives to these inappropriate transfers in
some 10 DRGs, there are many other cases not assigned to these DRGs in
which such transfers could occur.
Another potential abuse related to duplication of Medicare payment
could occur with respect to the preadmission payment window provisions
of section 1886(a)(4) of the Act (implemented under regulations at
Secs. 412.2(c)(5) and 413.40(c)(2)). Under the regulations, services
provided by the hospital or by an entity wholly owned or operated by
the hospital within the 3 calendar days before admission to a
prospective payment system hospital, or within 1 calendar day before
admission to a hospital excluded from the prospective payment system,
are treated for payment purposes as if they had been furnished during
the inpatient stay. For prospective payment system hospitals, the
provision is designed to prevent services historically furnished by
hospitals during the early parts of inpatient stays from being
``unbundled'' and furnished just prior to admission and billed on an
outpatient basis. If this situation were to occur, the result would be
that outpatient payment under Medicare Part B would be made for
services for which Part A payment is provided under the prospective
payment system, that is, duplication of payments for outpatient and
inpatient services. For hospitals excluded from the prospective payment
system, the payment window provision is intended to minimize
beneficiary liability for Part B deductible and coinsurance amounts
while encouraging use of outpatient facilities rather than inpatient
facilities when appropriate.
If excluded hospitals were able to set up satellite facilities
within hospitals paid under the prospective payment system and obtain
exclusion from the prospective payment system for the satellite
facilities, the two hospitals could easily circumvent the preadmission
payment window requirements by setting up outpatient departments of
both hospitals at each site where both have inpatient facilities, and
scheduling patients who are to be admitted to one hospital to receive
preadmission care at the outpatient department of the other hospital.
Thus, exclusion of satellite facilities could result in payments that
are inconsistent with the purpose of the payment window. (We note that
this abuse could also occur, at least theoretically, if the satellite
facilities were not excluded from the prospective payment system.
However, allowing exclusion from the
[[Page 24742]]
prospective payment system of satellites increases the likelihood that
such arrangements will actually be set up.)
There also is a potential for satellite facilities to be used as a
means to avoid the effects of section 4416 of the BBA, which is
implemented in regulations at Sec. 413.40(f)(2)(ii). This section
limits the target amounts for psychiatric and rehabilitation hospitals
and units and long-term care hospitals that are first paid as hospitals
excluded from the prospective payment system on or after October 1,
1997, to 110 percent of the national median of the target amounts of
similarly classified hospitals. This limitation applies to the
hospital's first two 12-month cost reporting periods. Section
413.40(c)(4)(iii), which implements provisions of section 4414 of the
BBA, sets the 75th percentile of the target amounts of similarly
classified hospitals as a limit on costs for psychiatric and
rehabilitation hospitals and units and long-term care hospitals
excluded from the prospective payment system before October 1, 1997. If
we permitted exclusion of satellite facilities, a hospital chain could
set up new locations and avoid the limits applicable to new providers
by characterizing the new locations as satellites of existing
hospitals. This result would effectively nullify the anticipated
budgetary savings of section 4416 of the BBA in such situations.
While many hospitals furnish care to cancer patients, exclusion
from the prospective payment system as a cancer hospital is not
available to a facility unless it was classified as such on or before
December 31, 1991 (section 1886(d)(10)(B)(v) of the act and regulations
at Sec. 412.23(f)). The statute effectively prohibits recognition of
newly established hospitals as cancer hospitals. If we were to permit
satellite locations of excluded hospitals to be set up within
prospective payment system hospitals and to be excluded from the
prospective payment system, existing cancer hospitals might set up
satellite locations in prospective payment hospitals, thus avoiding the
prohibition on new cancer hospitals. This practice would be
inconsistent with section 1886(d)(10)(B)(v) and its implementing
regulations. It also could potentially allow a hospital under the
prospective payment system to admit or transfer all high-cost cancer
patients to the ``cancer hospital satellite'' while making a profit on
the low-cost cancer patients remaining at the prospective payment
system hospital.
Finally, we note that rehabilitation units that are excluded from
the prospective payment system are required to have a medical director
of rehabilitation who furnishes services to the unit or its patients at
least 20 hours per week (Sec. 412.29(f)(1)). However, this requirement
presumably would not apply if the facility is described not as a unit
of the hospital in which it is based, but as a satellite of an existing
rehabilitation hospital, since that hospital would already have its
medical director. The existence of a high level of physician oversight
of rehabilitation is a key identifier of the kind of unit that provides
inpatient hospital-level rehabilitation care as its primary activity,
not merely as an adjunct or extension of acute care. We believe
allowing satellites of rehabilitation hospitals to be set up in
prospective payment system hospitals and excluded from the prospective
payment system would undermine the requirement for that level of
physician oversight, and limit our ability to exclude only those units
providing the appropriate level of rehabilitation services.
We believe that a number of excluded hospitals are seeking
satellite arrangements so that the services furnished in the satellite
facility are inappropriately paid on an excluded basis when they should
be paid on a prospective basis. We also believe that a number of
excluded hospitals are seeking satellite arrangements in order to avoid
the effect of the payment caps that apply to new hospitals and would
apply to the satellite facility if the satellite facility received
separate certification. And, as discussed above, satellite arrangements
can lead to other problems. To prevent inappropriate Medicare payment
for services furnished in satellite facilities, we propose to revise
Secs. 412.22 and 412.25 to provide for payment to satellite facilities
of hospitals and units that are excluded from the prospective payment
system under specific rules. With respect to both hospitals and units,
we would define ``satellite facility'' as a part of a hospital that
provides inpatient services in a building also used by another
hospital, or in one or more buildings on the same campus as buildings
also used by another hospital, but is not a ``hospital-within-a-
hospital,'' since it is also part of another hospital. If the satellite
facility is located in a hospital that is paid under the prospective
payment system, Medicare would pay for services furnished at the
satellite facility by using the same rates that apply to the
prospective payment hospital within which the satellite is located. As
explained earlier, we believe that, if the satellite facility is
effectively ``part of'' the prospective payment system hospital, then
it should be paid under the prospective payment system.
If the satellite facility is located in a hospital excluded from
the prospective payment system, then Medicare would pay for the
services furnished in the satellite facility as follows: we would
examine the discharges of the satellite facility and we would apply the
target amount for the excluded hospital in which the hospital is
located, subject to the applicable cap for the hospital of which the
satellite is a part. Also, when the satellite facility is established,
we would treat the satellite facility as a new hospital for payment
purposes. That is, for the satellite's first two 12-month cost
reporting periods, the satellite would be subject to the cap that
applies to new hospitals of the same class as the hospital of which the
satellite is a part. We believe that application of the cap for new
hospitals is appropriate because we believe that a number of hospitals
are attempting to avoid the new hospital caps by characterizing
entities as satellites rather than new hospitals.
Under our proposal, satellite facilities excluded from the
prospective payment system prior to the effective date of the revised
regulations (October 1, 1999) would not be subject to those new
regulations as long as they operate under the same terms and conditions
in effect on September 30, 1999. We would make this exception available
only to those facilities that can document to the HCFA regional offices
that they are operating as satellite facilities excluded from the
prospective payment system as of that date, not to facilities that
might be excluded from the prospective payment system as of that date
and at some later time enter into satellite arrangements. The proposed
rules for payments to satellite facilities would not apply to
multicampus arrangements, that is, those in which a hospital has
several locations but does not share a building or a campus with any
other hospital at any location.
We also solicit comment on a possible further exception. In section
4417 of the BBA, Congress extended the long-term care hospital
exclusion to a hospital ``that first received payment under this
subsection [subsection 1886(d)(1)(B)(iv) of the Act] in 1986 which has
an average inpatient length of stay (as determined by the Secretary) of
greater than 20 days and that has 80 percent or more of its annual
Medicare inpatient discharges with a principal diagnosis of neoplastic
disease in the 12-month cost reporting period ending in fiscal year
1997.'' In view of the specific provision made for a hospital meeting
these requirements, we are considering whether a satellite facility
opened by such a hospital
[[Page 24743]]
should be exempt from the proposed rules on satellites on this
preamble. We welcome comment on this issue and on whether such an
exclusion could be implemented without compromising the effectiveness
of the proposed changes.
We recognize that there may be some operational difficulties
differentiating services, costs, and discharges of the satellite
facilities from those of the existing hospital that is excluded from
the prospective payment system. If these operational problems cannot be
overcome, we might, in the final rule, revise Secs. 412.22 and 412.25
to prohibit exclusion of any hospital or hospital unit from the
prospective payment system that is structured, entirely or in part, as
a satellite facility in a hospital paid under the prospective payment
system. The effect of this change would be that all Medicare payments
to such a hospital or hospital unit with a satellite facility would be
made under the prospective payment system.
Before deciding to propose these changes, we considered whether the
hospital-within-a-hospital rules in Sec. 412.22(e) provide adequate
protection against abuses of the prospective payment system exclusion
by satellite facilities. For the reasons described below, we concluded
that they do not.
The current hospital-within-a-hospital criteria were issued through
proposed rules published in the Federal Register on May 27, 1994 (59 FR
27708) and final rules published on September 1, 1994 (59 FR 45330). In
those documents, we explained that the DRG system is based on an
averaging concept that provides appropriate payment for the type and
mix of cases treated by acute care hospitals, but that the averaging
concept underlying the DRG system does not apply to long-stay
hospitals, which have few short-stay or low-cost cases and might be
systematically underpaid if the prospective payment system were applied
to them. We explained that it would not be appropriate to make
prospective payment system exclusion available to long-stay units of
acute hospitals, since those units account for only part of the
hospital's patient load and the principles underlying the prospective
payment system do apply to the larger hospital. We also stated that the
hospital-within-a-hospital criteria, now codified at Sec. 412.22(e),
ensure that facilities structured as hospitals-within-hospitals are
sufficiently separate from the host hospitals to warrant exclusion from
the prospective payment system as separate hospitals.
The considerations that make it inappropriate to exclude long-stay
units of general hospitals from the prospective payment system also
make it inappropriate, in our view, to allow exclusion from prospective
payment system of facilities that treat only a part of the patient load
of the larger prospective payment system hospitals in which they are
located, but are presented as satellites of another facility. In
responding to a comment in the September 1, 1994 final rule, we stated
that we believe that the hospital-within-a-hospital criteria should
have application in all cases involving joint occupancy of a building
or campus by an applicant long-term hospital and another hospital (59
FR 45330). After further review of the issue, however, we have now
concluded that while the hospital-within-a-hospital criteria are
designed to prevent potential abuses similar to those posed by
satellites, the criteria themselves cannot be effectively applied to
satellite arrangements. This is because the criteria are designed to
apply to hospitals that exist only in one location. For example, under
Sec. 412.22(e)(5)(ii), one criterion for showing separate operation of
a hospital-within-a-hospital is that the hospital's costs of services
obtained under contracts or other arrangements from the host hospital
(or from a controlling third entity) be no more than 15 percent of the
hospital's total inpatient operating cost. Because a satellite facility
would integrate its costs with those of the hospital with which it is
affiliated, it is possible that the entire hospital could meet this
test even though all costs of the satellite facility were incurred
under contracts or arrangements. Likewise, the criterion regarding the
source of inpatient referrals (Sec. 412.22(e)(5)(iii)) could be met by
an entire hospital, even though most or all patients treated at a
satellite facility were referred from the hospital in which the
satellite is located. Thus, existing hospital-within-a-hospital
criteria are not adequate to deal with satellite issues.
D. Responsibility for Care of Patients in Hospitals Within Hospitals
Normally, hospitals that admit patients, including hospitals
subject to the prospective payment system and ``hospitals-within-
hospitals'' that are excluded from the prospective payment system,
accept overall responsibility for the patients' care and furnish all
services they require. In accordance with section 1886(d)(5)(I) of the
Act and implementing regulations at Sec. 412.4, for payment purposes,
the prospective payment system distinguishes between ``discharges''
(situations in which a patient leaves an acute care hospital paid under
the prospective payment system after receiving complete acute care
treatment) and ``transfers'' (situations in which acute care treatment
is not completed at the first hospital and the patient is transferred
to another acute care hospital for continued, related care). The
payment rules at Sec. 413.30, which apply to hospitals excluded from
the prospective payment system, also are premised on the assumption
that discharges occur only when the excluded hospital's care of the
patient is complete.
It has come to our attention that, given the co-location of
prospective payment system facilities and facilities excluded from the
prospective payment system in a hospital-within-a-hospital, and the
absence of clinical constraints on the movement of patients, there may
be situations where, in such settings, patients appear to have been
moved from one facility to another for financial rather than clinical
reasons. The excluded hospital-within-a-hospital might have incentives
to inappropriately discharge patients early (to the prospective payment
system hospital within which it is located) in order to minimize its
overall costs and in turn to minimize its cost per discharge. If the
excluded hospital-within-a-hospital inappropriately discharges patients
to the prospective payment system hospital without providing a complete
episode of the type of care furnished by the excluded hospital, then
Medicare would make inappropriate payments to the hospital-within-a-
hospital. This is the case because payments made to an excluded
hospital are made on a per-stay basis, up to the hospital's per
discharge target amount, and any artificial decrease in the hospital's
cost per stay could lead to the hospital inappropriately avoiding its
target amount cap mandated by section 4414 of the BBA and receiving
inappropriate bonus and relief payments under section 4415 of the BBA.
For example, if a long-term care hospital has an average length of
stay of 30 days and incurs a cost per patient-day of $1,500, its
average cost per stay is $45,000 ($1,500 x 30). If that hospital
discharged 20 percent of its patients to a prospective payment system
hospital before the 30th day of their stay at the long-term care
hospital, the patients might still stay, on average, a total of 30 days
at the two hospitals. However, by transferring an increased number of
patients early during the period, the long-term care hospital would be
able to reduce its cost per discharge.
If the hospital's cap on its target amount is $38,593 and the
hospital's cost per discharge is $45,000, then the hospital's payments
would be based on
[[Page 24744]]
a target amount of $38,593. If, as a result of the inappropriate
discharges, the cost per stay is $37,500, Medicare payment to the
hospital would be based on a target amount of $37,500, plus an
additional amount under the bonus provisions of Sec. 413.40(d)(2). In
addition, a separate DRG payment would be made to the prospective
payment system hospital that completed the treatment at the satellite
location. Thus, Medicare payments for a 30-day period of inpatient care
would increase without any additional quality of care or benefit to the
patient. The additional payment would merely be a result of
artificially decreasing the long-term care hospital's cost per
discharge and adding a second payment to the prospective payment system
hospital.
We believe it is important to address possible financial incentives
for inappropriate early discharges from excluded hospitals-within-
hospitals to prospective payment system hospitals. Therefore, we
considered several approaches for preventing inappropriate Medicare
payments to an excluded hospital-within-a-hospital for inappropriate
discharges to the prospective payment system hospital in which it is
located. One approach would be to provide that, if an excluded
hospital-within-a-hospital transfers patients from its beds to beds of
the prospective payment system hospital with which it is located, the
hospital-within-a-hospital would not qualify for exclusion in the next
cost reporting period. We recognize that this approach might
``penalize'' hospitals for transfers that are medically appropriate.
However, we need to balance (1) our concern with preventing
inappropriate Medicare payment and (2) our need to have a rule that is
administratively feasible.
A second possible approach would be to provide that the hospital-
within-a-hospital would qualify for exclusion only if it transfers
patients to the prospective payment system hospital only when the
services the patients require cannot be furnished by the hospital-
within-a-hospital. This approach has the advantage of specifically
targeting inappropriate early discharges, but it has the significant
disadvantage of being difficult if not impossible to administer because
of the extent of case review that would be required to implement it.
After considering these options, we have decided to propose a third
approach. Under this approach, we would deny exclusion to a hospital-
within-a-hospital for a cost reporting period if, during the most
recent cost reporting period for which information is available, the
excluded hospital-within-a-hospital transferred more than 5 percent of
its inpatients to the prospective payment system hospital in which it
is located. We believe that a 5-percent allowance of transfers under
this approach would (1) avoid the need for administratively burdensome
case review, (2) provide adequate flexibility for transfers in those
cases where the hospital-within-a-hospital is not equipped or staffed
to provide the services required by the patient, and (3) limit the
extent to which patients may be transferred inappropriately.
We welcome comments on our proposed approach as well as suggestions
on other ways to address the possible incentives for inappropriate
transfers in a manner that is administratively feasible.
E. Critical Access Hospitals (CAHS)
1. Emergency Response Time Requirements for CAHs in Frontier and Remote
Areas
Because of the high cost of staffing rural hospital emergency rooms
and the low volume of services in those facilities, we do not require
CAHs to have emergency personnel on site at all times. Thus, for CAHs,
the regulations at Sec. 485.618(d) require a doctor of medicine or a
doctor of osteopathy, a physician assistant, or a nurse practitioner
with training and experience in emergency care to be on call and
immediately available by telephone or radio contact, and available on
site within 30 minutes, on a 24-hour basis. We included this
requirement because we recognize the need of rural residents to have
reasonable access to emergency care in their local communities.
Section 1820(h) of the Act, as added by section 4201 of the BBA,
states that any medical assistance facility (MAF) in Montana shall be
deemed to have been certified by the Secretary as a CAH if that
facility is otherwise eligible to be designated by the State as a CAH.
However, under the current requirements, following the initial
transition of a MAF to CAH status, the former MAF would be subject to
the CAH requirements during any subsequent review, one of which is the
30-minute emergency response time for emergency services currently
required under Sec. 485.518(d).
Recently, some facilities have suggested that in many ``frontier''
areas (that is, those having fewer than six residents per square mile),
the requirement of a 30-minute response might be too restrictive for
CAHs, especially those MAFs transitioning to CAH status.
We are aware it is costly and difficult to recruit and train the
personnel needed to operate emergency rooms in the most remote,
sparsely populated rural areas. On the other hand, in contemplating any
changes to the emergency response timeframe for CAHs, we must ensure
that the response time is not extended to the point that patient health
and safety are jeopardized.
In order to recognize the special needs of sparsely populated rural
areas in meeting beneficiaries' health needs, and at the same time to
protect patients' health and safety, we are proposing to revise
Sec. 485.618(d) to allow a response time of up to 60 minutes for a CAH
if (1) it is located in an area of the State that is defined as a
frontier area (that is, having fewer than six residents per square mile
based on the latest population data published by the Bureau of the
Census) or meets other criteria for a remote location adopted by the
State and approved by HCFA under criteria specified in its rural health
care plan under section 1820(b) of the Act; (2) the State determines
that, under its rural health care plan, allowing the longer emergency
response time is the only feasible method of providing emergency care
to residents of the area; and (3) the State maintains documentation
showing that a response time up to 60 minutes at a particular CAH it
designates is justified because other available alternatives would
increase the time required to stabilize the patient in an emergency.
The criteria for remote location would, like other parts of the rural
health care plan, be subject to review and approval by the HCFA
Regional Office, as would the State's documentation regarding the
emergency response time.
We note that, under the terms of the Montana State Code applicable
to MAFs, at times when no emergency response person is available to
come to the facility, a MAF's director of nursing is permitted to come
to the facility and authorize the transfer of a patient seeking
emergency services to another facility. Under one possible reading of
the State requirement, this activity could be seen as an alternative
way of complying with the emergency services requirement and the MAF's
(and CAH's) responsibilities under section 1867 of the Act (the
Emergency Medical Treatment and Active Labor Amendments Provision) to
provide emergency medical screening and stabilization services to
patients who come to the hospital seeking emergency treatment. We
request comments on
[[Page 24745]]
whether the Medicare regulations in Secs. 485.618(d) and 489.24 should
be further revised to explicitly permit this practice to continue
following the transition of a MAF to CAH status. We are particularly
interested in obtaining comment from practitioners on the risks and
benefits involved in adoption of this practice.
2. Compliance With Minimum Data Set (MDS) Requirements by CAHs With
Swing-Bed Approval
Existing regulations allow CAHs to obtain approval from HCFA to use
their inpatient beds to provide posthospital SNF care (Sec. 485.645).
To obtain such approval, however, the CAH must agree to meet specific
requirements that also apply to SNFs, including the comprehensive
assessment requirements at Sec. 483.20(b) of the SNF conditions of
participation.
Section 483.20(b)(1) specifies that a SNF must make a comprehensive
assessment of a resident's needs, using the resident assessment
instrument specified by the State. Section 483.20(b)(2) further
specifies that, subject to the timeframes in Sec. 413.343(b), the
assessments must be conducted within 14 calendar days after the patient
is admitted; within 14 days after the facility determines, or should
have determined, that there is a significant change in the patient's
physical or mental condition; and at least once every 12 months.
Section 413.343(b) specifies that in accordance with the methodology in
Sec. 413.337(c) related to the adjustment of the Federal rates for
case-mix (the SNF prospective payment system), patient assessments must
be performed on the 5th, 14th, 30th, 60th, and 90th days following
admission.
It is clear that the timeframes for patient assessments required
under Sec. 413.343(b) are linked to the prospective payment system for
SNFs. The methodology specifically referenced in Sec. 413.337(c) refers
to the SNF prospective payment system. Therefore, it is apparent that
the patient assessments and concomitant timeframes for performing such
assessments are inextricably intertwined with the case-mix adjustment
under the SNF prospective payment system. CAHs with swing-bed approval
are not paid for their services to SNF-level patients under that SNF
prospective payment system but are paid under the payment method
described in Sec. 413.114, which does not include a case-mix
adjustment. Therefore, the timeframes for patient assessments as
dictated by Sec. 413.343(b) are not applicable to CAHs and are not
required to be met by CAHs. Nevertheless, to make it explicit that the
patient assessment timeframes required under Sec. 413.343(b) do not
apply, we propose to revise Sec. 485.645 to state that the requirements
in Sec. 413.343(b), and the timeframes specified in Sec. 483.20, do not
apply to CAHs.
VII. MedPAC Recommendations
We have reviewed the March 1, 1999 report submitted by MedPAC to
Congress and have given its recommendations careful consideration in
conjunction with the proposals set forth in this document.
Recommendations 3A and 3B concerning the update factors for inpatient
hospital operating costs and for hospitals and hospital distinct-part
units excluded from the prospective payment system are discussed in
Appendix D to this proposed rule. Other recommendations are discussed
below.
A. Excluded Hospitals and Hospital Units (Recommendations 4B and 4C)
Recommendation: The Congress should adjust the wage-related portion
of the excluded hospital target amount caps (the 75th percentile of
target amounts for hospitals in the same class (psychiatric hospital or
unit, rehabilitation hospital or unit, or long-term care hospitals)) to
account for geographic differences in labor costs. The Commission
presumes legislation would be necessary to adjust the caps for wages.
Response: We previously addressed this issue in the May 12, 1998
final rule (63 FR 26345). In that discussion, we explain why we believe
the statutory language, the statutory scheme, and the legislative
history, viewed together, strongly argue against making a wage
adjustment in applying the target amount caps under the current
statute.
Recommendation: Additional research in case-mix classification
systems for psychiatric patients should be encouraged, with the aim of
developing a case-mix adjusted prospective payment system for
psychiatric patients in the future.
Response: As MedPAC indicated in its recommendation discussion,
prior research has indicated substantial difficulties in developing a
psychiatric case-mix classification system. Another issue is the
adequate identification of a system that reflects the unique
characteristics of psychiatric care for the Medicare population,
primarily the elderly. During the past year, we have met with industry
representatives to discuss further research efforts on this issue as
well as understand the initial impacts of the recent legislative
changes to excluded hospital payment system on psychiatric hospitals
and units. We will continue these efforts in FY 2000.
B. Disproportionate Share Hospitals (DSH) (Recommendations 3C, 3D, and
3E)
Recommendations: The Congress should require that disproportionate
share payments be distributed according to each hospital's share of
low-income patient costs, defined broadly to include all care to the
poor. The measure of low-income costs should reflect: (1) Medicare
patients eligible for Supplemental Security Income, Medicaid patients,
patients sponsored by other indigent care programs, and uninsured and
underinsured patients as represented by uncompensated care (both
charity and bad debts); and (2) services provided in both inpatient and
outpatient settings.
As under current policy, disproportionate share payment should be
made in the form of an adjustment to the per-case payment rate. In this
way, the total payment each hospital receives will reflect its volume
of Medicare patients.
Through a minimum threshold for low-income share, the formula for
distributing disproportionate share payments should concentrate
payments among hospitals with the highest shares of poor patients. A
reasonable range for this threshold would be levels that make between
50 percent and 60 percent of hospitals eligible for a payment. The size
of the payment adjustment, however, should increase gradually from zero
at the threshold. The same distribution formula should apply to all
hospitals covered by prospective payment.
The Secretary should collect the data necessary to revise the
disproportionate share payment system from all hospitals paid under
prospective payment system.
Response: We continue to give careful consideration to MedPAC's
recommendations concerning the DSH adjustment made to operating
payments under the prospective payment system.
We are in the process of preparing a report to Congress on the
Medicare DSH adjustment that includes several options for amending the
statutory disproportionate share adjustment formula. We believe that
any adjustment to the DSH formula or data sources should be directed
and supported by the Congress.
The MedPAC option involves collecting data on uncompensated care,
that is, charity and bad debts. Ideally, this would be a direct measure
of a hospital's indigent care burden. However, there are problems
associated with verification of such data and
[[Page 24746]]
consistency of reporting nationally. We appreciate the Commission's
recommendations about and assistance with the Medicare DSH adjustment
as we formulate our legislative proposal and await Congressional
action.
VIII. Other Required Information
A. Requests for Data From the Public
In order to respond promptly to public requests for data related to
the prospective payment system, we have set up a process under which
commenters can gain access to the raw data on an expedited basis.
Generally, the data are available in computer tape or cartridge format;
however, some files are available on diskette as well as on the
Internet at HTTP://WWW.HCFA.GOV/STATS/PUBFILES.HTML. 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, that is, discharges occurring October 1 through September 30
of the requested year.) 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, an agreement for use of HCFA Beneficiary Encrypted Files must
be signed by the purchaser before release of these data. For all files
requiring a signed 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. This file, scheduled to be available by the end of
April, 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. The FY 1998
MedPAR file used for the FY 2000 final rule will be cutoff 6 months
after the end of the fiscal year (March file) and is scheduled to be
available by the end of April.
Media: Tape/Cartridge
File Cost: $3,655.00 per fiscal year
Periods Available: FY 1988 through FY 1998
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, an agreement
for use of HCFA Beneficiary Encrypted Files 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. This file,
scheduled to be available by the end of April, 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. The FY 1998
MedPAR file used for the FY 2000 final rule will be cutoff 6 months
after the end of the fiscal year (March file) and is scheduled to be
available by the end of April.
Media: Tape/Cartridge
File Cost: $1,130.00 per State per year
Periods Available: FY 1988 through FY 1998
3. HCFA Wage Data
This file contains the hospital hours and salaries for 1996 used to
create the proposed FY 2000 prospective payment system wage index. The
file will be available by the beginning of February for the NPRM and
the beginning of May for the final rule.
------------------------------------------------------------------------
Wage data PPS fiscal
Processing year year year
------------------------------------------------------------------------
1999.......................................... 1996 2000
1998.......................................... 1995 1999
1997.......................................... 1994 1998
1996.......................................... 1993 1997
1995.......................................... 1992 1996
1994.......................................... 1991 1995
1993.......................................... 1990 1994
1992.......................................... 1989 1993
1991.......................................... 1988 1992
------------------------------------------------------------------------
These files support the following:
NPRM published in the Federal Register.
Final Rule published in the Federal Register.
Media: Diskette/most recent year on the Internet
File Cost: $165.00 per year
Periods Available: FY 2000 PPS Update
4. HCFA Hospital Wages Indices (Formerly: Urban and Rural Wage Index
Values Only)
This file contains a history of all wage indices since October 1,
1983.
Media: Diskette/most recent year on the Internet
File Cost: $165.00 per year
Periods Available: FY 2000 PPS Update
5. PPS SSA/FIPS MSA State and County Crosswalk
This file contains a crosswalk of State and county codes used by
the Social Security Administration (SSA) and the Federal Information
Processing Standards (FIPS), county name, and a historical list of
Metropolitan Statistical Area (MSA)
.Media: Diskette/Internet
File Cost: $165.00 per year
Periods Available: FY 2000 PPS Update
6. Reclassified Hospitals New Wage Index (Formerly: Reclassified
Hospitals by Provider Only)
This file contains a list of hospitals that were reclassified for
the purpose of assigning a new wage index. Two versions of these files
are created each year. They support the following:
NPRM published in the Federal Register.
Final Rule published in the Federal Register.
Media: Diskette/Internet
File Cost: $165.00 per year
Periods Available: FY 2000 PPS Update
7. PPS-IV to PPS-XII Minimum Data Sets
The Minimum Data Set contains cost, statistical, financial, and
other information from Medicare hospital cost reports. The data set
includes only the most current cost report (as submitted,
[[Page 24747]]
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 and before
on 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-XIII and PPS-XIV Minimum Data Sets are part of the
PPS-XIII and PPS-XIV Hospital Data Set Files.)
File Cost: $770.00 per year
8. 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 and before
on 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-XIII and PPS-XIV Capital Data Sets are part of the
PPS-XIII and PPS-XIV Hospital Data Set Files.)
File Cost: $770.00 per year
9. PPS-XIII and PPS-XIV Hospital Data Set
The file contains cost, statistical, financial, and other data from
the Medicare Hospital Cost Report. The data set includes only the most
current cost (as submitted, final settled, or reopened) submitted for a
Medicare Certified Hospital by the Medicare Fiscal Intermediary to
HCFA. The data set are updated at the end of each calendar quarter and
is available on the last day of the following month.
Media: Diskette/Internet
File Cost: $2,500.00
------------------------------------------------------------------------
Periods
beginning and before
on or after
------------------------------------------------------------------------
PPS-XIII...................................... 10/01/95 10/01/96
PPS-XIV....................................... 10/01/96 10/01/97
------------------------------------------------------------------------
10. 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: Diskette/Internet
File Cost: $265.00
Periods Available: FY 2000 PPS Update
11. 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.
Final rule published in the Federal Register.
Media: Diskette/most recent year on Internet
Price: $165.00 per year/per file
Periods Available: FY 1985 through FY 1998
12. DRG Relative Weights (Formerly Table 5 DRG)
This file contains a listing of DRGs, DRG narrative description,
relative weights, and geometric and arithmetic mean lengths of stay 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:
NPRM.
Final rule.
Media: Diskette/Internet
File Cost: $165.00
Periods Available: FY 2000 PPS Update
13. 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: $165.00
Periods Available: FY 2000 PPS Update
14. 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.
Final rule published in the Federal Register.
Media: Diskette/Internet
File Cost: $165.00
Periods Available: FY 2000 PPS Update
For further information concerning these data tapes, contact The
HCFA Public Use Files Hotline at (410) 786-3691.
Commenters interested in obtaining or discussing any other data
used in constructing this rule should contact Stephen Phillips at (410)
786-4531.
B. 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 2000 be published by
August 1, 1999, we will consider only those
[[Page 24748]]
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 483
Grant programs-health, Health facilities, Health professions,
Health records, Medicaid, Medicare, Nursing homes, Nutrition, Reporting
and recordkeeping requirements, Safety.
42 CFR Part 485
Grant programs-health, Health facilities, Medicaid, Medicare,
Reporting and recordkeeping requirements.
42 CFR Chapter IV is amended as set forth below:
PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL
SERVICES
A. Part 412 is amended as follows:
1. The authority citation for Part 412 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
2. Section 412.22 is amended by adding new paragraphs (e)(6) and
(h) to read as follows:
Sec. 412.22 Excluded hospitals and hospital units: General rules.
* * * * *
(e) Hospitals-within-hospitals. * * *
(6) Responsibility for care of patients. During the most recent
cost reporting period for which information is available, the hospital
transferred no more than 5 percent of its inpatients to the prospective
payment system hospital within which it is located.
* * * * *
(h) Satellite facilities. (1) For purposes of paragraphs (h)(2)
through (h)(5) of this section, a satellite facility is a part of a
hospital that provides inpatient services in a building also used by
another hospital, or in one or more entire buildings located on the
same campus as buildings used by another hospital.
(2) Effective for cost reporting periods beginning on or after
October 1, 1999, payment for services furnished in satellite facilities
of hospitals excluded from the prospective payment systems is made in
accordance with the rules specified in paragraphs (h)(3) and (h)(4) of
this section.
(3) If the satellite facility occupies space in the same building
or on the same campus as a hospital paid under the prospective payment
system, payment for services furnished at the satellite facility is
based on the same rates that apply to the prospective payment system
hospital within which the satellite is located.
(4) If the satellite facility occupies space in the same building
or on the same campus as a hospital excluded from the prospective
payment systems, payment for services furnished at the satellite
facility is made as follows:
(i) For the first two 12-month cost reporting periods during which
the satellite facility treats patients, payment for services furnished
at the satellite facility is made in accordance with the provisions of
Sec. 413.40(f)(2) of this subchapter.
(ii) For subsequent cost reporting periods, payment for services
furnished at the satellite facility is made based on the target amount
of the excluded hospital in which the satellite is located, but is
subject to the cap at the hospital of which the satellite is a part.
(5) The provisions of paragraphs (h)(2) through (h)(4) of this
section do not apply to any hospital or entity structured as a
satellite facility on September 30, 1999, and excluded from the
prospective payment systems on that date, to the extent the hospital
continues operating under the same terms and conditions, including the
number of beds and square footage considered, for purposes of Medicare
participation and payment, to be part of the hospital, in effect on
September 30, 1999.
3. Section 412.25 is amended by revising paragraphs (b) and (c) and
adding a new paragraph (e) to read as follows:
Sec. 412.25 Excluded hospital units: common requirements.
* * * * *
(b) Changes in the size of excluded units. For purposes of
exclusions from the prospective payment systems under this section,
changes in the number of beds and square footage considered to be part
of each excluded unit are allowed as specified in paragraphs (b)(1) and
(b)(2) of this section.
(1) Increase in size. The number of beds and square footage of an
excluded unit may be increased only at the start of a cost reporting
period.
(2) Decrease in size. The number of beds and square footage of an
excluded unit may be decreased at any time during a cost reporting
period if the hospital notifies the fiscal intermediary and the HCFA
Regional Office in writing of the planned decrease at least 30 days
before the date of the decrease, and maintains the information needed
to accurately determine costs that are attributable to the excluded
unit. Any decrease in the number of beds or square footage considered
to be part of an excluded unit made during a cost reporting period
continues in effect for the remainder of that period.
(c) Changes in the status of hospital units. For purposes of
exclusions from the prospective payment systems under this section, the
status of each hospital unit (excluded or not excluded) is determined
as specified in paragraphs (c)(1) and (c)(2) of this section.
(1) The status of a hospital unit may be changed from not excluded
to excluded only at the start of a cost reporting period. If a unit is
added to a hospital after the start of a cost reporting period, it
cannot be excluded from the prospective payment systems before the
start of a hospital's next cost reporting period.
(2) The status of a hospital unit may be changed from excluded to
not excluded at any time during a cost reporting period, but only if
the hospital notifies the fiscal intermediary and the HCFA Regional
Office in writing of the change at least 30 days before the date of the
change, and maintains the information needed to accurately determine
costs that are or are not attributable to the excluded unit. A change
in the status of a unit from excluded to not excluded that is made
during a cost reporting period continues in effect for the remainder of
that period.
* * * * *
(e) Satellite facilities. (1) For purposes of paragraphs (e)(2)
through (e)(5) of this section, a satellite facility is a part of a
hospital that provides inpatient services in a building also used by
another hospital, or in one or more entire buildings located on the
same campus as buildings used by another hospital.
(2) Effective for cost reporting periods beginning on or after
October 1, 1999, payment for services furnished in psychiatric or
rehabilitation units that are structured, entirely or in part, as
satellite facilities are made in accordance with the rules specified in
paragraphs (e)(3) and (e)(4) of this section.
(3) If the satellite facility occupies space in the same building
or on the same campus as a hospital paid under the prospective payment
systems,
[[Page 24749]]
payment for services furnished at the satellite facility is based on
same rates that apply to the prospective payment system hospital within
which the satellite is located.
(4) If the satellite facility occupies space in the same building
or on the same campus as a hospital excluded from the prospective
payment systems, payment for services furnished at the satellite
facility is made as follows:
(i) For the first two 12-month cost reporting periods during which
the satellite facility treats patients, payment for services furnished
at the satellite facility is made in accordance with the provisions of
Sec. 413.40(f)(2) of this subchapter.
(ii) For subsequent cost reporting periods, payment for services
furnished at the satellite facility is made based on the target amount
of the excluded hospital in which the satellite is located, but is
subject to the cap of the hospital of which the satellite is a part.
(5) The provisions of paragraph (e)(2) through (e)(4) of this
section do not apply to any unit structured as a satellite facility on
September 30, 1999, and excluded from the prospective payment systems
on that date, to the extent the unit continues operating under the same
terms and conditions, including the number of beds and square footage
considered to be part of the unit, in effect on September 30, 1999.
Sec. 412.105 [Amended]
4. Section 412.105 is amended by revising the cross reference
``paragraph (g)(1)(ii) of this section'' in paragraphs (f)(1)(iii)
(three times) and (f)(2)(v) to read ``paragraph (f)(1)(ii) of this
section''.
Sec. 412.256 [Amended]
5. In Sec. 412.256, paragraph (c)(2), the date ``October 1'',
appearing in two places, is revised to read ``September 1''.
6. Section 412.276 is amended by revising paragraph (a) to read as
follows:
Sec. 412.276 Timing of MGCRB decision and its appeal.
(a) Timing. The MGCRB notifies the parties in writing, with a copy
to HCFA, and issues a decision within 180 days after the first day of
the 13-month period preceding the Federal fiscal year for which a
hospital has filed a complete application. The hospital has 15 days
from the date of the decision to request Administrator review.
* * * * *
PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR
END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED
PAYMENT RATES FOR SKILLED NURSING FACILITIES
B. Part 413 is amended as follows:
1. The authority citation for Part 413 is revised to read as
follows:
Authority: Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (i), and
(n), 1871, 1881, 1883, and 1886 of the Social Security Act (42
U.S.C. 1302, 1395f(b), 1395g, 1395l, 1395l(a), (i), and (n),
1395x(v), 1395hh, 1395rr, 1395tt, and 1395ww).
2. Section 413.40 is amended by revising paragraphs (b)(1)(iii) and
(g)(1) to read as follows:
Sec. 413.40 Ceiling on the rate-of-increase in hospital inpatient
costs.
* * * * *
(b) Cost reporting periods subject to the rate-of-increase ceiling.
(1) Base period. * * *
(iii) When the operational structure of a hospital or unit changes
(that is, a freestanding hospital becomes a unit or vice versa, or an
entity of a multicampus hospital becomes a newly created hospital or
unit or vice versa), the base period for the hospital or unit that
changed its operational structure is the first cost reporting period of
at least 12 months effective with the revised Medicare certification
classification.
* * * * *
(g) Adjustment. (1) General rules. (i) HCFA may adjust the amount
of the operating costs considered in establishing the rate-of-increase
ceiling for one or more cost reporting periods, including both periods
subject to the ceiling and the hospital's base period, under the
circumstances specified in paragraphs (g)(2), (g)(3), and (g)(4) of
this section.
(ii) When an adjustment is requested by the hospital, HCFA makes an
adjustment only to the extent that the hospital's operating costs are
reasonable, attributable to the circumstances specified separately,
identified by the hospital and verified by the intermediary.
(iii) When an adjustment is requested by the hospital, HCFA makes
an adjustment only if the hospital's operating costs exceed the rate-
of-increase ceiling imposed under this section.
(iv) In the case of a psychiatric hospital or unit, rehabilitation
hospital or unit, or long-term care hospital, the amount of payment
under paragraph (g)(3) of this section may not exceed the payment
amount based on the target amount determined under paragraph
(c)(4)(iii) of this section.
(v) In the case of a hospital or unit that received a revised FY
1998 target amount under the rebasing provisions of paragraph
(b)(1)(iv) of this section, the amount of an adjustment payment for a
cost reporting period is based on a comparison of the hospital's
operating costs for the cost reporting period to the average costs and
statistics for the cost reporting periods used to determine the FY 1998
rebased target amount.
* * * * *
Sec. 413.86 [Amended]
3. Section 413.86 is amended as follows:
a. In paragraph (b), the definition of ``approved geriatric
program'' is revised to read: ``Approved geriatric program means a
fellowship program of one or more years in length that is approved by
one of the national organizations listed in Sec. 415.152 of this
chapter under that respective organization's criteria for geriatric
fellowship programs.''
b. In paragraph (b), under paragraph (1) of the definition of
``approved medical residency program'', the reference ``Sec. 415.200(a)
of this chapter'' is revised to read ``Sec. 415.152 of this chapter''.
c. In paragraph (e)(1)(ii)(C), the reference ``paragraph (j)(2) of
this section'' is revised to read ``paragraph (k)(1) of this section''.
d. In paragraph (e)(1)(iv), the reference, ``paragraph (j)(1) of
this section'', is revised to read ``paragraph (k)(1) of this
section''.
e. A new paragraph (f)(4)(iii) is added, paragraphs (g)(1) (i),
(ii), and (iii), (g)(6) introductory text and (g)(6) (i) and (ii) are
revised, paragraph (g)(7) is redesignated as paragraph (g)(9), and new
paragraphs (g)(7) and (g)(8) are added to read as follows:
Sec. 413.86 Direct graduate medical education payments.
* * * * *
(f) Determining the total number of FTE residents. * * *
(4) * * *
(iii) The hospital must incur all or substantially all of the costs
for the training program in the nonhospital setting in accordance with
the definition in paragraph (b) of this section.
(g) Determining the weighted number of FTE residents. * * *
(1) * * *
(i) For residency programs other than those specified in paragraphs
(g)(1)(ii) and (g)(1)(iii) of this section, the initial residency
period is the minimum
[[Page 24750]]
number of years of formal training necessary to satisfy the
requirements for initial board eligibility in the particular specialty
for which the resident is training, as specified in the most recently
published edition of the Graduate Medical Education Directory.
(ii) For residency programs in osteopathy, dentistry, and podiatry,
the minimum requirement for certification in a specialty or
subspecialty is the minimum number of years of formal training
necessary to satisfy the requirements of the appropriate approving body
listed in Sec. 415.152 of this chapter.
(iii) For residency programs in geriatric medicine accredited by
the appropriate approving body listed in Sec. 415.152 of this chapter,
these programs are considered approved programs on the later of--
(A) The starting date of the program within a hospital; or
(B) The hospital's cost reporting periods beginning on or after
July 1, 1985.
* * * * *
(6) If a hospital establishes a new medical residency training
program as defined in paragraph (g)(9) of this section on or after
January 1, 1995, the hospital's FTE cap described under paragraph
(g)(4) of this section may be adjusted as follows:
(i) If a hospital had no allopathic or osteopathic residents in its
most recent cost reporting period ending on or before December 31,
1996, and it establishes a new medical residency training program on or
after January 1, 1995, the hospital's unweighted FTE resident cap under
paragraph (g)(4) of this section may be adjusted based on the product
of the highest number of residents in any program year during the third
year of the first program's existence for all new residency training
programs and the number of years in which residents are expected to
complete the program based on the minimum accredited length for the
type of program. The adjustment to the cap may not exceed the number of
accredited slots available to the hospital for the new program.
(A) If the residents are spending an entire program year (or years)
at one hospital and the remainder of the program at another hospital,
the adjustment to each respective hospital's cap is equal to the
product of the highest number of residents in any program year during
the third year of the first program's existence and the number of years
the residents are training at each respective hospital.
(B) Prior to the implementation of the hospital's adjustment to its
FTE cap beginning with the fourth year of the hospital's residency
program(s), the hospital's cap may be adjusted during each of the first
3 years of the hospital's new residency program using the actual number
of residents participating in the new program. The adjustment may not
exceed the number of accredited slots available to the hospital for
each program year.
(C) Except for rural hospitals, the cap will not be adjusted for
new programs established more than 3 years after the first program
begins training residents.
(D) Rural hospitals that qualify for an adjustment to its FTE cap
under paragraph (g)(6)(i) of this section are permitted to be part of
the same affiliated group for purposes of an aggregate FTE limit.
(ii) If a hospital had allopathic or osteopathic residents in its
most recent cost reporting period ending on or before December 31,
1996, the hospital's unweighted FTE cap may be adjusted for new medical
residency training programs established on or after January 1, 1995 and
on or before August 5, 1997. The adjustment to the hospital's FTE
resident limit for the new program is based on the product of the
highest number of residents in any program year during the third year
of the newly established program and the number of years in which
residents are expected to complete each program based on the minimum
accredited length for the type of program.
(A) If the residents are spending an entire program year (or years)
at one hospital and the remainder of the program at another hospital,
the adjustment to each respective hospital's cap is equal to the
product of the highest number of residents in any program year during
the third year of the first program's existence and the number of years
the residents are training at each respective hospital.
(B) Prior to the implementation of the hospital's adjustment to its
FTE cap beginning with the fourth year of the hospital's residency
program, the hospital's cap may be adjusted during each of the first 3
years of the hospital's new residency program, using the actual number
of residents in the new programs. The adjustment may not exceed the
number of accredited slots available to the hospital for each program
year.
* * * * *
(7) A hospital that began construction of its facility prior to
August 5, 1997, sponsored new medical residency training programs, and
temporarily trained those residents at another hospital(s) until the
facility was completed may receive an adjustment to its FTE cap.
(i) The newly constructed hospital's FTE cap is equal to the lesser
of:
(A) The product of the highest number of residents in any program
year during the third year of the first program's existence for all new
residency training programs and the number of years in which residents
are expected to complete the programs based on the minimum accredited
length for each type of program; or
(B) The number of accredited slots available to the hospital for
each year of the programs.
(ii) If the medical residency training programs sponsored by the
newly constructed hospital have been in existence for 3 years or more
by the time the residents begin training at the newly constructed
hospital, the newly constructed hospital's cap will be based on the
number of residents training in the third year of the first of those
programs begun at the temporary training site.
(iii) If the medical residency training programs sponsored by the
newly constructed hospital have been in existence for less than 3 years
by the time the residents begin training at the newly constructed
hospital, the newly constructed hospital's cap will be based on the
number of residents training at the newly constructed hospital in the
third year of the first of those programs (including the years at the
temporary training site).
(iv) The provisions of this paragraph (g)(7) are applicable during
portions of cost reporting periods occurring on or after October 1,
1999.
(8) A hospital may receive a temporary adjustment to its FTE cap to
reflect residents added because of another hospital's closure if the
hospital meets the following criteria:
(i) The hospital is training additional residents from a hospital
that closed on or after July 1, 1996.
(ii) At least 60 days before the hospital begins to train the
residents, the hospital submits a request to its fiscal intermediary
for a temporary adjustment to its FTE cap, documents that the hospital
is eligible for this temporary adjustment by identifying the residents
who have come from the closed hospital and have caused the hospital to
exceed its cap, and specifies the length of time the adjustment is
needed.
* * * * *
[[Page 24751]]
PART 483--REQUIREMENTS FOR STATES AND LONG-TERM CARE FACILITIES
C. Part 483 is amended as set forth below:
1. The authority citation for Part 483 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
2. In Sec. 483.20, the introductory text of paragraph (b)(2) is
revised to read as follows:
Sec. 483.20 Resident assessment.
* * * * *
(b) Comprehensive assessments. * * *
(2) When required. Subject to the timeframes prescribed in
Sec. 413.343(b) of this chapter, a facility must conduct a
comprehensive assessment of a resident in accordance with the
timeframes specified in paragraphs (b)(2)(i) through (iii). However,
the timeframes prescribed in Sec. 413.343(b) of this chapter do not
apply to CAHs.
* * * * *
PART 485--CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS
D. Part 485 is amended as follows:
1. The authority citation for Part 485 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
2. Section 485.618 is amended by revising paragraph (d) to read as
follows:
Sec. 485.618 Conditions of participation: Emergency services.
* * * * *
(d) Standard: Personnel. There must be a doctor of medicine or
osteopathy, a physician assistant, or a nurse practitioner with
training or experience in emergency care on call and immediately
available by telephone or radio contact, and available on site within
the following timeframes:
(1) Within 30 minutes, on a 24-hour a day basis, if the CAH is
located in an area other than an area described in paragraph (d)(2) of
this section; or
(2) Within 60 minutes, on a 24-hour a day basis, if the following
requirements are met:
(i) The CAH is located in an area designated as frontier (that is,
an area having fewer than six residents per square mile based on the
latest population data published by the Bureau of the Census) or in an
area that meets criteria for a remote location adopted by the State in
its rural health care plan, and approved by HCFA, under section 1820(b)
of the Act;
(ii) The State has determined under criteria in its rural health
care plan that allowing an emergency response time longer than 30
minutes is the only feasible method of providing emergency care to
residents of the area served by the CAH; and
(iii) The State maintains documentation showing that the response
time of up to 60 minutes at a particular CAH it designates are
justified because other available alternatives would increase the time
needed to stabilize a patient in an emergency.
* * * * *
3. In Sec. 485.645, the introductory text of paragraph (d) is
republished and paragraph (d)(6) is revised to read as follows:
Sec. 485.645 Special requirements for CAH providers of long-term care
services (``swing beds'').
* * * * *
(d) SNF services. CAH is substantially in compliance with the
following SNF requirements contained in subpart B of part 483 of this
chapter:
* * * * *
(6) Comprehensive assessment, comprehensive care plan, and
discharge planning (Sec. 483.20(b), (d), and (e) of this chapter,
except that the CAH is not required to comply with the requirements for
frequency, scope and number of assessments prescribed in
Sec. 413.343(b)).
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance)
Dated: April 9, 1999.
Nancy Ann DeParle,
Administrator, Health Care Financing Administration.
Dated: April 26, 1999.
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 Occurring On or After October 1, 1999; Payment Amounts
for Blood Clotting Factor Effective for Discharges Occurring On or
After October 1, 1999; and Update Factors and Rate-of-Increase
Percentages Effective With Cost Reporting Periods Beginning On or
After October 1, 1999
I. Summary and Background
In this addendum, we are setting forth the 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, 1999, except for
sole community hospitals, Medicare-dependent, small rural hospitals,
and hospitals located in Puerto Rico, each hospital's payment per
discharge under the prospective payment system will be based on 100
percent of the Federal national rate.
Sole community hospitals are paid based on whichever of the
following rates yields the greatest aggregate payment: the Federal
national rate, the updated hospital-specific rate based on FY 1982 cost
per discharge, or the updated hospital-specific rate based on FY 1987
cost per discharge. Medicare-dependent, small rural hospitals are paid
based on the Federal national rate or, if higher, the Federal national
rate plus 50 percent of the difference between the Federal national
rate and the updated hospital-specific rate based on FY 1982 or FY 1987
cost per discharge, whichever is higher. For hospitals in Puerto Rico,
the payment per discharge is based on the sum of 50 percent of a Puerto
Rico rate and 50 percent of a national rate.
As discussed below in section II, we are proposing to make changes
in the determination of the prospective payment rates for Medicare
inpatient operating costs for FY 2000. The changes, to be applied
prospectively, would affect the calculation of the Federal rates. In
section III of this addendum, we are proposing updates to the payments
per unit for blood clotting factor provided to hospital inpatients who
have hemophilia. We also are proposing to add another product (clotting
factor, porcine (HCPCS code J7191)) to the list of clotting factors
that would be paid under this benefit.
In section IV of this addendum, we discuss our proposed changes for
[[Page 24752]]
determining the prospective payment rates for Medicare inpatient
capital-related costs for FY 2000. Section V of this addendum sets
forth our proposed changes for determining the rate-of-increase limits
for hospitals excluded from the prospective payment system for FY 2000.
The tables to which we refer in the preamble to the proposed rule are
presented at the end of this addendum in section VI.
II. Proposed Changes to Prospective Payment Rates for Inpatient
Operating Costs for FY 2000
The basic methodology for determining prospective payment rates for
inpatient operating costs is set forth at Sec. 412.63 for hospitals
located outside of Puerto Rico. The basic methodology for determining
the prospective payment rates for inpatient operating costs for
hospitals located in Puerto Rico is set forth at Secs. 412.210 and
412.212. Below, we discuss the proposed factors used for determining
the prospective payment rates. The Federal and Puerto Rico rate
changes, once issued as final, would be effective with discharges
occurring on or after October 1, 1999. As required by section
1886(d)(4)(C) of the Act, we must also adjust the DRG classifications
and weighting factors for discharges in FY 2000.
In summary, the proposed standardized amounts set forth in Tables
1A and 1C of section VI of this addendum reflect--
Updates of 0.9 percent for all areas (that is, the market
basket percentage increase of 2.7 percent minus 1.8 percentage points);
An adjustment to ensure budget neutrality as provided for
in sections 1886(d)(4)(C)(iii) and (d)(3)(E) of the Act by applying new
budget neutrality adjustment factors to the large urban and other
standardized amounts;
An adjustment to ensure budget neutrality as provided for
in section 1886(d)(8)(D) of the Act by removing the FY 1999 budget
neutrality factor and applying a revised factor;
An adjustment to apply the revised outlier offset by
removing the FY 1999 outlier offsets and applying a new offset; and
An adjustment in the Puerto Rico standardized amounts to
reflect the application of a Puerto Rico-specific wage index.
A. Calculation of Adjusted Standardized Amounts
1. Standardization of Base-Year Costs or Target Amounts
Section 1886(d)(2)(A) of the Act required the establishment of
base-year cost data containing allowable operating costs per discharge
of inpatient hospital services for each hospital. The preamble to the
September 1, 1983 interim final rule (48 FR 39763) contains a detailed
explanation of how base-year cost data were established in the initial
development of standardized amounts for the prospective payment system
and how they are used in computing the Federal rates.
Section 1886(d)(9)(B)(i) of the Act required us to determine the
Medicare target amounts for each hospital located in Puerto Rico for
its cost reporting period beginning in FY 1987. The September 1, 1987
final rule contains a detailed explanation of how the target amounts
were determined and how they are used in computing the Puerto Rico
rates (52 FR 33043, 33066).
The standardized amounts are based on per discharge averages of
adjusted hospital costs from a base period or, for Puerto Rico,
adjusted target amounts from a base period, updated and otherwise
adjusted in accordance with the provisions of section 1886(d) of the
Act. Sections 1886(d)(2)(B) and (C) of the Act required us to update
base-year per discharge costs for FY 1984 and then standardize the cost
data in order to remove the effects of certain sources of variation in
cost among hospitals. These effects include case mix, differences in
area wage levels, cost-of-living adjustments for Alaska and Hawaii,
indirect medical education costs, and payments to hospitals serving a
disproportionate share of low-income patients.
Under sections 1886(d)(2)(H) and (d)(3)(E) of the Act, in making
payments under the prospective payment system, the Secretary estimates
from time to time the proportion of costs that are wages and wage-
related costs. Since October 1, 1997, when the market basket was last
revised, we have considered 71.1 percent of costs to be labor-related
for purposes of the prospective payment system. The average labor share
in Puerto Rico is 71.3 percent. We are proposing to revise the
discharge-weighted national standardized amount for Puerto Rico to
reflect the proportion of discharges in large urban and other areas
from the FY 1998 MedPAR file.
2. Computing Large Urban and Other Area Averages
Sections 1886(d)(2)(D) and (3) of the Act require the Secretary to
compute two average standardized amounts for discharges occurring in a
fiscal year: one for hospitals located in large urban areas and one for
hospitals located in other areas. In addition, under sections
1886(d)(9)(B)(iii) and (C)(i) of the Act, the average standardized
amount per discharge must be determined for hospitals located in urban
and other areas in Puerto Rico. Hospitals in Puerto Rico are paid a
blend of 50 percent of the applicable Puerto Rico standardized amount
and 50 percent of a national standardized payment amount.
Section 1886(d)(2)(D) of the Act defines ``urban area'' as those
areas within a Metropolitan Statistical Area (MSA). A ``large urban
area'' is defined as an urban area with a population of more than
1,000,000. In addition, section 4009(i) of Public Law 100-203 provides
that a New England County Metropolitan Area (NECMA) with a population
of more than 970,000 is classified as a large urban area. As required
by section 1886(d)(2)(D) of the Act, population size is determined by
the Secretary based on the latest population data published by the
Bureau of the Census. Urban areas that do not meet the definition of a
``large urban area'' are referred to as ``other urban areas.'' Areas
that are not included in MSAs are considered ``rural areas'' under
section 1886(d)(2)(D) of the Act. Payment for discharges from hospitals
located in large urban areas will be based on the large urban
standardized amount. Payment for discharges from hospitals located in
other urban and rural areas will be based on the other standardized
amount.
Based on 1997 population estimates published by the Bureau of the
Census, 61 areas meet the criteria to be defined as large urban areas
for FY 2000. These areas are identified by a footnote in Table 4A.
3. Updating the Average Standardized Amounts
Under section 1886(d)(3)(A) of the Act, we update the area average
standardized amounts each year. In accordance with section
1886(d)(3)(A)(iv) of the Act, we are proposing to update the large
urban areas' and the other areas' average standardized amounts for FY
2000 using the applicable percentage increases specified in section
1886(b)(3)(B)(i) of the Act. Section 1886(b)(3)(B)(i)(XV) of the Act
specifies that, for hospitals in all areas, the update factor for the
standardized amounts for FY 2000 is equal to the market basket
percentage increase minus 1.8 percentage points.
The percentage change in the market basket reflects the average
change in the price of goods and services purchased by hospitals to
furnish inpatient care. The most recent forecast of the proposed
hospital market basket increase for FY 2000 is 2.7 percent. Thus, for
FY 2000,
[[Page 24753]]
the proposed update to the average standardized amounts equals 0.9
percent.
As in the past, we are adjusting the FY 1999 standardized amounts
to remove the effects of the FY 1999 geographic reclassifications and
outlier payments before applying the FY 2000 updates. That is, we are
increasing the standardized amounts to restore the reductions that were
made for the effects of geographic reclassification and outliers. We
then apply the new offsets to the standardized amounts for outliers and
geographic reclassifications for FY 2000.
Although the update factor for FY 2000 is set by law, we are
required by section 1886(e)(3) of the Act to report to the Congress on
our initial recommendation of update factors for FY 2000 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 C 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 MedPAC's recommendation concerning the update factor, are
set forth as Appendix D 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 requires us to update the hospital
wage index on an annual basis beginning October 1, 1993. This provision
also requires us to make any updates or adjustments to the wage index
in a manner that ensures that aggregate payments to hospitals are not
affected by the change in the wage index.
To comply with the requirement of section 1886(d)(4)(C)(iii) of the
Act that DRG reclassification and recalibration of the relative weights
be budget neutral, and the requirement in section 1886(d)(3)(E) of the
Act that the updated wage index be budget neutral, we used historical
discharge data to simulate payments and compared aggregate payments
using the FY 1999 relative weights and wage index to aggregate payments
using the proposed FY 2000 relative weights and wage index. The same
methodology was used for the FY 1999 budget neutrality adjustment. (See
the discussion in the September 1, 1992 final rule (57 FR 39832).)
Based on this comparison, we computed a budget neutrality adjustment
factor equal to 0.997393. We also adjust the Puerto Rico-specific
standardized amounts for the effect of DRG reclassification and
recalibration. We computed a budget neutrality adjustment factor for
Puerto Rico-specific standardized amounts equal to 0.999910. These
budget neutrality adjustment factors are applied to the standardized
amounts without removing the effects of the FY 1999 budget neutrality
adjustments. We do not remove the prior budget neutrality adjustment
because estimated aggregate payments after the changes in the DRG
relative weights and wage index should equal estimated aggregate
payments prior to the changes. If we removed the prior year adjustment,
we would not satisfy this condition.
In addition, we are proposing to apply these same adjustment
factors to the hospital-specific rates that are effective for cost
reporting periods beginning on or after October 1, 1999. (See the
discussion in the September 4, 1990 final rule (55 FR 36073).)
b. Reclassified Hospitals--Budget Neutrality Adjustment. Section
1886(d)(8)(B) of the Act provides that certain rural hospitals are
deemed urban effective with discharges occurring on or after October 1,
1988. In addition, section 1886(d)(10) of the Act provides for the
reclassification of hospitals based on determinations by the Medicare
Geographic Classification Review Board (MGCRB). Under section
1886(d)(10) of the Act, a hospital may be reclassified for purposes of
the standardized amount or the wage index, or both.
Under section 1886(d)(8)(D) of the Act, the Secretary is required
to adjust the standardized amounts so as to ensure that total aggregate
payments under the prospective payment system after implementation of
the provisions of sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the
Act are equal to the aggregate prospective payments that would have
been made absent these provisions. To calculate this budget neutrality
factor, we used historical discharge data to simulate payments, and
compared total prospective payments (including IME and DSH payments)
prior to any reclassifications to total prospective payments after
reclassifications. Based on these simulations, we are applying an
adjustment factor of 0.994453 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 1999 budget neutrality adjustment
factor. We note that the proposed FY 2000 adjustment reflects wage
index and standardized amount reclassifications approved by the MGCRB
or the Administrator as of February 26, 1999. The effects of any
additional reclassification changes resulting from appeals and reviews
of the MGCRB decisions for FY 2000 or from a hospital's request for the
withdrawal of a reclassification request 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 2000.
c. Outliers. Section 1886(d)(5)(A) of the Act provides for payments
in addition to the basic prospective payments for ``outlier'' cases,
cases involving extraordinarily high costs (cost outliers). Section
1886(d)(3)(B) of the Act requires the Secretary to adjust both the
large urban and other area national standardized amounts by the same
factor to account for the estimated proportion of total DRG payments
made to outlier cases. Similarly, section 1886(d)(9)(B)(iv) of the Act
requires the Secretary to adjust the large urban and other standardized
amounts applicable to hospitals in Puerto Rico to account for the
estimated proportion of total DRG payments made to outlier cases.
Furthermore, under section 1886(d)(5)(A)(iv) of the Act, outlier
payments for any year must be projected to be not less than 5 percent
nor more than 6 percent of total payments based on DRG prospective
payment rates.
For FY 1999, the fixed loss cost outlier threshold is equal to the
prospective payment for the DRG plus $11,100 ($10,129 for hospitals
that have not yet entered the prospective payment system for capital-
related costs). The marginal cost factor for cost outliers (the percent
of costs paid after costs for the case exceed the threshold) is 80
percent. We applied an outlier adjustment to the FY 1999 standardized
amounts of 0.948740 for the large urban and other areas rates and
0.9392 for the capital Federal rate.
In accordance with section 1886(d)(5)(A)(iv) of the Act, we
calculated proposed outlier thresholds for FY 2000 so that outlier
payments are projected to equal 5.1 percent of total payments based on
DRG prospective
[[Page 24754]]
payment rates. In accordance with section 1886(d)(3)(E), we reduced the
proposed FY 2000 standardized amounts by the same percentage to account
for the projected proportion of payments paid to outliers. To calculate
FY 2000 outlier thresholds, we simulated payments by applying FY 2000
rates and policies to the December 1998 update of the FY 1998 MedPAR
file and the December 1998 update of the provider-specific file. As we
have explained in the past, to calculate outlier thresholds we apply a
cost inflation factor to update costs for the cases used to simulate
payments. For FY 1998, we used a cost inflation factor of minus 2.005
percent (a cost per case decrease of 2.005 percent). For FY 1999, we
used a cost inflation factor of minus 1.724 percent. To set the
proposed FY 2000 outlier thresholds, we used a cost inflation factor
(or cost adjustment factor) of zero percent. This factor reflects our
analysis of the best available cost report data as well as calculations
(using the best available data) indicating that the percentage of
actual outlier payments for FY 1998, is higher than we projected before
the beginning of FY 1998, and that the percentage of actual outlier
payments for FY 1999 will likely be higher than we projected before the
beginning of FY 1999. The calculations of ``actual'' outlier payments
are discussed further below. Based on these simulations, we are
proposing a fixed loss cost outlier threshold in FY 2000 equal to the
prospective payment rate for the DRG plus $14,575 ($13,309 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.
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 2000 will result in outlier
payments equal to 5.1 percent of operating DRG payments and 6.0 percent
of capital payments based on the Federal rate.
The proposed outlier adjustment factors applied to the standardized
amounts for FY 2000 are as follows:
------------------------------------------------------------------------
Operating Capital
standardized Federal
amounts rate
------------------------------------------------------------------------
National..................................... 0.948934 0.9397
Puerto Rico.................................. 0.969184 0.9334
------------------------------------------------------------------------
We apply the proposed outlier adjustment factors after removing the
effects of the FY 1999 outlier adjustment factors on the standardized
amounts.
Table 8A in section VI of this addendum contains the updated
Statewide average operating cost-to-charge ratios for urban hospitals
and for rural hospitals to be used in calculating cost outlier payments
for those hospitals for which the intermediary is unable to compute a
reasonable hospital-specific cost-to-charge ratio. These Statewide
average ratios would replace the ratios published in the July 31, 1998
final rule (63 FR 41099), effective October 1, 1999. 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 0.212473 greater than 1.280336 and capital
cost-to-charge ratios lower than 0.0130310 or greater than 0.17166.
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 during FY 2000 when hospital-specific cost-to-charge
ratios based on the latest settled cost report are either not available
or outside the three standard deviations range.
In the July 31, 1998 final rule (63 FR 41009), we stated that,
based on available data, we estimated that actual FY 1998 outlier
payments would be approximately 5.4 percent of actual total DRG
payments. This was computed by simulating payments using actual FY 1997
bill data available at the time. That is, the estimate of actual
outlier payments did not reflect actual FY 1998 bills but instead
reflected the application of FY 1998 rates and policies to available FY
1997 bills. Our current estimate, using available FY 1998 bills, is
that actual outlier payments for FY 1998 were approximately 6.5 percent
of actual total DRG payments. We note that the MedPAR file for FY 1998
discharges continues to be updated. Thus, the data indicate that, for
FY 1998, the percentage of actual outlier payments relative to actual
total payments is higher than we projected before FY 1998 (and thus
exceeds the percentage by which we reduced the standardized amounts for
FY 1998). In fact, the data indicate that the proportion of actual
outlier payments for FY 1998 exceeds 6 percent. Nevertheless,
consistent with the policy and statutory interpretation we have
maintained since the inception of the prospective payment system, we do
not plan to recoup money and make retroactive adjustments to outlier
payments for FY 1998.
We currently estimate that actual outlier payments for FY 1999 will
be approximately 6.2 percent of actual total DRG payments, higher than
the 5.1 percent we projected in setting outlier policies for FY 1999.
This estimate is based on simulations using the December 1998 update of
the provider-specific file and the December 1998 update of the FY 1998
MedPAR file (discharge data for FY 1998 bills). We used these data to
calculate an estimate of the actual outlier percentage for FY 1999 by
applying FY 1999 rates and policies to available FY 1998 bills.
5. FY 2000 Standardized Amounts
The adjusted standardized amounts are divided into labor and
nonlabor portions. Table 1A contains the two national standardized
amounts that we are proposing to be applicable to all hospitals, except
for hospitals in Puerto Rico. Under section 1886(d)(9)(A)(ii) of the
Act, the Federal portion of the Puerto Rico payment rate is based on
the discharge-weighted average of the national large urban standardized
amount and the national other standardized amount (as set forth in
Table 1A). The labor and nonlabor portions of the national average
standardized amounts for Puerto Rico hospitals are set forth in Table
1C. This table also includes the Puerto Rico standardized amounts.
B. Adjustments for Area Wage Levels and Cost of Living
Tables 1A and 1C, as set forth in this addendum, contain the
proposed labor-related and nonlabor-related shares that would 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 requires
that we make an adjustment to the labor-related portion of the
prospective payment rates to account for area differences in hospital
wage levels. This
[[Page 24755]]
adjustment is made by multiplying the labor-related portion of the
adjusted standardized amounts by the appropriate wage index for the
area in which the hospital is located. In section III of this preamble,
we discuss the data and methodology for the proposed wage index. The
proposed wage index is set forth in Tables 4A through 4F of this
addendum.
2. Adjustment for Cost-of-Living in Alaska and Hawaii
Section 1886(d)(5)(H) of the Act authorizes an adjustment to take
into account the unique circumstances of hospitals in Alaska and
Hawaii. Higher labor-related costs for these two States are taken into
account in the adjustment for area wages described above. For FY 2000,
we 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 July 1, 1999, we will publish them in the
final rule and use them in determining FY 2000 payments.
Table of Cost-of-Living Adjustment Factors, Alaska and Hawaii Hospitals
------------------------------------------------------------------------
------------------------------------------------------------------------
Alaska--All areas............................................. 1.25
Hawaii:
County of Honolulu.......................................... 1.25
County of Hawaii............................................ 1.15
County of Kauai............................................. 1.225
County of Maui.............................................. 1.225
County of Kalawao........................................... 1.225
------------------------------------------------------------------------
(The above factors are based on data obtained from the U.S. Office of
Personnel Management.)
C. DRG Relative Weights
As discussed in section II of the preamble, we have developed a
classification system for all hospital discharges, assigning them into
DRGs, and have developed relative weights for each DRG that reflect the
resource utilization of cases in each DRG relative to Medicare cases in
other DRGs. Table 5 of section VI of this addendum contains the
relative weights that we propose to use for discharges occurring in FY
2000. These factors have been recalibrated as explained in section II
of the preamble.
D. Calculation of Prospective Payment Rates for FY 2000
General Formula for Calculation of Prospective Payment Rates for FY
2000
Prospective payment rate for all hospitals located outside of
Puerto Rico except sole community hospitals and Medicare-dependent,
small rural hospitals = Federal rate.
Prospective payment rate for sole community hospitals = Whichever
of the following rates yields the greatest aggregate payment: 100
percent of the Federal rate, 100 percent of the updated FY 1982
hospital-specific rate, or 100 percent of the updated FY 1987 hospital-
specific rate.
Prospective payment rate for Medicare-dependent, small rural
hospitals = 100 percent of the Federal rate, or, if the greater of the
updated FY 1982 hospital-specific rate or the updated FY 1987 hospital-
specific rate is higher than the Federal rate, 100 percent of the
Federal rate plus 50 percent of the difference between the applicable
hospital-specific rate and the Federal rate.
Prospective payment rate for Puerto Rico = 50 percent of the Puerto
Rico rate + 50 percent of a discharge-weighted average of the national
large urban standardized amount and the national other standardized
amount.
1. Federal Rate
For discharges occurring on or after October 1, 1999 and before
October 1, 2000, except for sole community hospitals, Medicare-
dependent, small rural hospitals, and hospitals in Puerto Rico, the
hospital's payment is based exclusively on the Federal national rate.
The payment amount is determined as follows:
Step 1--Select the appropriate national standardized amount
considering the type of hospital and designation of the hospital as
large urban or other (see Table 1A in section VI of this addendum).
Step 2--Multiply the labor-related portion of the standardized
amount by the applicable wage index for the geographic area in which
the hospital is located (see Tables 4A, 4B, and 4C of section VI of
this addendum).
Step 3--For hospitals in Alaska and Hawaii, multiply the nonlabor-
related portion of the standardized amount by the appropriate cost-of-
living adjustment factor.
Step 4--Add the amount from Step 2 and the nonlabor-related portion
of the standardized amount (adjusted, if appropriate, under Step 3).
Step 5--Multiply the final amount from Step 4 by the relative
weight corresponding to the appropriate DRG (see Table 5 of section VI
of this addendum).
2. Hospital-Specific Rate (Applicable Only to Sole Community Hospitals
and Medicare-Dependent, Small Rural Hospitals)
Sections 1886(d)(5)(D)(i) and (b)(3)(C) of the Act provide that
sole community hospitals are paid based on whichever of the following
rates yields the greatest aggregate payment: the Federal rate, the
updated hospital-specific rate based on FY 1982 cost per discharge, or
the updated hospital-specific rate based on FY 1987 cost per discharge.
Sections 1886(d)(5)(G) and (b)(3)(D) of the Act provide that
Medicare-dependent, small rural hospitals are paid based on whichever
of the following rates yields the greatest aggregate payment: the
Federal rate or the Federal rate plus 50 percent of the difference
between the Federal rate and the greater of the updated hospital-
specific rate based on FY 1982 and FY 1987 cost per discharge.
Hospital-specific rates have been determined for each of these
hospitals based on both the FY 1982 cost per discharge and the FY 1987
cost per discharge. For a more detailed discussion of the calculation
of the FY 1982 hospital-specific rate and the FY 1987 hospital-specific
rate, we refer the reader to the September 1, 1983 interim final rule
(48 FR 39772); the April 20, 1990 final rule with comment (55 FR
15150); and the September 4, 1990 final rule (55 FR 35994).
a. Updating the FY 1982 and FY 1987 Hospital-Specific Rates for FY
2000. We are proposing to increase the hospital-specific rates by 0.9
percent (the hospital market basket percentage increase of 2.7 percent
minus 1.8 percentage points) for sole community hospitals and Medicare-
dependent, small rural hospitals located in all areas for FY 2000.
Section 1886(b)(3)(C)(iv) of the Act provides that the update factor
applicable to the hospital-specific rates for sole community hospitals
equals the update factor provided under section 1886(b)(3)(B)(iv) of
the Act, which, for FY 2000, is the market basket rate of increase
minus 1.8 percentage points. Section 1886(b)(3)(D) of the Act provides
that the update factor applicable to the hospital-specific rates for
Medicare-dependent, small rural hospitals equals the update factor
provided under section 1886(b)(3)(B)(iv) of the Act, which, for FY
2000, is the market basket rate of increase minus 1.8 percentage
points.
b. Calculation of Hospital-Specific Rate. For sole community
hospitals and
[[Page 24756]]
Medicare-dependent, small rural hospitals, the applicable FY 2000
hospital-specific rate would be calculated by increasing the hospital's
hospital-specific rate for the preceding fiscal year by the applicable
update factor (0.9 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,
0.997393) 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 or Medicare-dependent, small rural hospital is paid
for its discharges beginning on or after October 1, 1999, based on the
formula set forth above.
3. General Formula for Calculation of Prospective Payment Rates for
Hospitals Located in Puerto Rico Beginning On or After October 1, 1999
and Before October 1, 2000.
a. Puerto Rico Rate. The Puerto Rico prospective payment rate is
determined as follows:
Step 1--Select the appropriate adjusted average standardized amount
considering the large urban or other designation of the hospital (see
Table 1C of section VI of the addendum).
Step 2--Multiply the labor-related portion of the standardized
amount by the appropriate Puerto Rico-specific wage index (see Table 4F
of section VI of the addendum).
Step 3--Add the amount from Step 2 and the nonlabor-related portion
of the standardized amount.
Step 4--Multiply the result in Step 3 by 50 percent.
Step 5--Multiply the amount from Step 4 by the appropriate DRG
relative weight (see Table 5 of section VI of the addendum).
b. National Rate. The national prospective payment rate is
determined as follows:
Step 1--Multiply the labor-related portion of the national average
standardized amount (see Table 1C of section VI of the addendum) by the
appropriate national wage index (see Tables 4A and 4B of section VI of
the addendum).
Step 2--Add the amount from Step 1 and the nonlabor-related portion
of the national average standardized amount.
Step 3--Multiply the result in Step 2 by 50 percent.
Step 4--Multiply the amount from Step 3 by the appropriate DRG
relative weight (see Table 5 of section VI of the addendum).
The sum of the Puerto Rico rate and the national rate computed
above equals the prospective payment for a given discharge for a
hospital located in Puerto Rico.
III. Proposed Changes to the Payment Rates for Blood Clotting
Factor for Hemophilia Inpatients
As discussed in our August 29, 1997 final rule with comment period
(62 FR 46002) and our May 12, 1998 final rule (63 FR 26327), section
4452 of Public Law 105-33 amended section 6011(d) of Public Law 101-239
to reinstate the add-on payment for the costs of administering blood
clotting factor to Medicare beneficiaries who have hemophilia and who
are hospital inpatients for discharges occurring on or after October 1,
1997.
We are proposing to calculate the add-on payment for FY 2000 using
the same methodology we described in the August 29, 1997 and May 12,
1998 final rules. That is, we are proposing to establish a price per
unit of clotting factor based on the average wholesale price (AWP). To
identify the AWP, we are using the most recent data available from
First DataBank, a commercial source of AWPs in electronic format. The
add-on payment amount for each clotting factor, as described by HCFA's
Common Procedure Coding System (HCPCS), is based on the median AWP of
the several products available in that category of factor, discounted
by 15 percent.
We also are proposing to add HCPCS code J7191 (clotting factor,
porcine) to the list of clotting factors that will be paid under this
benefit. This code was recently reestablished in the HCPCS coding
system because it represents a unique product that is different from
the other clotting factors listed.
Based on the methodology described above, we are proposing the
following prices per unit of factor for FY 2000:
J7190 Factor VIII (antihemophilic factor, human)................ 0.79
J7191 Factor VIII (antihemophilic factor, porcine).............. 1.87
J7192 Factor VIII (antihemophilic factor, recombinant).......... 1.03
J7194 Factor IX (complex)....................................... 0.45
J7196 Other hemophilia clotting factors (for example, anti- 1.43
inhibitors).....................................................
Q0160 Factor IX (antihemophilic factor, purified, 0.97
nonrecombinant).................................................
Q0161 Factor IX (antihemophilic factor, purified, recombinant).. 1.00
These prices for blood clotting factor administered to inpatients
who have hemophilia would be effective for discharges beginning on or
after October 1, 1999 through September 30, 2000. Payment will be made
for blood clotting factor only if there is an ICD-9-CM diagnosis code
for hemophilia included on the bill.
IV. Proposed Changes to Payment Rates for Inpatient Capital-Related
Costs for FY 2000
The prospective payment system for hospital inpatient capital-
related costs was implemented for cost reporting periods beginning on
or after October 1, 1991. Effective with that cost reporting period and
during a 10-year transition period extending through FY 2001, hospital
inpatient capital-related costs are paid on the basis of an increasing
proportion of the capital prospective payment system Federal rate and a
decreasing proportion of a hospital's historical costs for capital.
The basic methodology for determining Federal capital prospective
rates is set forth at Secs. 412.308 through 412.352. Below we discuss
the factors that we used to determine the proposed Federal rate and the
hospital-specific rates for FY 2000. The rates would be effective for
discharges occurring on or after October 1, 1999.
For FY 1992, we computed the standard Federal payment rate for
capital-related costs under the prospective payment system by updating
the FY 1989 Medicare inpatient capital cost per case by an actuarial
estimate of the increase in Medicare inpatient capital costs per case.
Each year after FY 1992, we update the standard Federal rate, as
provided in Sec. 412.308(c)(1), to account for capital input price
increases and other factors. Also, Sec. 412.308(c)(2) provides that the
Federal rate is adjusted annually by a factor equal to the estimated
proportion of outlier payments under the Federal rate to total capital
payments under the Federal rate. In addition, Sec. 412.308(c)(3)
requires that the Federal rate be reduced by an adjustment factor equal
to the estimated proportion of payments for exceptions under
Sec. 412.348. Furthermore, Sec. 412.308(c)(4)(ii) requires that the
Federal rate be adjusted so that the annual DRG reclassification and
the recalibration of DRG weights and changes in the geographic
adjustment factor are budget neutral. For FYs 1992 through 1995,
Sec. 412.352 required that the Federal rate also be adjusted by a
budget neutrality factor so that aggregate payments for inpatient
hospital capital costs were projected to equal 90 percent of the
payments that would have been made for capital-related costs on a
reasonable cost basis during the fiscal year. That provision expired in
FY 1996. Section 412.308(b)(2) describes the 7.4 percent reduction to
the rate that was made in FY 1994, and Sec. 412.308(b)(3) describes the
0.28 percent reduction to the rate made in FY 1996 as a result of
[[Page 24757]]
the revised policy of paying for transfers. In the FY 1998 final rule
with comment period (62 FR 45966) we implemented section 4402 of the
BBA, which requires that for discharges occurring on or after October
1, 1997, and before October 1, 2002, the unadjusted standard Federal
rate is reduced by 17.78 percent. A small part of that reduction will
be restored effective October 1, 2002. As a result of the February 25,
1999 final rule (64 FR 9378), the Federal rate changed effective March
1, 1999, because of revisions to the GAF.
For each hospital, the hospital-specific rate was calculated by
dividing the hospital's Medicare inpatient capital-related costs for a
specified base year by its Medicare discharges (adjusted for
transfers), and dividing the result by the hospital's case mix index
(also adjusted for transfers). The resulting case-mix adjusted average
cost per discharge was then updated to FY 1992 based on the national
average increase in Medicare's inpatient capital cost per discharge and
adjusted by the exceptions payment adjustment factor and the budget
neutrality adjustment factor to yield the FY 1992 hospital-specific
rate. Since FY 1992, the hospital-specific rate has been updated
annually for inflation and for changes in the exceptions payment
adjustment factor. For FYs 1992 through 1995, the hospital-specific
rate was also adjusted by a budget neutrality adjustment factor. For
discharges occurring on or after October 1, 1997, and before October 1,
2002, the unadjusted hospital-specific rate is reduced by 17.78
percent. A small part of this reduction will be restored effective
October 1, 2002.
To determine the appropriate budget neutrality adjustment factor
and the exceptions payment adjustment factor, we developed a dynamic
model of Medicare inpatient capital-related costs, that is, a model
that projects changes in Medicare inpatient capital-related costs over
time. With the expiration of the budget neutrality provision, the model
is still used to estimate the exceptions payment adjustment and other
factors. The model and its application are described in greater detail
in Appendix B of this proposed rule.
In accordance with section 1886(d)(9)(A) of the Act, under the
prospective payment system for inpatient operating costs, hospitals
located in Puerto Rico are paid for operating costs under a special
payment formula. Prior to FY 1998, hospitals in Puerto Rico were paid a
blended rate that consisted of 75 percent of the applicable
standardized amount specific to Puerto Rico hospitals and 25 percent of
the applicable national average standardized amount. However, effective
October 1, 1998, as a result of section 4406 of the BBA, operating
payments to hospitals in Puerto Rico are based on a blend of 50 percent
of the applicable standardized amount specific to Puerto Rico hospitals
and 50 percent of the applicable national average standardized amount.
In conjunction with this change to the operating blend percentage,
effective with discharges on or after October 1, 1997, we compute
capital payments to hospitals in Puerto Rico based on a blend of 50
percent of the Puerto Rico rate and 50 percent of the Federal rate.
Section 412.374 provides for the use of this blended payment system for
payments to Puerto Rico hospitals under the prospective payment system
for inpatient capital-related costs. Accordingly, for capital-related
costs we compute a separate payment rate specific to Puerto Rico
hospitals using the same methodology used to compute the national
Federal rate for capital.
A. Determination of Federal Inpatient Capital-Related Prospective
Payment Rate Update
In the July 31, 1998 final rule (63 FR 41011) we established a
capital Federal rate of $378.05 for FY 1999. As of the March 1, 1999
revision, the Federal rate for FY 1999 is $378.10. As a result of the
changes we are proposing to the factors used to establish the Federal
rate in this preamble, the proposed FY 2000 Federal rate is $374.31.
In the discussion that follows, we explain the factors that were
used to determine the proposed FY 2000 capital Federal rate. In
particular, we explain why the proposed FY 2000 Federal rate has
decreased 1.00 percent compared to the FY 1999 Federal rate. Even
though the proposed FY 2000 Federal capital rate is less than the FY
1999 Federal rate, we estimate aggregate capital payments will increase
by 2.66 percent during this same period. This increase is primarily due
to the increase in the Federal blend percentage from 80 to 90 percent
for fully prospective payment hospitals.
Total payments to hospitals under the prospective payment system
are relatively unaffected by changes in the capital prospective
payments. Since capital payments constitute about 10 percent of
hospital payments, a 1 percent change in the capital Federal rate
yields only about 0.1 percent change in actual payments to hospitals.
Aggregate payments under the capital prospective payment transition
system are estimated to increase in FY 2000 compared to FY 1999.
1. Standard Federal Rate Update
a. Description of the Update Framework. Under section
412.308(c)(1), the standard Federal rate is updated on the basis of an
analytical framework that takes into account changes in a capital input
price index and other factors. The update framework consists of a
capital input price index (CIPI) and several policy adjustment factors.
Specifically, we have adjusted the projected CIPI rate of increase as
appropriate each year for case-mix index related changes, for
intensity, and for errors in previous CIPI forecasts. The proposed
update factor for FY 2000 under that framework is -0.6 percent. This
proposal is based on a projected 0.5 percent increase in the CIPI, a
-0.7 percent adjustment for the FY 1998 DRG reclassification and
recalibration, and a forecast error correction of -0.4 percent. We
explain the basis for the FY 2000 CIPI projection in section II.D of
this addendum. Here we describe the policy adjustments that have been
applied.
The case-mix index is the measure of the average DRG weight for
cases paid under the prospective payment system. Because the DRG weight
determines the prospective payment for each case, any percentage
increase in the case-mix index corresponds to an equal percentage
increase in hospital payments.
The case-mix index can change for any of several reasons:
The average resource use of Medicare patients changes
(``real'' case-mix change);
Changes in hospital coding of patient records result in
higher weight DRG assignments (``coding effects''); and
The annual DRG reclassification and recalibration changes
may not be budget neutral (``reclassification effect'').
We define real case-mix change as actual changes in the mix (and
resource requirements) of Medicare patients as opposed to changes in
coding behavior that result in assignment of cases to higher-weighted
DRGs but do not reflect higher resource requirements. In the update
framework for the prospective payment system for operating costs, we
adjust the update upwards to allow for real case-mix change, but remove
the effects of coding changes on the case-mix index. We also remove the
effect on total payments of prior changes to the DRG classifications
and relative weights, in order to retain budget neutrality for all
case-mix index-related changes other than patient severity. (For
example, we adjusted for the effects of the FY 1998 DRG
reclassification and
[[Page 24758]]
recalibration as part of our FY 2000 update recommendation.) We have
adopted this case-mix index adjustment in the capital update framework
as well.
For FY 2000, we are projecting a 0.5 percent increase in the case-
mix index. We estimate that real case-mix increase will equal 0.5
percent in FY 2000. Therefore, the proposed net adjustment for case-mix
change in FY 2000 is 0.0 percentage points.
We estimate that FY 1998 DRG reclassification and recalibration
resulted in a 0.7 percent change in the case mix when compared with the
case-mix index that would have resulted if we had not made the
reclassification and recalibration changes to the DRGs. Therefore, we
are making a -0.7 percent adjustment for DRG reclassification and
recalibration in the proposed update for FY 2000.
The capital update framework contains an adjustment for forecast
error. The input price index forecast is based on historical trends and
relationships ascertainable at the time the update factor is
established for the upcoming year. In any given year there may be
unanticipated price fluctuations that may result in differences between
the actual increase in prices and the forecast used in calculating the
update factors. In setting a prospective payment rate under the
framework, we make an adjustment for forecast error only if our
estimate of the change in the capital input price index for any year is
off by 0.25 percentage points or more. There is a 2-year lag between
the forecast and the measurement of the forecast error. A forecast
error of -0.4 percentage points was calculated for the FY 1998 update.
That is, current historical data indicate that the FY 1998 CIPI used in
calculating the forecasted FY 1998 update factor overstated realized
price increases by 0.4 percent. Therefore, we are making a -0.4 percent
adjustment for forecast error in the proposed update for FY 2000.
Under the capital prospective payment system update framework, we
also make an adjustment for changes in intensity. We calculate this
adjustment using the same methodology and data as in the framework for
the operating prospective payment system. The intensity factor for the
operating update framework reflects how hospital services are utilized
to produce the final product, that is, the discharge. This component
accounts for changes in the use of quality-enhancing services, changes
in within-DRG severity, and expected modification of practice patterns
to remove cost-ineffective services.
We calculate case-mix constant intensity as the change in total
charges per admission, adjusted for price level changes (the CPI
hospital component), and changes in real case mix. The use of total
charges in the calculation of the proposed intensity factor makes it a
total intensity factor, that is, charges for capital services are
already built into the calculation of the factor. Therefore, we have
incorporated the intensity adjustment from the operating update
framework into the capital update framework. Without reliable estimates
of the proportions of the overall annual intensity increases that are
due, respectively, to ineffective practice patterns and to the
combination of quality-enhancing new technologies and within-DRG
complexity, we assume, as in the revised operating update framework,
that one-half of the annual increase is due to each of these factors.
The capital update framework thus provides an add-on to the input price
index rate of increase of one-half of the estimated annual increase in
intensity to allow for within-DRG severity increases and the adoption
of quality-enhancing technology.
For FY 2000, we have developed a Medicare-specific intensity
measure based on a 5-year average using FY 1994-1998 data. In
determining case-mix constant intensity, we found that observed case-
mix increase was 0.8 percent in FY 1994, 1.7 percent in FY 1995, 1.6
percent in FY 1996, 0.3 percent in FY 1997, and -0.4 percent in FY
1998. For FY 1995 and FY 1996, we estimate that real case-mix increase
was 1.0 to 1.4 percent each year. The estimate for those years is
supported by past studies of case-mix change by the RAND Corporation.
The most recent study was ``Has DRG Creep Crept Up? Decomposing the
Case Mix Index Change Between 1987 and 1988'' by G. M. Carter, J.P.
Newhouse, and D.A. Relles, R-4098-HCFA/ProPAC (1991). The study
suggested that real case-mix change was not dependent on total change,
but was usually a fairly steady 1.0 to 1.5 percent per year. We use 1.4
percent as the upper bound because the RAND study did not take into
account that hospitals may have induced doctors to document medical
records more completely in order to improve payment. Following that
study, we consider up to 1.4 percent of observed case-mix change as
real for FY 1994 through FY 1998. Based on this analysis, we believe
that all of the observed case-mix increase for FY 1994, FY 1997 and FY
1998 is real. The increases for FY 1995 and FY 1996 were in excess of
our estimate of real case mix increase.
We calculate case-mix constant intensity as the change in total
charges per admission, adjusted for price level changes (the CPI
hospital component), and changes in real case-mix. Given estimates of
real case mix of 0.8 percent for FY 1994, 1.0 percent for FY 1995, 1.0
percent for FY 1996, 0.3 percent for FY 1997, and -0.4 for FY 1998, we
estimate that case-mix constant intensity declined by an average 1.3
percent during FYs 1994 through 1998, for a cumulative decrease of 6.3
percent. If we assume that real case-mix increase was 0.8 percent for
FY 1994, 1.4 percent for FY 1995, 1.4 percent for FY 1996, 0.3 percent
for FY 1997, and -0.4 for FY 1998, we estimate that case-mix constant
intensity declined by an average 1.5 percent during FYs 1994 through
1998, for a cumulative decrease of 7.1 percent. Since we estimate that
intensity has declined during that period, we are recommending a 0.0
percent intensity adjustment for FY 2000.
b. Comparison of HCFA and MedPAC Update Recommendations. MedPAC
recommends a -1.1 to 1.8 percent update to the standard capital Federal
rate and we are recommending a -0.6 percent update. There are some
significant differences between the HCFA and MedPAC update frameworks,
which account for the difference in the respective update
recommendations. A major difference is the input price index that each
framework uses as a beginning point to estimate the change in input
prices since the previous year. The HCFA capital input price index (the
CIPI) includes price measures for interest expense, which are an
indicator of the interest rates facing hospitals during their capital
purchasing decisions. The MedPAC capital market basket does not include
interest expense; instead the MedPAC update framework includes a
financing policy adjustment when necessary to account for the prolonged
changes in interest rates. HCFA's CIPI is vintage-weighted, meaning
that it takes into account price changes from past purchases of capital
when determining the current period update. MedPAC's capital market
basket is not vintage-weighted, accounting only for the current year
price changes. This year, due to the difference between HCFA's and
MedPAC's input price index, the percentage change in HCFA's CIPI is 0.5
percent, and the percentage change in MedPAC's market basket is 1.9
percent.
MedPAC and HCFA also differ in the adjustments they make to their
price indices. (See Table 1 for a comparison
[[Page 24759]]
of HCFA and MedPAC's update recommendations.) MedPAC makes an
adjustment for productivity, while HCFA has not adopted an adjustment
for capital productivity or efficiency. MedPAC employs the same
productivity adjustment in its operating and capital framework. We have
identified a total intensity factor but have not identified an adequate
total productivity measure. For the FY 2000 update, the Commission is
also including a site-of-care substitution adjustment to account for
the decline in the average length of Medicare acute inpatient stays.
This adjustment is designed to shift funding along with associated
costs when Medicare patients are discharged to postacute settings that
replace acute impatient days. Other factors, such as technological
advances that allow for a decreased need in follow-up care and BBA
mandated policy on payment for transfer cases that limits payments
within certain DRGs, are reflected in the site-of-care substitution
adjustment as well. A negative intensity adjustment would capture the
site of care substitution accounted for in MedPAC's update framework.
However, we did not make a negative adjustment for intensity this year.
We may examine the appropriateness of adopting a negative intensity
adjustment at a later date.
MedPAC recommends a -1.8 to a -0.9 adjustment for site-of-care
substitutions for FY 2000. For FY 2000, MedPAC recommends a -1.0 to a
0.0 adjustment for productivity. We recommend a 0.0 intensity
adjustment. Additionally, since long-term interest rates are low by
historical standards, MedPAC recommends a -0.3 to a 0.0 adjustment to
the update for FY 2000, to reflect changes in the real interest rates.
We recommend a 0.0 total case mix adjustment since we are
projecting a 0.5 percent increase in the case mix index and we estimate
that real case-mix increase will equal 0.5 percent in FY 2000. MedPAC
makes a two-part adjustment for case mix changes, which takes into
account changes in case mix in the past year. They recommend a 0.0
adjustment for coding change and an 0.0 to 0.2 adjustment for within-
DRG complexity change. We recommend a -0.4 adjustment for forecast
error correction, and MedPAC recommends a -0.4 adjustment for forecast
error correction.
The net result of these adjustments is that MedPAC has recommended
a -1.1 to 1.8 percent update to the capital Federal rate for FY 2000.
MedPAC believes that the annual updates to the capital and operating
payments under the prospective payment system should not differ
substantially, even though they are determined separately, since they
correspond to costs generated by providing the same inpatient hospital
services to the same Medicare patients. This range for the capital
update is consistent with the prospective payment system operating
update range of 0.0 to 2.6 recommended by the Commission. We describe
the basis for our proposed -0.6 percent total update in the preceding
section. Our recommendation is within the range recommended by MedPAC.
Also, MedPAC argued that the distinction between inpatient
operating and capital payment rates is arbitrary and does not foster
efficient overall decision making about the allocation of resources.
Accordingly, MedPAC recommended that once the transition to fully
perspective capital payment is completed, a single PPS payment rate
should be developed for hospital inpatient services to Medicare
beneficiaries. MedPAC indicated that a single PPS payment rate for both
operating and capital PPS costs would be consistent with the way that
hospitals purchase a majority of goods and services.
We responded to a similar comment in the July 31, 1998 final rule
(63 FR 41013) and in the September 1, 1995 final rule (60 FR 45816). In
those rules, we stated that our long-term goal was to develop a single
update framework for operating and capital prospective payments and
that we would begin development of a unified framework. We indicated
that, in the meantime, we would maintain as much consistency as
possible between the current operating and capital frameworks in order
to facilitate the eventual development of a unified framework. In
addition, we stated that because of the similarity of the update
frameworks, the update frameworks could be combined without too much
difficulty. We maintain our goal of combining the update frameworks at
the end of the capital transition period and may examine combining the
payment systems after the conclusion of the capital prospective payment
transition period.
Table 1.--HCFA's FY 2000 Update Factor and MedPAC's Recommendation
------------------------------------------------------------------------
HCFA's
update MedPAC's
factor recommendation
------------------------------------------------------------------------
Capital Input Price Index Financing Policy 0.5 1.9
Adjustment..................................
Financing Policy Adjustment.............. ......... -0.3 to 0.0
Policy Adjustment Factors:
Productivity............................. ......... -1.0 to 0.0
Intensity................................ 0.0 ..............
Science and Technology............... ......... 0.5 to 1.0
Intensity............................ ......... (1)
Real within DRG Change............... ......... (2)
Site-of-Care Substitution................ ......... -1.8 to -0.9
--------------------------
Subtotal......................... 0.0 -2.3 to 0.1
Case-Mix Adjustment Factors: ......... ..............
Projected Case-Mix Change................ -0.5 ..............
Real Across DRG Change................... 0.5 ..............
Coding Change............................ ......... 0.0
Real within DRG Change................... (3) 0.0 to 0.2
--------------------------
Subtotal......................... 0.0 0.0 to 0.2
Effect of FY 1998 Reclassification and 0.7 ..............
Recalibration...............................
Forecast Error Correction.................... -0.4 -0.4
==========================
[[Page 24760]]
Total Update..................... -0.6 -1.1 to 1.8
------------------------------------------------------------------------
1 Included in MedPAC's productivity measure.
2 Included in MedPAC's case-mix adjustment.
3 Included in HCFA's intensity factor.
2. Outlier Payment Adjustment Factor
Section 412.312(c) establishes a unified outlier methodology for
inpatient operating and inpatient capital-related costs. A single set
of thresholds is used to identify outlier cases for both inpatient
operating and inpatient capital-related payments. Outlier payments are
made only on the portion of the Federal rate that is used to calculate
the hospital's inpatient capital-related payments (for example, 90
percent for cost reporting periods beginning in FY 2000 for hospitals
paid under the fully prospective payment methodology). Section
412.308(c)(2) provides that the standard Federal rate for inpatient
capital-related costs be reduced by an adjustment factor equal to the
estimated proportion of outlier payments under the Federal rate to
total inpatient capital-related payments under the Federal rate. The
outlier thresholds are set so that operating outlier payments are
projected to be 5.1 percent of total operating DRG payments. The
inpatient capital-related outlier reduction factor reflects the
inpatient capital-related outlier payments that would be made if all
hospitals were paid 100 percent of the Federal rate. For purposes of
calculating the outlier thresholds and the outlier reduction factor, we
model payments as if all hospitals were paid 100 percent of the Federal
rate because, as explained above, outlier payments are made only on the
portion of the Federal rate that is included in the hospital's
inpatient capital-related payments.
In the July 31, 1998 final rule, we estimated that outlier payments
for capital in FY 1999 would equal 6.08 percent of inpatient capital-
related payments based on the Federal rate (63 FR 41013). Accordingly,
we applied an outlier adjustment factor of 0.9392 to the Federal rate.
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 6.03
percent of inpatient capital-related payments based on the Federal rate
in FY 2000. Therefore, we are proposing an outlier adjustment factor of
0.9397 to the Federal rate. Thus, estimated capital outlier payments
for FY 2000 represent a lower percentage of total capital standard
payments than in FY 1999.
The outlier reduction factors are not built permanently into the
rates; that is, they are not applied cumulatively in determining the
Federal rate. Therefore, the proposed net change in the outlier
adjustment to the Federal rate for FY 2000 is 1.0005 (0.9397/0.9392).
The outlier adjustment increases the FY 2000 Federal rate by 0.05
percent compared with the FY 1999 outlier adjustment.
3. Budget Neutrality Adjustment Factor for Changes in DRG
Classifications and Weights and the Geographic Adjustment Factor
Section 412.308(c)(4)(ii) requires that the Federal rate be
adjusted so that aggregate payments for the fiscal year based on the
Federal rate after any changes resulting from the annual DRG
reclassification and recalibration and changes in the GAF are projected
to equal aggregate payments that would have been made on the basis of
the Federal rate without such changes. We use the actuarial model,
described in Appendix B of this proposed rule, to estimate the
aggregate payments that would have been made on the basis of the
Federal rate without changes in the DRG classifications and weights and
in the GAF. We also use the model to estimate aggregate payments that
would be made on the basis of the Federal rate as a result of those
changes. We then use these figures to compute the adjustment required
to maintain budget neutrality for changes in DRG weights and in the
GAF.
For FY 1999, we calculated a GAF/DRG budget neutrality factor of
1.0027. In the February 25, 1999 final rule (64 FR 9381), we adopted an
incremental GAF/DRG budget neutrality factor of 1.0028 for discharges
on or after March 1, 1999. For FY 2000, we are proposing a GAF/DRG
budget neutrality factor of 0.9986. The GAF/DRG budget neutrality
factors are built permanently into the rates; that is, they are applied
cumulatively in determining the Federal rate. This follows from the
requirement that estimated aggregate payments each year be no more than
they would have been in the absence of the annual DRG reclassification
and recalibration and changes in the GAF. The proposed incremental
change in the adjustment from FY 1999 to FY 2000 is 0.9986. The
proposed cumulative change in the rate due to this adjustment is 1.0015
(the product of the incremental factors for FY 1993, FY 1994, FY 1995,
FY 1996, FY 1997, FY 1998, FY 1999, and the proposed incremental factor
for FY 2000: 0.9980 x 1.0053 x 0.9998 x 0.9994 x 0.9987 x
0.9989 x 1.0028 x 0.9986 = 1.0015).
This proposed factor accounts for DRG reclassifications and
recalibration and for changes in the GAF. It also incorporates the
effects on the GAF of FY 2000 geographic reclassification decisions
made by the MGCRB compared to FY 1999 decisions. However, it does not
account for changes in payments due to changes in the DSH and IME
adjustment factors or in the large urban add-on.
4. Exceptions Payment Adjustment Factor
Section 412.308(c)(3) requires that the standard Federal rate for
inpatient capital-related costs be reduced by an adjustment factor
equal to the estimated proportion of additional payments for exceptions
under Sec. 412.348 relative to total payments under the hospital-
specific rate and Federal rate. We use 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 1999, we estimated that exceptions payments would equal 2.17
percent of aggregate payments based on the Federal rate and the
hospital-specific rate. Therefore, we applied an exceptions reduction
factor of 0.9783 (1-0.0217) in determining the Federal rate. For this
proposed rule, we estimate that exceptions payments for FY 2000 will
equal 2.48 percent of aggregate payments based on the Federal rate and
the hospital-specific rate. Therefore, we are proposing an exceptions
payment reduction factor of 0.9752 to the Federal rate for FY 2000. The
proposed
[[Page 24761]]
exceptions reduction factor for FY 2000 is 0.32 percent lower than the
factor for FY 1999.
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 2000
Federal rate is 0.9752/0.9783, or 0.9968.
5. Standard Capital Federal Rate for FY 2000
For FY 1999 (effective March 1, 1999), the capital Federal rate was
$378.10. As a result of changes we are proposing to the factors used to
establish the Federal rate, the proposed FY 2000 Federal rate is
$374.31. The proposed Federal rate for FY 2000 was calculated as
follows:
The proposed FY 2000 update factor is 0.9940; that is, the
proposed update is -0.60 percent.
The proposed FY 2000 budget neutrality adjustment factor
that is applied to the standard Federal payment rate for changes in the
DRG relative weights and in the GAF is 0.9986.
The proposed FY 2000 outlier adjustment factor is 0.9397.
The proposed FY 2000 exceptions payments adjustment factor
is 0.9752.
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 GAF.
We are providing a chart that shows how each of the factors and
adjustments for FY 2000 affected the computation of the proposed FY
2000 Federal rate in comparison to the FY 1999 Federal rate. The
proposed FY 2000 update factor has the effect of decreasing the Federal
rate by 0.60 percent compared to the rate in FY 1999, while the
proposed geographic and DRG budget neutrality factor has the effect of
decreasing the Federal rate by 0.14 percent. The proposed FY 2000
outlier adjustment factor has the effect of increasing the Federal rate
by 0.05 percent compared to FY 1999. The proposed FY 2000 exceptions
reduction factor has the effect of decreasing the Federal rate by 0.32
percent compared to the exceptions reduction for FY 1999. The combined
effect of all the proposed changes is to decrease the proposed Federal
rate by 1.00 percent compared to the Federal rate for FY 1999.
Comparison of Factors and Adjustments: FY 1999 Federal Rate and Proposed FY 2000 Federal Rate
----------------------------------------------------------------------------------------------------------------
Proposed FY Percent
FY 1999 2000 Change change
----------------------------------------------------------------------------------------------------------------
Update factor 1............................................. 1.0010 0.9940 0.9940 -0.60
GAF/DRG Adjustment Factor 1................................. 1.0028 0.9986 0.9986 -0.14
Outlier Adjustment Factor 2................................. 0.9392 0.9397 1.0005 0.05
Exceptions Adjustment Factor 2.............................. 0.9783 0.9752 0.9968 -0.32
Federal Rate................................................ $378.10 $374.31 0.9900 -1.00
----------------------------------------------------------------------------------------------------------------
1 The update factor and the GAF/DRG budget neutrality factors are built permanently into the rates. Thus, for
example, the incremental change from FY 1999 to FY 2000 resulting from the application of the 0.9986 GAF/DRG
budget neutrality factor for FY 2000 is 0.9986.
2 The outlier reduction factor and the exceptions reduction factor are not built permanently into the rates;
that is, these factors are not applied cumulatively in determining the rates. Thus, for example, the net
change resulting from the application of the FY 2000 outlier reduction factor is 0.9397/0.9392, or 1.0005.
6. Special Rate for Puerto Rico Hospitals
As explained at the beginning of section IV of this Addendum,
hospitals in Puerto Rico are paid based on 50 percent of the Puerto
Rico rate and 50 percent of the Federal rate. The Puerto Rico rate is
derived from the costs of Puerto Rico hospitals only, while the Federal
rate is derived from the costs of all acute care hospitals
participating in the prospective payment system (including Puerto
Rico). To adjust hospitals' capital payments for geographic variations
in capital costs, we apply a geographic adjustment factor (GAF) to both
portions of the blended rate. The GAF is calculated using the operating
PPS wage index and varies depending on the MSA or rural area in which
the hospital is located. We use the Puerto Rico wage index to determine
the GAF for the Puerto Rico part of the capital blended rate and the
national wage index to determine the GAF for the national part of the
blended rate.
Since we implemented a separate GAF for Puerto Rico in 1998, we
also propose to apply separate budget neutrality adjustments for the
national GAF and for the Puerto Rico GAF. We apply the same budget
neutrality factor for DRG reclassifications and recalibration
nationally and for Puerto Rico. The Puerto Rico GAF budget neutrality
factor is 1.0015, while the DRG adjustment is 1.0001, for a combined
cumulative adjustment of 1.0016.
In computing the payment for a particular Puerto Rico hospital, the
Puerto Rico portion of the rate (50 percent) is multiplied by the
Puerto Rico-specific GAF for the MSA in which the hospital is located,
and the national portion of the rate (50 percent) is multiplied by the
national GAF for the MSA in which the hospital is located (which is
computed from national data for all hospitals in the United States and
Puerto Rico). In FY 1998, we implemented a 17.78 percent reduction to
the Puerto Rico rate as a result of the BBA. For FY 1999, before
application of the GAF, the special rate for Puerto Rico hospitals was
$181.10. With the changes we are proposing to the factors used to
determine the rate, the proposed FY 2000 special rate for Puerto Rico
is $174.15.
B. Determination of Hospital-Specific Rate Update
Section 412.328(e) of the regulations provides that the hospital-
specific rate for FY 2000 be determined by adjusting the FY 1999
hospital-specific rate by the following factors:
1. Hospital-Specific Rate Update Factor
The hospital-specific rate is updated in accordance with the update
factor for the standard Federal rate determined under
Sec. 412.308(c)(1). For FY 2000, we are proposing that the hospital-
specific rate be updated by a factor of 0.9940.
2. Exceptions Payment Adjustment Factor
For FYs 1992 through FY 2001, the updated hospital-specific rate is
multiplied by an adjustment factor to account for estimated exceptions
payments for capital-related costs under Sec. 412.348, determined as a
proportion of the total amount of payments under the hospital-specific
rate and the Federal rate. For FY 2000, we estimate that
[[Page 24762]]
exceptions payments will be 2.48 percent of aggregate payments based on
the Federal rate and the hospital-specific rate. Therefore, we propose
that the updated hospital-specific rate be reduced by a factor of
0.9752. The exceptions reduction factors are not built permanently into
the rates; that is, the factors are not applied cumulatively in
determining the hospital-specific rate. The proposed net adjustment to
the FY 2000 hospital-specific rate is 0.9752/0.9783, or 0.9968.
3. Net Change to Hospital-Specific Rate
We are providing a chart to show the net change to the hospital-
specific rate. The chart shows the factors for FY 1999 and FY 2000 and
the net adjustment for each factor. It also shows that the proposed
cumulative net adjustment from FY 1999 to FY 2000 is 0.9908, which
represents a proposed decrease of 0.92 percent to the hospital-specific
rate. For each hospital, the proposed FY 2000 hospital-specific rate is
determined by multiplying the FY 1999 hospital-specific rate by the
cumulative net adjustment of 0.9908.
Proposed FY 2000 Update and Adjustments to Hospital-Specific Rates
----------------------------------------------------------------------------------------------------------------
Proposed FY Net Percent
FY 1999 2000 adjustment change
----------------------------------------------------------------------------------------------------------------
Update Factor............................................... 1.0010 0.9940 0.9940 -0.60
Exceptions Payment Adjustment Factor........................ 0.9783 0.9752 0.9968 -0.32
Cumulative Adjustments...................................... 0.9793 0.9703 0.9908 -0.92
----------------------------------------------------------------------------------------------------------------
Note: The update factor for the hospital-specific rate is applied cumulatively in determining the rates. Thus,
the incremental increase in the update factor from FY 1999 to FY 2000 is 0.9940. In contrast, the exceptions
payment adjustment factor is not applied cumulatively. Thus, for example, the incremental increase in the
exceptions reduction factor from FY 1999 to FY 2000 is 0.9752/0.9783, or 0.9968.
C. Calculation of Inpatient Capital-Related Prospective Payments for FY
2000
During the capital prospective payment system transition period, a
hospital is paid for the inpatient capital-related costs under one of
two payment methodologies--the fully prospective payment methodology or
the hold-harmless methodology. The payment methodology applicable to a
particular hospital is determined when a hospital comes under the
prospective payment system for capital-related costs by comparing its
hospital-specific rate to the Federal rate applicable to the hospital's
first cost reporting period under the prospective payment system. The
applicable Federal rate was determined by making adjustments as
follows:
For outliers by dividing the standard Federal rate by the
outlier reduction factor for that fiscal year; and,
For the payment adjustment factors applicable to the
hospital (that is, the hospital's GAF, the disproportionate share
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 (GAF) x (Large Urban
Add-on, if applicable) x
(COLA adjustment for hospitals located in Alaska and Hawaii) x (1 +
Disproportionate Share Adjustment Factor + IME Adjustment Factor, if
applicable).
The result is the adjusted Federal rate.
Payments under the hold-harmless methodology are determined under
one of two formulas. A hold-harmless hospital is paid the higher of the
following:
100 percent of the adjusted Federal rate for each
discharge; or
An old capital payment equal to 85 percent (100 percent
for sole community hospitals) of the hospital's allowable Medicare
inpatient old capital costs per discharge for the cost reporting period
plus a new capital payment based on a percentage of the adjusted
Federal rate for each discharge. The percentage of the adjusted Federal
rate equals the ratio of the hospital's allowable Medicare new capital
costs to its total Medicare inpatient capital-related costs in the cost
reporting period.
Once a hospital receives payment based on 100 percent of the
adjusted Federal rate in a cost reporting period beginning on or after
October 1, 1994 (or the first cost reporting period after obligated
capital that is recognized as old capital under Sec. 412.302(c) is put
in use for patient care, if later), the hospital continues to receive
capital prospective payment system payments on that basis for the
remainder of the transition period.
Payment for each discharge under the fully prospective methodology
is the sum of the following:
The hospital-specific rate multiplied by the DRG relative
weight for the discharge and by the applicable hospital-specific
transition blend percentage for the cost reporting period; and
The adjusted Federal rate multiplied by the Federal
transition blend percentage.
The blend percentages for cost reporting periods beginning in FY
2000 are 90 percent of the adjusted Federal rate and 10 percent of the
hospital-specific rate.
Hospitals may also receive outlier payments for those cases that
qualify under the thresholds established for each fiscal year. Section
412.312(c) provides for a single set of thresholds to identify outlier
cases for both inpatient operating and inpatient capital-related
payments. Outlier payments are made only on that portion of the Federal
rate that is used to calculate the hospital's inpatient capital-related
payments. For fully prospective hospitals, that portion is 90 percent
of the Federal rate for discharges occurring in cost reporting periods
beginning during FY 2000. Thus, a fully prospective hospital will
receive 90 percent of the capital-related outlier payment calculated
for the case for discharges occurring in cost reporting periods
beginning in FY 2000. For hold-harmless hospitals paid 85 percent of
their reasonable costs for old inpatient capital, the portion of the
Federal rate that is included in the hospital's outlier payments is
based on the hospital's ratio of Medicare inpatient costs for new
capital to total Medicare inpatient capital costs. For hold-harmless
hospitals that are paid 100 percent of the Federal rate, 100 percent of
the Federal rate is included in the hospital's outlier payments.
The proposed outlier thresholds for FY 2000 are in section II.A.4.c
of this
[[Page 24763]]
Addendum. For FY 2000, 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 $14,575.
During the capital prospective payment system transition period, a
hospital may also receive an additional payment under an exceptions
process if its total inpatient capital-related payments are less than a
minimum percentage of its allowable Medicare inpatient capital-related
costs. The minimum payment level is established by class of hospital
under Sec. 412.348. The proposed minimum payment levels for portions of
cost reporting periods occurring in FY 2000 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.
D. Capital Input Price Index
1. Background
Like the prospective payment hospital operating input price index,
the Capital Input Price Index (CIPI) is a fixed-weight price index that
measures the price changes associated with costs during a given year.
The CIPI differs from the operating input price index in one important
aspect--the CIPI reflects the vintage nature of capital, which is the
acquisition and use of capital over time. Capital expenses in any given
year are determined by the stock of capital in that year (that is,
capital that remains on hand from all current and prior capital
acquisitions). An index measuring capital price changes needs to
reflect this vintage nature of capital. Therefore, the CIPI was
developed to capture the vintage nature of capital by using a weighted-
average of past capital purchase prices up to and including the current
year.
Using Medicare cost reports, AHA data, and Securities Data
Corporation data, a vintage-weighted price index was developed to
measure price increases associated with capital expenses. We
periodically update the base year for the operating and capital input
prices to reflect the changing composition of inputs for operating and
capital expenses. Currently, the CIPI is based to FY 1992 and was last
rebased in 1997. The most recent explanation of the CIPI was discussed
in the final rule with comment period for FY 1998 published in the
August 29, 1997 Federal Register (62 FR 46050). The following Federal
Register documents also describe development and revisions of the
methodology involved with the construction of the CIPI: September 1,
1992 (57 FR 40016), May 26, 1993 (58 FR 30448), September 1, 1993 (58
FR 46490), May 27, 1994 (59 FR 27876), September 1, 1994 (59 FR 45517),
June 2, 1995 (60 FR 29229), and September 1, 1995 (60 FR 45815), May
31, 1996 (61 FR 27466), August 30, 1996 (61 FR 46196), June 2, 1997 (62
FR 29953), August 29, 1997 (62 FR 46050), May 8, 1998 (63 FR 25619),
and July 31, 1998 (63 FR 41017).
2. Forecast of the CIPI for Federal Fiscal Year 2000
We are forecasting the CIPI to increase 0.5 percent for FY 2000.
This reflects a projected 1.6 percent increase in vintage-weighted
depreciation prices (building and fixed equipment, and movable
equipment) and a 3.2 percent increase in other capital expense prices
in FY 2000, partially offset by a 3.2 percent decline in vintage-
weighted interest rates in FY 2000. The weighted average of these three
factors produces the 0.5 percent increase for the CIPI as a whole.
V. Proposed Changes to Payment Rates for Excluded Hospitals and
Hospital Units: Rate-of-Increase Percentages
A. Rate-of-Increase Percentages for Excluded Hospitals and Hospital
Units
The inpatient operating costs of hospitals and hospital units
excluded from the prospective payment system are subject to rate-of-
increase limits established under the authority of section 1886(b) of
the Act, which is implemented in regulations at Sec. 413.40. Under
these limits, a hospital-specific target amount (expressed in terms of
the inpatient operating cost per discharge) is set for each hospital,
based on the hospital's own historical cost experience trended forward
by the applicable rate-of-increase percentages (update factors). In the
case of a psychiatric hospital or hospital unit, rehabilitation
hospital or hospital unit, or long-term care hospital, the target
amount may not exceed the updated figure for the 75th percentile of
target amounts for hospitals and units in the same class (psychiatric,
rehabilitation, and long-term care) for cost reporting periods ending
during FY 1996. The target amount is multiplied by the number of
Medicare discharges in a hospital's cost reporting period, yielding the
ceiling on aggregate Medicare inpatient operating costs for the cost
reporting period.
Each hospital-specific target amount is adjusted annually, at the
beginning of each hospital's cost reporting period, by an applicable
update factor.
Section 1886(b)(3)(B) of the Act, which is implemented in
regulations at Sec. 413.40(c)(3)(vii), provides that for cost reporting
periods beginning on or after October 1, 1999 and before October 1,
2000, the update factor depends on the hospital's or hospital unit's
costs in relation to the ceiling. For hospitals with costs exceeding
the ceiling by 10 percent or more, the update factor is the market
basket increase. For hospitals with costs exceeding the ceiling by less
than 10 percent, the update factor is the market basket minus .25
percent for each percentage point by which costs are less than 10
percent over the ceiling. For hospitals with costs equal to or less
than the ceiling but greater than 66.7 percent of the ceiling, the
update factor is the greater of 0 percent or the market basket minus
2.5 percent. For hospitals with costs that do not exceed 66.7
[[Page 24764]]
percent of the ceiling, the update factor is 0.
The most recent forecast of the market basket increase for FY 2000
for hospitals and hospital units excluded from the prospective payment
system is 2.6 percent. Therefore, the update to a hospital's target
amount for its cost reporting period beginning in FY 2000 would be
between 0 and 2.6 percent.
In addition, Sec. 413.40(c)(4)(iii) requires that for cost
reporting periods beginning on or after October 1, 1999 and before
October 1, 2000, the target amount for each psychiatric hospital or
hospital unit, rehabilitation hospital or hospital unit, and long-term
care hospital cannot exceed a cap on the target amounts for hospitals
in the same class. For cost reporting periods beginning in FY 2000, the
proposed caps are $11,076 for psychiatric hospitals and hospital units,
$20,071 for rehabilitation hospitals and hospital units, and $39,596
for long-term care hospitals. Regulations at Sec. 413.40(d) specify the
formulas for determining bonus and relief payments for excluded
hospitals and specify established criteria for an additional bonus
payment for continuous improvement. Regulations at
Sec. 413.40(f)(2)(ii) specify the payment methodology for new hospitals
and hospital units (psychiatric, rehabilitation, and long-term care)
effective October 1, 1997.
VI. Tables
This section contains the tables referred to throughout the
preamble to this 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, 4F, 5, 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 1998 and Hospital Average Hourly Wage for Federal Fiscal
Year 2000 Wage Index
Table 4A--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Urban Areas
Table 4B--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Rural Areas
Table 4C--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Hospitals That Are Reclassified
Table 4D--Average Hourly Wage for Urban Areas
Table 4E--Average Hourly Wage for Rural Areas
Table 4F--Puerto Rico Wage Index and Capital Geographic Adjustment
Factor (GAF)
Table 5--List of Diagnosis Related Groups (DRGs), Relative Weighting
Factors, Geometric Mean Length of Stay, and Arithmetic Mean Length of
Stay Points Used in the Prospective Payment System
Table 7A--Medicare Prospective Payment System Selected Percentile
Lengths of Stay FY 98 MEDPAR Update 12/98 GROUPER V16.0
Table 7B--Medicare Prospective Payment System Selected Percentile
Lengths of Stay FY 98 MEDPAR Update 12/98 GROUPER V17.0
Table 8A--Statewide Average Operating Cost-to-Charge Ratios for Urban
and Rural Hospitals (Case Weighted) March 1999
Table 1A.--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor
------------------------------------------------------------------------
Large urban areas Other areas
------------------------------------------------------------------------
Labor-related Nonlabor-related Labor-related Nonlabor-related
------------------------------------------------------------------------
2,804.51 1,139.95 2,760.12 1,121.90
------------------------------------------------------------------------
Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
Large urban areas Other areas
---------------------------------------------------------------
Labor Nonlabor Labor Nonlabor
----------------------------------------------------------------------------------------------------------------
National........................................ 2,780.77 1,130.30 2,780.77 1,130.30
Puerto Rico..................................... 1,335.82 537.70 1,314.67 529.19
----------------------------------------------------------------------------------------------------------------
Table 1D.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
Rate
------------------------------------------------------------------------
National................................................... 374.31
Puerto Rico................................................ 174.15
------------------------------------------------------------------------
[[Page 24765]]
Table 3C.--Hospital Case Mix Indexes for Discharges Occurring in Federal
Fiscal Year 1998; Hospital Average Hourly Wage for Federal Fiscal Year
2000 Wage Index
------------------------------------------------------------------------
Avg.
Prov. Case mix hourly
index wage
------------------------------------------------------------------------
010001................................................ 1.4554 15.85
010004................................................ 0.9916 15.02
010005................................................ 1.1743 16.26
010006................................................ 1.4464 17.31
010007................................................ 1.1415 14.80
010008................................................ 1.1818 17.65
010009................................................ 1.0947 17.53
010010................................................ 1.0813 15.91
010011................................................ 1.5845 20.63
010012................................................ 1.2638 19.30
010015................................................ 1.0478 18.35
010016................................................ 1.2449 16.13
010018................................................ 0.9705 18.96
010019................................................ 1.2752 15.49
010021................................................ 1.2478 14.63
010022................................................ 0.9572 20.51
010023................................................ 1.6841 16.26
010024................................................ 1.4253 16.03
010025................................................ 1.3495 14.53
010027................................................ 0.8128 14.93
010029................................................ 1.5973 16.41
010031................................................ 1.4197 18.02
010032................................................ 0.8709 12.65
010033................................................ 1.9994 19.23
010034................................................ 1.0469 14.73
010035................................................ 1.2391 17.48
010036................................................ 1.0924 22.58
010038................................................ 1.2343 18.33
010039*............................................... 1.6327 18.81
010040................................................ 1.4992 19.10
010043................................................ 1.0500 16.20
010044................................................ 1.0251 17.02
010045................................................ 1.1784 15.01
010046................................................ 1.4732 17.18
010047................................................ 0.9281 16.38
010049................................................ 1.1802 14.48
010050................................................ 1.0767 15.42
010051................................................ 0.8974 9.94
010052................................................ 1.0154 13.86
010053................................................ 1.0510 13.18
010054................................................ 1.1343 17.12
010055................................................ 1.4214 18.19
010056................................................ 1.3310 19.08
010058................................................ 1.0341 12.78
010059................................................ 1.0571 18.19
010061................................................ 1.1108 15.92
010062................................................ 1.0103 13.57
010064................................................ 1.7507 20.90
010065................................................ 1.3275 15.64
010066................................................ 0.8966 12.07
010068................................................ 1.3058 18.74
010069................................................ 1.1341 13.57
010072................................................ 1.0767 14.35
010073................................................ 0.8779 12.83
010078................................................ 1.2917 17.71
010079................................................ 1.1849 16.87
010080................................................ ........ 13.85
010081................................................ 1.6352 10.92
010083................................................ 1.0573 16.21
010084................................................ 1.5014 18.78
010085................................................ 1.3174 23.43
010086................................................ 1.0101 14.93
010087................................................ 1.7240 18.39
010089................................................ 1.2016 16.61
010090................................................ 1.6543 18.11
010091................................................ 0.9852 16.36
010092................................................ 1.4229 16.25
010094................................................ 1.1553 18.56
010095................................................ 1.0478 11.90
010097................................................ 0.8658 12.90
010098................................................ 0.9903 14.28
010099................................................ 1.1704 15.93
010100................................................ 1.2946 15.48
010101................................................ 1.0189 15.42
010102................................................ 0.9304 12.73
010103................................................ 1.8373 19.09
010104................................................ 1.6940 17.84
010108................................................ 1.1487 8.43
010109................................................ 1.0505 14.09
010110................................................ 0.9677 15.91
010112................................................ 1.1430 15.11
010113................................................ 1.6124 17.24
010114................................................ 1.2547 17.26
010115................................................ 0.8486 13.75
010118................................................ 1.2460 17.93
010119................................................ 0.8454 18.17
010120................................................ 0.9887 17.03
010121................................................ 1.2837 15.18
010123................................................ 1.1677 18.16
010124................................................ 1.2293 16.27
010125................................................ 1.0592 14.42
010126................................................ 1.1226 17.64
010127................................................ 1.3140 19.61
010128................................................ 0.9181 12.57
010129................................................ 1.0657 14.43
010130................................................ 1.0438 16.35
010131................................................ 1.3316 17.91
010134................................................ 0.8091 10.78
010138................................................ 0.9201 12.13
010139................................................ 1.6352 19.95
010143................................................ 1.2331 15.67
010144................................................ 1.4122 17.12
010145................................................ 1.3320 19.99
010146................................................ 1.1893 18.86
010148................................................ 0.9793 14.64
010149................................................ 1.2499 17.08
010150................................................ 1.0444 16.87
010152................................................ 1.2458 15.08
010155................................................ 1.0820 16.70
020001................................................ 1.5225 27.97
020001................................................ 0.8749 ......
020002................................................ 1.0518 26.91
020004................................................ 1.1822 26.40
020005................................................ 0.8955 29.01
020006................................................ 1.1279 26.77
020007................................................ 0.8238 24.96
020009................................................ 0.8160 23.18
020010................................................ 0.9401 18.64
020011................................................ 0.9160 29.47
020012................................................ 1.2784 23.92
020013................................................ 0.9595 26.82
020014................................................ 1.1175 24.09
020014................................................ 1.4452 18.50
020017................................................ 1.4913 24.97
020018................................................ 0.9175 ......
020019................................................ 0.7991 ......
020021................................................ 0.7833 ......
020024................................................ 1.1070 22.73
020025................................................ 0.8911 27.15
020026................................................ 1.2510 ......
020027................................................ 0.9446 ......
030001................................................ 1.2609 19.47
030002................................................ 1.8047 21.41
030003................................................ 2.2773 23.68
030004................................................ 0.9879 17.73
030006................................................ 1.5274 17.64
030007................................................ 1.2554 18.56
030008................................................ 2.1835 ......
030009................................................ 1.2480 17.93
030010................................................ 1.3865 18.80
030011................................................ 1.4370 20.08
030012................................................ 1.2400 19.28
030012................................................ 1.3439 17.62
030013................................................ 1.2707 21.02
030014................................................ 1.5090 19.47
030016................................................ 1.2344 20.56
030017................................................ 1.4184 19.80
030018................................................ 1.8588 18.91
030019................................................ 1.2360 19.91
030022................................................ 1.4920 15.79
030023................................................ 1.4956 22.44
030024*............................................... 1.7461 21.86
030025................................................ 0.9555 17.67
030027................................................ 0.9637 17.56
030030................................................ 1.6444 21.62
030033................................................ 1.2359 16.84
030034................................................ 0.9867 19.09
030035................................................ 1.1565 19.72
030036................................................ 1.2807 18.94
030037................................................ 2.0840 21.43
030038................................................ 1.6154 22.08
030040................................................ 1.0766 17.97
030041................................................ 0.8876 17.44
030043................................................ 1.2210 20.58
030044................................................ 0.8783 16.47
030047................................................ 0.8953 19.69
030049................................................ 0.8732 19.09
030054................................................ 0.8646 14.49
030055................................................ 1.2321 18.28
030059................................................ 1.2861 21.05
030060................................................ 1.1438 16.77
030061................................................ 1.6876 17.35
030062................................................ 1.1773 17.48
030064................................................ 1.7545 18.54
030065................................................ 1.8106 19.93
030067................................................ 1.0273 15.62
030068................................................ 1.0198 17.35
030069................................................ 1.3658 19.00
030071................................................ 0.9615 ......
030073................................................ 1.0330 ......
030074................................................ 0.8723 ......
030075................................................ 0.8002 ......
030076................................................ 0.8839 ......
[[Page 24766]]
030077................................................ 0.8563 ......
030078................................................ 1.1466 ......
030079................................................ 0.9065 ......
030080................................................ 1.3765 19.99
030083................................................ 1.2782 23.64
030084................................................ 1.1334 ......
030085................................................ 1.4665 17.84
030087................................................ 1.6818 20.39
030088................................................ 1.3654 19.58
030089................................................ 1.6757 19.50
030092................................................ 1.5829 21.56
030093................................................ 1.4182 19.47
030094................................................ 1.2704 19.78
030095................................................ 1.1383 14.25
030099................................................ 0.9405 18.07
030100................................................ 2.0377 ......
030101................................................ 1.4091 ......
030102................................................ 2.6049 ......
040001................................................ 1.0898 15.57
040002................................................ 1.1548 14.09
040003................................................ 1.1009 14.00
040004................................................ 1.6240 17.29
040005................................................ 1.0392 12.88
040007................................................ 1.6923 19.52
040008................................................ 1.0369 12.70
040011................................................ 0.9437 12.27
040014................................................ 1.3239 15.39
040015................................................ 1.2153 14.60
040016................................................ 1.6757 17.54
040017................................................ 1.1681 14.95
040018................................................ 1.2213 17.56
040019................................................ 1.0343 25.71
040020................................................ 1.6155 14.81
040021................................................ 1.1803 16.28
040022................................................ 1.4732 16.00
040024................................................ 0.9967 15.73
040025................................................ 0.9089 10.95
040026................................................ 1.5803 18.24
040027................................................ 1.2533 14.54
040028................................................ 1.0058 12.84
040029................................................ 1.2994 17.78
040030................................................ 0.8774 14.15
040032................................................ 0.9640 13.33
040035................................................ 0.9449 11.21
040036................................................ 1.4553 17.91
040037................................................ 1.0573 13.48
040039................................................ 1.2280 13.84
040040................................................ 0.9016 17.43
040041................................................ 1.2600 13.36
040041................................................ 1.3395 22.59
040042................................................ 1.1970 14.66
040044................................................ 1.0388 11.44
040045................................................ 1.0120 18.77
040047................................................ 1.0272 16.39
040048................................................ ........ 15.82
040050................................................ 1.1538 11.79
040051................................................ 1.0863 16.28
040053................................................ 1.0741 15.82
040054................................................ 0.9793 15.04
040055................................................ 1.4239 16.10
040058................................................ 1.0515 15.67
040060................................................ 0.9756 11.47
040062................................................ 1.6588 17.28
040064................................................ 1.0572 12.40
040066................................................ 1.0456 17.64
040067................................................ 1.0993 13.49
040069................................................ 1.0282 16.11
040070................................................ 0.9322 15.48
040071................................................ 1.6635 16.12
040072................................................ 1.0381 15.84
040074................................................ 1.2312 17.38
040075................................................ 1.0116 12.75
040076................................................ 1.0811 18.55
040077................................................ 1.0517 12.46
040078................................................ 1.5208 17.86
040080................................................ 1.0062 15.74
040081................................................ 0.8665 10.68
040082................................................ 1.0845 16.51
040084................................................ 1.1071 17.25
040085................................................ 1.1521 15.78
040088................................................ 1.3888 15.67
040090................................................ 0.8936 17.55
040091................................................ 1.1718 17.04
040093................................................ 0.9205 12.90
040100................................................ 1.1466 14.97
040105................................................ 0.9914 14.24
040106................................................ 0.9670 15.40
040107................................................ 1.0684 19.62
040109................................................ 1.1501 13.98
040114................................................ 1.8323 18.31
040116................................................ 1.1343 19.57
040118................................................ 1.4187 17.43
040119................................................ 1.1546 14.62
040124................................................ 1.0493 17.25
040126................................................ 0.9485 11.68
040132................................................ ........ 13.18
040134................................................ 2.7108 ......
040135................................................ 2.3711 ......
050002................................................ 1.4958 27.60
050006................................................ 1.4137 19.53
050007................................................ 1.4826 29.54
050008................................................ 1.4218 25.86
050009................................................ 1.6817 26.25
050013................................................ 1.9898 24.85
050014................................................ 1.2086 24.53
050015................................................ 1.4488 25.38
050016................................................ 1.1530 20.15
050017*............................................... 2.0931 23.63
050018................................................ 1.3662 14.66
050021................................................ ........ 28.50
050022................................................ 1.6635 22.55
050024................................................ 1.3224 20.34
050025*............................................... 1.7835 20.30
050026*............................................... 1.5148 28.57
050028................................................ 1.3534 16.45
050029................................................ 1.4007 23.29
050030................................................ 1.3133 21.01
050033................................................ 1.4634 24.56
050036................................................ 1.7263 20.47
050038................................................ 1.3484 27.83
050039................................................ 1.6233 22.25
050040................................................ 1.1965 30.67
050042................................................ 1.2702 22.23
050043................................................ 1.4929 33.51
050045................................................ 1.2651 20.73
050046................................................ 1.1767 26.35
050047................................................ 1.5561 29.44
050051................................................ 1.1204 17.84
050054................................................ 1.1916 19.37
050055................................................ 1.2420 29.09
050056................................................ 1.3412 23.82
050057................................................ 1.6051 21.27
050058................................................ 1.4966 25.37
050060................................................ 1.5503 20.92
050061................................................ 1.4118 23.74
050063*............................................... 1.3493 23.07
050065................................................ 1.6823 21.18
050066................................................ 1.3020 21.42
050067................................................ 1.2472 21.30
050068................................................ 1.1039 28.48
050069................................................ 1.6089 29.30
050070................................................ 1.2353 32.60
050071................................................ 1.3248 33.14
050072................................................ 1.3875 32.97
050073................................................ 1.2629 34.61
050074................................................ 0.8073 ......
050075................................................ 1.3484 33.52
050076................................................ 2.0314 33.88
050077................................................ 1.5621 23.22
050078................................................ 1.2974 25.98
050079................................................ 1.4850 30.03
050082................................................ 1.6712 21.70
050084................................................ 1.6107 23.10
050088................................................ 0.9686 24.06
050089................................................ 1.3384 19.12
050090................................................ 1.2640 23.81
050091................................................ 1.0925 22.22
050092................................................ 0.8469 15.38
050093................................................ 1.5659 24.08
050095................................................ ........ 33.38
050096................................................ 1.1356 21.67
050097................................................ 1.5113 22.61
050099................................................ 1.4590 23.66
050100................................................ 1.6407 30.06
050101................................................ 1.3575 30.01
050102................................................ 1.3583 21.29
050103*............................................... 1.5762 25.38
050104................................................ 1.4490 25.44
050107................................................ 1.4605 21.76
050108................................................ 1.8355 26.46
050109................................................ ........ 26.48
050110................................................ 1.2159 20.18
050111................................................ 1.2944 21.74
050112................................................ 1.3623 26.31
050113................................................ 1.3163 27.73
050114................................................ 1.3788 25.91
050115................................................ 1.4961 20.94
050116................................................ 1.5241 24.81
050117................................................ 1.3978 20.44
050118................................................ 1.1846 23.94
050121................................................ 1.2928 18.94
050122................................................ 1.5685 ......
050124................................................ 1.2796 23.02
[[Page 24767]]
050125................................................ 1.3663 24.04
050126................................................ 1.4556 23.84
050127................................................ 1.2518 19.76
050128................................................ 1.6084 24.18
050129................................................ 1.7494 13.86
050131................................................ 1.2640 29.06
050132................................................ 1.3640 22.91
050133................................................ 1.2704 24.40
050135................................................ 1.4808 27.03
050136................................................ 1.3536 24.43
050137................................................ 1.2990 30.07
050138................................................ 2.0444 37.41
050139................................................ 1.2535 31.38
050140................................................ 1.3204 33.66
050144................................................ 1.4207 25.75
050145................................................ 1.3756 33.06
050146................................................ 1.5841 ......
050148................................................ 1.1044 21.06
050149................................................ 1.4969 21.91
050150................................................ 1.2679 23.48
050152................................................ 1.3293 28.42
050153................................................ 1.6402 29.59
050155................................................ 1.0988 22.94
050158................................................ 1.2998 27.67
050159................................................ 1.3323 25.21
050167................................................ 1.3726 21.68
050168................................................ 1.5375 24.56
050169................................................ 1.4739 24.64
050170................................................ 1.4500 22.20
050172................................................ 1.2520 17.70
050173................................................ 1.3744 23.33
050174................................................ 1.7008 31.21
050175................................................ 1.2719 27.38
050177................................................ 1.1869 20.25
050179................................................ 1.2306 19.29
050180................................................ 1.5813 32.19
050183................................................ 1.2743 19.98
050186................................................ 1.3455 21.91
050188................................................ 1.4391 27.44
050189................................................ 0.9661 23.24
050191................................................ 1.4683 19.96
050193................................................ 1.1582 23.73
050194................................................ 1.2312 28.27
050195................................................ 1.5639 34.54
050196................................................ 1.2815 16.69
050197................................................ 1.9562 31.26
050204................................................ 1.5299 24.39
050205................................................ 1.2841 24.02
050211................................................ 1.3183 31.15
050213................................................ 1.5713 20.73
050214................................................ 1.5448 20.87
050215................................................ 1.5700 29.63
050215................................................ 1.2334 23.00
050217................................................ 1.2876 19.89
050219................................................ 1.1425 25.47
050219................................................ ........ 26.32
050222................................................ 1.5157 27.04
050224................................................ 1.5832 23.79
050225................................................ 1.5625 20.93
050225................................................ 1.0612 20.15
050226................................................ 1.3274 24.24
050228................................................ 1.3089 30.16
050230................................................ 1.4112 25.30
050231................................................ 1.6440 25.63
050232................................................ 1.5636 23.38
050233................................................ ........ 31.40
050234................................................ 1.1512 27.98
050235................................................ 1.5544 25.86
050236................................................ 1.5146 26.27
050238................................................ 1.5288 24.00
050239*............................................... 1.5967 20.55
050240................................................ 1.5246 25.18
050241................................................ 1.1378 27.22
050242................................................ 1.4446 30.14
050243................................................ 1.5312 22.91
050245................................................ 1.5041 22.10
050248................................................ 1.2054 25.99
050251................................................ 1.1113 18.50
050253................................................ 1.4184 19.76
050254................................................ 1.1991 19.69
050256................................................ 1.7681 21.74
050257................................................ 0.9509 19.59
050260................................................ 0.9690 23.52
050261................................................ 1.2103 20.45
050262................................................ 1.8148 28.30
050264................................................ 1.3466 29.45
050267................................................ 1.6936 24.75
050270................................................ 1.3630 23.83
050272................................................ 1.3986 21.44
050274................................................ 0.9467 21.19
050276................................................ 1.1725 28.51
050276................................................ 1.4351 23.14
050277................................................ 1.4815 22.31
050278................................................ 1.5070 23.84
050279................................................ 1.2886 21.06
050280................................................ 1.6534 24.46
050282................................................ 1.3492 23.98
050286................................................ 0.9172 17.80
050289................................................ 1.7279 28.87
050290................................................ 1.6741 26.37
050291................................................ 1.1709 26.49
050292................................................ 1.1236 22.38
050293................................................ 1.0656 19.18
050295................................................ 1.4569 20.28
050296................................................ 1.2171 25.32
050298................................................ 1.3268 20.52
050299................................................ 1.3252 25.26
050300................................................ 1.4143 22.46
050301................................................ 1.2326 26.03
050302................................................ ........ 29.19
050305................................................ 1.5862 32.71
050307................................................ 1.2747 24.39
050308................................................ 1.5099 28.40
050309................................................ 1.2834 24.40
050310................................................ ........ 20.62
050312................................................ 1.9696 23.79
050313................................................ 1.1560 23.10
050315................................................ 1.3473 21.92
050317................................................ ........ 19.45
050320................................................ 1.2371 30.56
050324................................................ 2.0030 26.27
050327................................................ 1.6651 22.32
050329................................................ 1.2991 19.54
050331................................................ 1.3646 25.53
050334................................................ 1.7493 32.02
050335................................................ 1.4570 21.04
050336................................................ 1.3561 20.10
050342................................................ 1.2512 21.90
050343................................................ 0.9711 17.24
050348................................................ 1.7865 20.71
050349................................................ 0.8866 15.05
050350................................................ 1.4046 23.77
050351................................................ 1.4821 24.94
050352................................................ 1.3151 23.59
050353................................................ 1.6183 23.25
050355................................................ 0.8385 17.16
050357................................................ 1.3583 23.64
050359................................................ 1.2481 20.40
050360................................................ 1.4309 31.76
050366................................................ 1.3334 21.40
050367................................................ 1.2586 29.48
050369................................................ 1.3031 19.87
050373................................................ 1.4037 21.92
050376................................................ 1.4260 25.30
050377................................................ 1.0300 25.64
050377................................................ 0.8258 ......
050378................................................ 1.0916 22.24
050379................................................ 1.0223 16.90
050380................................................ 1.6105 30.58
050382................................................ 1.3610 21.00
050385................................................ 1.3408 25.92
050388................................................ 0.8708 13.20
050390................................................ 1.1966 22.39
050391................................................ 1.3438 22.42
050392................................................ 0.9321 21.93
050394................................................ 1.5689 22.32
050396................................................ 1.6448 23.63
050397................................................ 0.9378 20.77
050401................................................ 1.1055 17.78
050404................................................ 1.0623 19.28
050406................................................ 1.0266 17.12
050407................................................ 1.2842 30.12
050410................................................ 1.0721 16.47
050411................................................ 1.3571 32.24
050414................................................ 1.3002 24.34
050417................................................ 1.3224 21.89
050419................................................ 1.3788 23.12
050420................................................ 1.3048 22.68
050421................................................ 1.2343 ......
050423................................................ 1.0115 22.33
050424................................................ 1.8351 23.78
050425................................................ 1.2290 33.69
050426................................................ 1.3912 23.71
050427................................................ 0.9378 20.07
050430................................................ 1.0036 21.14
050432................................................ 1.5223 21.50
050433................................................ 0.9711 16.80
050434................................................ 1.0630 15.63
050435................................................ 1.1647 32.99
050436................................................ 1.0075 16.36
050436................................................ 0.9233 18.33
050438................................................ 1.7365 24.08
050440................................................ 1.2718 30.82
[[Page 24768]]
050441................................................ 1.9387 29.05
050443................................................ 0.8693 16.43
050444................................................ 1.3199 24.67
050446................................................ 0.8088 20.54
050447................................................ 1.0794 18.34
050448................................................ 1.1060 20.08
050449................................................ 1.2885 22.13
050454*............................................... 1.7746 28.69
050455................................................ 1.7950 19.92
050455................................................ 1.2816 23.39
050456................................................ 1.2213 17.62
050457................................................ 1.9135 31.18
050459................................................ 1.5161 37.09
050464................................................ 1.7086 22.31
050468................................................ 1.5610 23.17
050469................................................ 1.1462 19.84
050470................................................ 1.1450 17.03
050470................................................ 1.2419 24.35
050471................................................ 1.8998 24.29
050476................................................ 1.3673 23.14
050477................................................ 1.4363 27.71
050478................................................ 0.9815 23.05
050481................................................ 1.3946 22.95
050482................................................ 1.0697 16.93
050483................................................ 2.2575 21.60
050483................................................ 1.5954 26.32
050485................................................ 1.6061 23.70
050486................................................ ........ 24.50
050488................................................ 1.3254 32.86
050491................................................ 1.1970 24.15
050492................................................ 1.4174 21.42
050494................................................ 1.2385 25.41
050496................................................ 1.7580 33.02
050498................................................ 1.2265 24.87
050502................................................ 1.7255 22.63
050503................................................ 1.3465 23.59
050506................................................ 1.3628 21.22
050510................................................ 1.2780 33.46
050512................................................ 1.4414 34.31
050515................................................ 1.3431 35.04
050516................................................ 1.5018 25.14
050517................................................ 1.2038 20.37
050522................................................ 1.1580 31.73
050523................................................ 1.2445 28.42
050526................................................ 1.2949 23.19
050528................................................ 1.1896 18.69
050531................................................ 1.1101 20.73
050534................................................ 1.2830 23.31
050535................................................ 1.5228 24.23
050537................................................ 1.3702 22.21
050539................................................ 1.3242 22.78
050541................................................ 1.5636 34.62
050542................................................ 0.9778 19.06
050543................................................ 0.8445 20.38
050545................................................ 0.7605 27.57
050546................................................ 0.6961 27.76
050547................................................ 0.9021 27.08
050548................................................ ........ 26.59
050549................................................ 1.6004 27.34
050550................................................ 1.3676 25.54
050551................................................ 1.3528 24.05
050552................................................ 1.2749 22.87
050557................................................ 1.5186 21.92
050559................................................ 1.2852 24.67
050561................................................ 1.2134 33.93
050564................................................ 1.3221 24.51
050565................................................ 1.3123 22.88
050567................................................ 1.5510 24.23
050568................................................ 1.3424 20.73
050569................................................ 1.2039 24.94
050570................................................ 1.6495 24.50
050571................................................ 1.3940 24.37
050573................................................ 1.5642 25.14
050575................................................ 1.1445 ......
050577................................................ 1.3610 20.52
050578................................................ 1.2810 30.24
050579................................................ 1.4312 30.07
050581................................................ 1.4505 23.58
050583................................................ 1.6150 23.36
050584................................................ 1.2149 23.16
050585................................................ 1.2567 26.50
050586................................................ 1.3530 23.84
050588................................................ 1.2804 30.39
050590................................................ 1.3223 ......
050591................................................ 1.3152 22.29
050592................................................ 1.2657 26.05
050594................................................ 1.6258 22.78
050597................................................ 1.2269 22.78
050598................................................ 1.3408 28.11
050601................................................ 1.6473 32.87
050603................................................ 1.4112 22.61
050604................................................ 1.4593 33.32
050607................................................ ........ 24.10
050608................................................ 1.2805 16.15
050609................................................ 1.4876 31.93
050613................................................ 1.1408 22.73
050615................................................ 1.5445 23.61
050616................................................ 1.3408 22.80
050618................................................ 1.0867 21.70
050623................................................ 1.6040 30.32
050624................................................ 1.3287 20.88
050625................................................ 1.6313 24.43
050630................................................ 1.2732 24.10
050633................................................ 1.2945 21.98
050635................................................ ........ 37.85
050636................................................ 1.4342 20.83
050638................................................ 1.1056 23.63
050641................................................ 1.2985 21.30
050643................................................ 0.9493 ......
050644................................................ 1.0737 23.12
050660................................................ 1.4981 ......
050661................................................ ........ 20.48
050662................................................ 0.8152 28.29
050663................................................ 1.1713 23.71
050667................................................ 1.0811 24.11
050668................................................ 1.1187 39.90
050670................................................ 0.7555 21.88
050674................................................ 1.2384 36.24
050675................................................ 2.2195 15.84
050676................................................ 1.0018 17.53
050677................................................ 1.3671 33.71
050678................................................ 1.2889 19.79
050680................................................ 1.1161 27.32
050682................................................ 0.9235 17.97
050684................................................ 1.2411 21.81
050685................................................ 1.1904 32.13
050686................................................ 1.2873 33.25
050688................................................ 1.1889 30.00
050689................................................ 1.4877 34.19
050690................................................ 1.4194 33.83
050693................................................ 1.3143 33.30
050694................................................ 1.3869 22.23
050695................................................ 1.0637 23.52
050696................................................ 2.1089 26.41
050697................................................ 1.3282 21.47
050699................................................ 0.5913 28.48
050700................................................ ........ 28.45
050701................................................ 1.3166 27.62
050702................................................ ........ 12.25
050704................................................ 1.0850 20.76
050707................................................ 0.9714 27.51
050708................................................ 1.4521 21.91
050709................................................ 1.2542 19.42
050710................................................ 1.3382 26.81
050713................................................ 0.7909 15.30
050714................................................ 1.3545 ......
050715................................................ ........ 19.12
050717................................................ 1.2615 ......
050718................................................ 0.7586 ......
050719................................................ 3.1984 ......
050720................................................ 0.9144 ......
060001................................................ 1.6827 19.81
060003................................................ 1.2712 19.32
060004................................................ 1.2022 21.79
060006................................................ 1.2559 17.86
060007................................................ 1.1616 16.38
060008................................................ 1.0845 17.09
060009................................................ 1.5000 21.18
060010................................................ 1.6680 22.72
060011................................................ 1.3912 22.01
060012................................................ 1.3799 19.77
060013................................................ 1.3198 19.14
060014................................................ 1.8158 20.45
060015................................................ 1.6295 23.57
060016................................................ 1.1644 15.96
060018................................................ 1.2890 22.76
060020................................................ 1.6161 17.73
060022................................................ 1.5680 19.65
060023................................................ 1.6349 19.68
060024................................................ 1.7013 21.98
060027................................................ 1.6853 21.67
060028................................................ 1.5673 22.25
060029................................................ 0.8934 21.41
060030................................................ 1.3522 20.03
060031................................................ 1.5399 19.40
060032................................................ 1.4830 22.37
060033................................................ 1.1419 13.82
060034................................................ 1.5815 21.41
060036................................................ 1.1374 19.24
060037................................................ 1.0041 14.05
060038................................................ 0.9494 14.31
060041................................................ 0.9290 14.83
060042................................................ 1.0390 20.08
[[Page 24769]]
060043................................................ 0.8765 13.05
060044................................................ 1.1677 18.54
060046................................................ 1.0277 20.44
060047................................................ 0.9573 15.12
060049................................................ 1.3269 20.83
060050................................................ 1.2499 16.80
060052................................................ 1.0358 12.55
060053................................................ 1.0148 14.94
060054................................................ 1.4104 19.39
060056................................................ 0.9009 17.05
060057................................................ 1.0271 23.38
060058................................................ 0.9425 16.91
060058................................................ 1.3708 24.88
060060................................................ 0.9192 14.89
060062................................................ 0.8672 14.94
060063................................................ ........ 15.09
060064................................................ 1.4858 20.93
060065................................................ 1.2927 24.30
060066................................................ 0.9930 14.07
060068................................................ ........ 19.64
060070................................................ 1.1240 16.58
060071................................................ 1.2070 16.95
060073................................................ 0.9583 15.84
060075................................................ 1.2386 22.85
060076................................................ 1.4334 19.29
060087................................................ ........ 21.03
060088................................................ 1.0054 16.67
060090................................................ 0.9024 14.51
060096................................................ 1.1102 23.11
060100................................................ 1.5342 22.00
060103................................................ 1.3190 22.34
060104................................................ 1.2281 22.30
060107................................................ 1.1971 13.64
060109................................................ 1.0979 ......
070001................................................ 1.7556 26.51
070002................................................ 1.8370 25.46
070003................................................ 1.1151 26.09
070004................................................ 1.2021 17.57
070005................................................ 1.4405 25.57
070006................................................ 1.3841 28.71
070007................................................ 1.3504 20.38
070008................................................ 1.2547 26.03
070010................................................ 1.6964 25.94
070011................................................ 1.3837 18.74
070012................................................ 1.1748 23.84
070015................................................ 1.3856 21.37
070016................................................ 1.4249 26.23
070017................................................ 1.3692 25.33
070018................................................ 1.3688 28.88
070019................................................ 1.1852 24.70
070020................................................ 1.3279 25.66
070021................................................ 1.2354 27.20
070022................................................ 1.8624 25.08
070024................................................ 1.3266 24.98
070025*............................................... 1.8697 21.03
070026................................................ ........ 18.79
070027................................................ 1.3119 23.11
070028................................................ 1.5539 24.76
070029................................................ 1.3338 22.75
070030................................................ 1.2872 25.55
070031................................................ 1.2430 21.66
070033................................................ 1.4104 28.06
070034................................................ 1.3899 27.67
070035................................................ 1.4195 23.06
070036................................................ 1.7249 28.95
070038................................................ 0.7820 ......
070039................................................ 0.9541 29.07
080001................................................ 1.7050 25.28
080001................................................ 1.3001 16.14
080002................................................ ........ 15.60
080003................................................ 1.3859 22.40
080004................................................ 1.2655 19.76
080005................................................ ........ 14.43
080006................................................ 1.2940 22.26
080007................................................ 1.4146 20.38
090001................................................ 1.6063 25.97
090002................................................ 1.3508 19.70
090003*............................................... 1.3694 28.74
090004................................................ 1.7901 24.54
090006................................................ 1.3157 20.08
090007................................................ 1.3060 21.66
090008................................................ 1.5079 21.25
090010................................................ 1.0721 15.87
090011................................................ 2.1212 27.37
100001*............................................... 1.5321 17.59
100002................................................ 1.4384 21.32
100004................................................ 1.0139 15.25
100006................................................ 1.6140 20.63
100007................................................ 1.8868 21.89
100008................................................ 1.6004 20.72
100009................................................ 1.4674 24.29
100010................................................ 1.5057 21.91
100012................................................ 1.6358 18.17
100014................................................ 1.4840 19.83
100015................................................ 1.4801 18.24
100017................................................ 1.5926 17.77
100018................................................ 1.5487 21.46
100019................................................ 1.5570 19.81
100020................................................ 1.3913 26.18
100022*............................................... 1.7896 25.89
100023................................................ 1.3582 21.11
100024................................................ 1.3508 20.78
100025................................................ 1.7579 19.12
100026................................................ 1.5828 20.78
100027................................................ 1.0140 12.94
100028................................................ 1.2109 19.75
100029................................................ 1.3427 19.18
100030................................................ 1.2532 18.82
100032................................................ 1.8549 19.32
100034................................................ 1.7609 18.23
100035................................................ 1.5876 19.58
100038................................................ 1.6639 24.78
100039................................................ 1.5294 20.25
100040................................................ 1.7522 18.37
100043................................................ 1.3301 17.46
100044................................................ 1.3902 21.14
100045................................................ 1.3907 20.04
100046................................................ 1.4313 ......
100047................................................ 1.8501 18.89
100048................................................ 0.9391 13.50
100049................................................ 1.2657 18.57
100050................................................ 1.1486 16.60
100051................................................ 1.2376 18.84
100052................................................ 1.3877 16.19
100053................................................ 1.2157 18.71
100054................................................ 1.2782 18.19
100055................................................ 1.3757 17.62
100056................................................ 1.4971 23.65
100057................................................ 1.3578 18.92
100060................................................ 1.8350 22.39
100060................................................ 1.5612 21.03
100061................................................ 1.4669 21.79
100062................................................ 1.7286 17.96
100063................................................ 1.1599 16.23
100067................................................ 1.3589 17.40
100068................................................ 1.3616 18.65
100070................................................ 1.4351 20.33
100071................................................ 1.2326 16.48
100072................................................ 1.2524 19.22
100073................................................ 1.7197 18.16
100075................................................ 1.5968 18.05
100076................................................ 1.3003 16.25
100077................................................ 1.3909 19.62
100078................................................ 1.0296 18.15
100079................................................ 1.3325 ......
100080................................................ 1.6003 21.16
100081................................................ 1.1021 13.83
100082................................................ 1.4970 19.80
100084................................................ 1.3481 20.40
100085................................................ 1.4397 21.08
100086................................................ 1.2342 21.16
100087................................................ 1.8333 22.84
100088................................................ 1.6475 19.90
100088................................................ 1.3183 18.47
100090................................................ 1.3787 17.88
100092................................................ 1.5757 18.19
100093................................................ 1.5959 16.63
100098................................................ 1.0984 19.03
100099................................................ 1.2201 15.30
100102................................................ 1.0153 19.33
100103................................................ 0.9381 18.10
100105................................................ 1.4533 21.50
100106................................................ 1.0265 19.31
100107................................................ 1.3135 18.01
100108................................................ 0.9981 11.47
100109................................................ 1.3849 22.76
100110................................................ 1.3691 19.64
100112................................................ 0.9729 9.77
100113................................................ 1.9447 22.26
100114................................................ 1.3410 23.45
100117................................................ 1.1881 18.73
100118................................................ 1.2985 19.76
100121................................................ 1.1822 19.34
100122................................................ 1.2062 18.06
100124................................................ 1.2948 18.95
100125................................................ 1.2698 17.33
100126................................................ 1.4687 17.90
100127................................................ 1.6571 19.87
100128................................................ 2.2008 21.37
100129................................................ 1.2934 18.57
100130................................................ 1.1799 19.10
100131................................................ 1.3441 22.17
100132................................................ 1.2951 16.90
[[Page 24770]]
100134................................................ 0.9749 13.47
100135................................................ 1.5663 18.14
100137................................................ 1.2769 19.05
100138................................................ 1.0055 11.01
100139................................................ 1.0923 15.64
100140................................................ 1.2176 17.39
100142................................................ 1.2184 18.68
100144................................................ 1.1622 15.02
100145................................................ ........ 19.11
100146................................................ 0.9700 17.87
100146................................................ 1.3080 19.02
100147................................................ 1.0087 14.68
100150................................................ 1.3244 21.02
100151................................................ 1.7633 19.41
100154................................................ 1.5916 19.85
100156................................................ 1.1116 17.13
100159................................................ 0.9604 16.38
100160................................................ 1.2033 21.63
100161................................................ 1.7011 21.50
100162................................................ 1.3957 19.52
100165................................................ 1.1517 15.32
100166................................................ 1.4343 19.96
100167................................................ 1.3554 21.81
100168................................................ 1.3364 20.13
100169................................................ 1.7635 20.78
100170*............................................... 1.4176 15.12
100172................................................ 1.4427 15.18
100173................................................ 1.6517 17.34
100174................................................ 1.3757 20.51
100175................................................ 1.1552 16.74
100176................................................ 2.0762 24.70
100177................................................ 1.2940 22.00
100179................................................ 1.7112 20.91
100180................................................ 1.4416 18.48
100181................................................ 1.1072 24.57
100183................................................ 1.1925 20.84
100187................................................ 1.4354 20.69
100189................................................ 1.3293 21.01
100199................................................ 1.3519 23.37
100200................................................ 1.2394 22.26
100203................................................ ........ 18.86
100204................................................ 1.6275 19.93
100206................................................ 1.3738 20.31
100207................................................ ........ 15.92
100208................................................ 1.3742 20.83
100209................................................ 1.4794 19.73
100210................................................ 1.5725 19.18
100211................................................ 1.3995 25.53
100212................................................ 1.6223 25.34
100213................................................ 1.5101 19.12
100217................................................ 1.2750 19.87
100220................................................ 1.6359 19.82
100221................................................ 1.8123 27.48
100222................................................ 0.9440 21.20
100223................................................ 1.4649 18.76
100224................................................ 1.3348 24.70
100225................................................ 1.3371 20.64
100226................................................ 1.3524 24.83
100228................................................ 1.2825 23.70
100229................................................ 1.3301 18.21
100230................................................ 1.3524 20.60
100231................................................ 1.6807 17.40
100232................................................ 1.2520 17.32
100234................................................ 1.2585 21.58
100235................................................ ........ 17.66
100236................................................ 1.3919 15.54
100237................................................ 2.1914 22.93
100238................................................ 1.5456 17.63
100239................................................ 1.4273 19.76
100240................................................ 1.0888 17.93
100241................................................ 0.8966 13.83
100242................................................ 1.4285 17.12
100243................................................ 1.4081 20.24
100244................................................ 1.3741 17.41
100246................................................ 1.3684 21.10
100248................................................ 1.5873 31.86
100252................................................ 1.2004 17.87
100253................................................ 1.4328 20.60
100254................................................ 1.5393 20.91
100255................................................ 1.2547 21.02
100256................................................ 2.0100 24.26
100258................................................ 1.6900 21.88
100259................................................ 1.3406 19.86
100260................................................ 1.4566 21.20
100262................................................ 1.3401 19.59
100263................................................ ........ 16.90
100264................................................ 1.3627 17.61
100265................................................ 1.2933 19.80
100266................................................ 1.3562 17.73
100267................................................ 1.3062 17.10
100268................................................ 1.1954 23.59
100269................................................ 1.4338 21.20
100270................................................ 1.0126 19.86
100271................................................ 1.7709 19.92
100275................................................ 1.3951 21.33
100276................................................ 1.2359 21.98
100277................................................ 1.0352 16.14
100279................................................ 1.2735 21.84
100280................................................ 1.2949 16.58
100281................................................ 1.2798 22.02
100282................................................ 1.0837 18.66
100284................................................ 1.0788 ......
110001................................................ 1.2556 17.87
110002................................................ 1.2532 17.37
110003................................................ 1.3668 16.02
110004................................................ 1.3570 20.11
110005................................................ 1.1963 19.26
110006................................................ 1.4200 20.13
110007................................................ 1.6126 14.39
110008................................................ 1.2429 18.26
110009................................................ 1.1330 14.82
110010................................................ 2.1782 24.55
110011................................................ 1.1632 18.28
110013................................................ 1.0596 16.03
110014................................................ 0.9440 16.12
110015................................................ 1.1403 19.48
110016................................................ 1.2276 15.77
110017................................................ 0.9321 10.54
110018................................................ 1.1960 21.04
110020................................................ 1.1927 18.44
110023................................................ 1.3373 18.54
110024................................................ 1.3655 19.75
110025................................................ 1.3797 18.65
110026................................................ 1.1361 16.14
110027................................................ 1.1146 14.83
110028................................................ 1.7778 19.89
110029................................................ 1.3534 20.05
110030................................................ 1.2999 17.68
110031................................................ 1.2251 21.58
110032................................................ 1.2506 16.19
110033................................................ 1.4221 22.19
110034................................................ 1.5852 18.24
110035................................................ 1.3916 20.98
110036................................................ 1.8560 23.78
110038................................................ 1.4425 16.38
110039................................................ 1.4188 20.77
110040................................................ 1.0642 16.40
110041................................................ 1.1822 16.69
110042................................................ 1.1544 20.55
110043................................................ 1.8078 17.16
110044................................................ 1.1887 19.60
110045................................................ 1.1386 19.94
110046................................................ 1.2456 19.23
110048................................................ 1.2374 15.65
110049................................................ 1.0998 14.21
110050................................................ 1.1806 18.76
110051................................................ 1.0250 15.75
110052................................................ ........ 15.06
110054................................................ 1.3606 19.32
110056................................................ 1.0843 16.50
110059................................................ 1.2164 17.70
110061................................................ 1.0960 13.72
110062................................................ 0.9058 12.21
110063................................................ 1.0542 17.97
110064................................................ 1.4839 18.24
110065................................................ 1.0322 13.32
110066................................................ 1.4496 20.65
110069................................................ 1.2569 18.35
110070................................................ 1.1398 18.23
110071................................................ 1.0981 14.83
110072................................................ 0.9722 12.43
110073................................................ 1.1437 15.14
110074................................................ 1.4973 20.04
110075................................................ 1.3226 17.01
110076................................................ 1.4639 20.40
110078................................................ 1.7586 24.70
110079................................................ 1.4465 20.14
110080................................................ 1.3579 23.43
110082................................................ 2.0915 22.01
110083*............................................... 1.7615 21.27
110086................................................ 1.2837 14.98
110087................................................ 1.3551 20.54
110089................................................ 1.2041 18.58
110091................................................ 1.2791 21.38
110092................................................ 1.0878 15.09
110094................................................ 0.9920 13.87
110095................................................ 1.3537 15.95
110096................................................ 1.0806 16.32
110097................................................ 1.0653 15.62
110098................................................ 0.9870 14.04
110100................................................ 1.0558 20.38
110101................................................ 1.1014 11.73
110103................................................ 0.9309 11.94
[[Page 24771]]
110104................................................ 1.0963 15.32
110105................................................ 1.2997 16.52
110107................................................ 1.8897 17.41
110108................................................ 0.9511 15.14
110109................................................ 1.1080 20.99
110111................................................ 1.2038 17.37
110112................................................ 0.9917 19.13
110113................................................ 1.0478 15.19
110114................................................ 1.0441 15.13
110115................................................ 1.7526 24.79
110118................................................ 1.1376 15.40
110120................................................ 1.0386 16.08
110121................................................ 1.2784 15.58
110122................................................ 1.3818 18.82
110124................................................ 1.2091 17.13
110125................................................ 1.2562 17.33
110127................................................ 0.8873 13.76
110128................................................ 1.1933 18.97
110130................................................ 1.0064 13.08
110132................................................ 1.1478 15.02
110134................................................ 0.9656 11.56
110135................................................ 1.3363 17.07
110136................................................ 1.0986 16.17
110140................................................ 1.0445 17.88
110141................................................ 0.9996 12.51
110142................................................ 0.9525 12.30
110142................................................ 0.9525 12.30
110142................................................ 1.0382 12.54
110143................................................ 1.4339 21.45
110144................................................ 1.0712 17.98
110146................................................ 1.0854 17.61
110150................................................ 1.4073 18.77
110152................................................ 1.0430 14.77
110153................................................ 1.0912 18.69
110154................................................ 0.9773 14.81
110155................................................ 1.1399 17.14
110156................................................ 1.0511 15.14
110161................................................ 1.3149 20.87
110162................................................ 0.7514 ......
110163................................................ 1.4628 18.99
110164................................................ 1.4190 19.40
110165................................................ 1.4270 19.00
110166................................................ 1.4482 19.85
110168................................................ 1.6676 19.82
110169................................................ 1.2028 18.72
110171................................................ 1.6118 20.18
110172................................................ 1.3576 25.44
110174................................................ 0.9161 14.30
110176................................................ 3.7291 22.39
110177................................................ 1.5099 19.66
110178................................................ ........ 16.92
110179................................................ 1.1507 20.38
110181................................................ 0.9038 13.72
110183................................................ 1.3120 21.44
110184................................................ 1.2434 20.72
110185................................................ 1.1874 16.25
110186................................................ 1.2548 17.21
110187................................................ 1.2728 21.45
110188................................................ 1.3549 19.95
110189................................................ 1.1692 18.84
110190................................................ 1.0644 19.43
110191................................................ 1.3076 19.11
110192................................................ 1.4458 20.77
110193................................................ 1.2436 18.78
110194................................................ 0.8938 15.09
110195................................................ 1.0992 10.52
110198................................................ 1.2884 26.19
110200................................................ 1.8855 17.14
110201................................................ 1.5094 19.24
110203................................................ 0.9314 20.30
110204................................................ 0.8249 20.57
110205................................................ 1.0578 26.12
110207................................................ 1.0103 12.87
110208................................................ 0.9617 14.89
110209................................................ 0.7100 20.46
110209................................................ 0.9560 17.78
110210................................................ ........ 11.07
110211................................................ 0.9611 21.82
110212................................................ 1.0043 12.66
110213................................................ ........ 13.20
110215................................................ 1.0941 ......
110216................................................ 2.1653 ......
110217................................................ 2.8336 ......
120001*............................................... 1.8196 26.74
120002................................................ 1.2037 24.38
120003................................................ 1.1393 23.85
120004................................................ 1.2630 24.05
120005................................................ 1.2464 20.54
120006................................................ 1.2735 23.72
120007................................................ 1.7320 23.27
120009................................................ 0.9632 19.02
120010*............................................... 1.8265 25.40
120011................................................ 1.3581 33.55
120012................................................ 0.8391 22.52
120014................................................ 1.2760 24.05
120016................................................ 1.0574 29.41
120018................................................ ........ 25.61
120019................................................ 1.3200 21.92
120019................................................ 0.9579 14.67
120021................................................ 0.9290 19.42
120022*............................................... 1.6850 17.94
120022*............................................... 1.6850 17.94
120022*............................................... 1.2230 15.96
120022*............................................... 1.2230 15.96
120024................................................ 1.0727 22.28
120025................................................ ........ 19.02
120026................................................ 1.2644 23.22
120027................................................ 1.4120 24.55
120028................................................ 1.2471 22.84
130001................................................ 0.9699 24.95
130002................................................ 1.3252 16.19
130003................................................ 1.3332 19.97
130005................................................ 1.4390 20.19
130006................................................ 1.8346 18.87
130007................................................ 1.6708 19.84
130008................................................ 0.9590 12.92
130009................................................ 0.9294 18.30
130010................................................ 0.8911 21.43
130011................................................ 1.2864 19.08
130012................................................ 0.9929 22.62
130013................................................ 1.3310 19.22
130014................................................ 1.3257 17.98
130015................................................ 0.8827 15.27
130016................................................ 1.0155 17.00
130017................................................ 1.1012 16.88
130018................................................ 1.6256 17.97
130019................................................ 1.1193 17.23
130021................................................ 0.9513 12.26
130022................................................ 1.2324 19.50
130024................................................ 1.1558 18.38
130025................................................ 1.0970 15.27
130026................................................ 1.1726 20.55
130027................................................ 0.9243 20.70
130028................................................ 1.2865 18.21
130029................................................ 1.0707 19.87
130030................................................ 0.8409 18.40
130031................................................ 1.0121 17.65
130034................................................ 1.0325 18.82
130034................................................ 1.8152 18.40
130035................................................ 1.1048 20.47
130036................................................ 1.3946 13.79
130037................................................ 1.3076 17.74
130043................................................ 0.9605 16.07
130044................................................ 0.9724 13.18
130045................................................ 0.9752 16.47
130048................................................ 0.9815 15.09
130049................................................ 1.2325 20.05
130049................................................ 1.5824 20.72
130056................................................ 0.8528 15.66
130058................................................ ........ 17.75
130060................................................ 1.2796 20.85
130061................................................ 1.2950 16.78
130061................................................ 1.1145 17.32
130062................................................ 0.6352 15.11
130063................................................ 1.3116 ......
140001................................................ 1.2277 15.44
140002................................................ 1.2578 19.26
140003................................................ 1.0026 16.59
140004................................................ 1.1657 17.52
140005................................................ 0.9695 10.87
140007................................................ 1.4700 22.40
140007................................................ 1.4015 21.54
140008................................................ 1.4683 20.79
140010................................................ 1.3722 24.43
140011................................................ 1.2029 17.28
140012................................................ 1.2779 20.11
140013................................................ 1.5702 17.35
140014................................................ 1.1734 20.76
140015................................................ 1.2861 15.02
140018................................................ 1.2551 20.84
140019................................................ 1.1122 15.34
140025................................................ 1.0822 16.43
140027................................................ 1.2700 17.50
140027................................................ 1.3076 18.47
140029................................................ 1.3389 21.03
140030................................................ 1.8231 22.44
140031................................................ 1.2022 15.82
140032................................................ 1.3343 17.34
140033................................................ 1.2879 22.56
140034................................................ 1.1842 18.96
140035................................................ 0.9867 13.00
140036................................................ 1.2425 17.04
140036................................................ 1.1031 25.40
[[Page 24772]]
140037................................................ 1.0365 12.50
140038................................................ 1.1040 16.59
140040................................................ 1.2582 16.25
140041................................................ 1.1609 17.28
140042................................................ 1.0170 15.61
140043................................................ 1.1892 18.95
140045................................................ 1.0337 20.65
140046................................................ 1.3056 16.46
140047................................................ 1.0942 15.68
140048................................................ 1.3053 20.58
140049................................................ 1.6549 18.31
140051................................................ 1.5123 21.59
140052................................................ 1.3010 19.60
140053................................................ 2.0144 17.82
140054................................................ 1.3340 26.64
140055................................................ 1.0128 14.80
140058................................................ 1.2361 17.27
140059................................................ 1.1346 15.39
140061................................................ 1.0918 15.96
140062................................................ 1.2453 27.09
140063................................................ 1.4369 22.39
140064................................................ 1.3182 19.26
140065................................................ 1.4623 22.75
140066................................................ 1.1771 16.14
140068................................................ 1.2906 18.87
140069................................................ 1.0478 17.29
140070................................................ 1.2528 19.30
140074................................................ 1.0760 19.01
140075................................................ 1.3678 22.51
140077................................................ 1.2460 16.64
140079................................................ 1.2649 24.08
140081................................................ 1.0822 15.51
140082................................................ 1.3677 22.62
140083................................................ 1.2487 18.13
140084................................................ 1.2530 19.97
140087................................................ 1.3481 18.36
140088................................................ 1.7061 24.19
140089................................................ 1.2734 17.21
140090*............................................... 1.5241 22.31
140091................................................ 1.9064 20.70
140093................................................ 1.1684 19.15
140094................................................ 1.3427 19.89
140097................................................ 0.9518 16.90
140100................................................ 1.3290 19.06
140101................................................ 1.2258 26.09
140102................................................ 1.0431 15.13
140103................................................ 1.4249 17.86
140105................................................ 1.2912 22.56
140107................................................ 1.0115 12.76
140108................................................ 1.3343 30.11
140109................................................ 1.1455 15.47
140110................................................ 1.2406 18.68
140112................................................ 1.1571 16.24
140113................................................ 1.5610 17.92
140114................................................ 1.3330 20.11
140116................................................ 1.2349 21.83
140117................................................ 1.5621 19.72
140118................................................ 1.7257 23.06
140119................................................ 1.7733 26.00
140120................................................ 1.3738 14.84
140121................................................ 1.3603 9.53
140122................................................ 1.5424 23.75
140125................................................ 1.3486 17.10
140127................................................ 1.4176 19.42
140128................................................ 1.0297 17.67
140129................................................ 1.1653 15.25
140130................................................ 1.2502 23.77
140132................................................ 1.4907 22.86
140133................................................ 1.4008 19.88
140135................................................ 1.2769 17.69
140137................................................ 1.0216 16.51
140138................................................ 1.0656 14.59
140139................................................ 1.1054 16.58
140140................................................ 1.1358 15.30
140141................................................ 1.2625 15.18
140143................................................ 1.0965 18.76
140144................................................ 0.9972 20.02
140145................................................ 1.1515 16.61
140146................................................ 1.0726 23.74
140147................................................ 1.2513 24.82
140148................................................ 1.8284 19.50
140150................................................ 1.6430 27.88
140151................................................ 1.0622 19.30
140152................................................ 1.1938 20.67
140155................................................ 1.3261 17.52
140158................................................ 1.3600 22.27
140160................................................ 1.1729 17.88
140161................................................ 1.2205 19.04
140162................................................ 1.6991 18.42
140164................................................ 1.4369 18.09
140165................................................ 1.0868 15.42
140166................................................ 1.1672 17.58
140167................................................ 1.0995 16.17
140168................................................ 1.1300 16.46
140170................................................ 1.1305 14.14
140171................................................ 0.9892 14.73
140172................................................ 1.5894 20.07
140173................................................ 0.8708 18.48
140174................................................ 1.6068 19.89
140176................................................ 1.2498 21.41
140177................................................ 1.2111 18.17
140179................................................ 1.3636 20.88
140180................................................ 1.4489 23.25
140181................................................ 1.4225 19.95
140182................................................ 1.3614 20.48
140184................................................ 1.2130 15.88
140185................................................ 1.4938 17.36
140186................................................ 1.3433 17.49
140187................................................ 1.5860 17.72
140188................................................ 0.9891 14.84
140189................................................ 1.2539 19.08
140190................................................ 1.0732 15.88
140191................................................ 1.4402 24.74
140193................................................ 1.0284 15.52
140197................................................ 1.2538 17.98
140199................................................ 1.0796 18.83
140200................................................ 1.4770 21.65
140202................................................ 1.3288 22.18
140203................................................ 1.1563 20.78
140205................................................ 0.9505 17.24
140206................................................ 1.2043 20.39
140207................................................ 1.2975 20.20
140208................................................ 1.7189 23.94
140209................................................ 1.6299 17.79
140210................................................ 1.1139 12.66
140211................................................ 1.2088 21.49
140213................................................ 1.2799 26.20
140215................................................ 0.9874 14.45
140217................................................ 1.3239 22.26
140218................................................ 0.9885 15.08
140220................................................ 1.1219 16.73
140223................................................ 1.5500 21.28
140224................................................ 1.4304 22.99
140228................................................ 1.6774 18.67
140230................................................ 0.9389 16.60
140231................................................ 1.5601 21.61
140233................................................ 1.7821 18.39
140234................................................ 1.2228 18.72
140236................................................ 1.0843 13.13
140239................................................ 1.7286 18.88
140240................................................ 1.3944 21.83
140242................................................ 1.6388 22.64
140246................................................ 1.0612 12.82
140250................................................ 1.3284 23.41
140251................................................ 1.3090 20.54
140252................................................ 1.4991 24.55
140253................................................ 1.1636 16.74
140258................................................ 1.5756 16.51
140271................................................ 0.9729 15.36
140275................................................ 1.2733 17.96
140276................................................ 2.0648 25.46
140280................................................ 1.3777 18.84
140285................................................ 1.2740 14.71
140286................................................ 1.1868 19.84
140288................................................ 1.6194 20.59
140289................................................ 1.3449 16.45
140290................................................ 1.3397 25.88
140291................................................ 1.3337 22.44
140292................................................ 1.2935 22.71
140297................................................ ........ 21.47
140300................................................ 1.4604 23.46
150001................................................ 1.1062 21.70
150002................................................ 1.4495 18.66
150003................................................ 1.7952 19.31
150004................................................ 1.5197 19.70
150005................................................ 1.1497 19.00
150006................................................ 1.2614 20.04
150007................................................ 1.1968 19.53
150009................................................ 1.3657 17.53
150010................................................ 1.3618 18.48
150011................................................ 1.2157 19.19
150012................................................ 1.6189 20.52
150013................................................ 1.1006 16.00
150014................................................ 1.6067 21.28
150015................................................ 1.2931 22.06
150017................................................ 1.9040 18.89
150018................................................ 1.4570 18.62
150019................................................ 1.0936 15.29
150020................................................ 1.1517 14.46
150021................................................ 1.6877 ......
150022................................................ 1.0903 17.92
150023................................................ 1.5766 18.71
150024................................................ 1.3391 17.83
[[Page 24773]]
150025................................................ 1.4398 18.15
150026................................................ 1.2090 20.51
150029................................................ 1.3389 21.74
150030................................................ 1.2446 17.33
150031................................................ 1.0811 18.01
150032................................................ ........ 20.64
150033................................................ 1.5737 21.69
150034................................................ 1.4854 21.29
150035................................................ 1.4921 19.82
150036................................................ 0.9960 20.38
150037................................................ 1.2881 17.79
150039................................................ 1.0016 17.42
150042................................................ 1.2830 17.12
150043................................................ 1.1042 17.98
150044................................................ 1.2625 17.64
150044................................................ 1.2486 18.32
150045................................................ 1.0927 17.04
150046................................................ 1.3943 17.32
150047................................................ 1.5983 20.57
150048................................................ 1.1912 16.96
150049................................................ 1.2166 16.85
150050................................................ 1.1659 17.14
150051................................................ 1.5099 18.20
150052................................................ 1.0909 15.36
150053................................................ 0.9867 18.75
150054................................................ 1.1350 17.33
150054................................................ 1.0816 15.23
150056................................................ 1.8874 23.30
150057................................................ 2.2401 16.86
150058................................................ 1.7056 20.94
150059................................................ 1.3586 20.80
150060................................................ 1.1860 16.01
150061................................................ 1.2108 17.21
150062................................................ 1.1076 18.41
150063................................................ 1.0891 21.09
150064................................................ 1.1810 16.88
150065................................................ 1.1695 19.01
150066................................................ 1.0226 14.60
150067................................................ 1.1260 17.08
150069................................................ 1.2233 17.39
150070................................................ 0.9579 17.20
150071................................................ 1.0955 14.73
150072................................................ 1.1997 16.11
150073................................................ 1.0623 19.03
150074................................................ 1.6321 18.80
150075................................................ 1.1204 14.98
150076................................................ 1.1815 22.34
150077................................................ 0.8126 17.58
150078................................................ 1.0515 19.01
150079................................................ 1.1737 15.45
150082................................................ 1.5261 17.88
150084................................................ 1.9911 22.92
150086................................................ 1.2506 17.34
150088................................................ 1.3443 19.45
150089................................................ 1.4584 22.79
150090................................................ 1.3311 19.06
150091................................................ 1.0358 19.89
150092................................................ 1.0071 15.92
150094................................................ 0.9754 18.34
150095................................................ 1.0873 17.12
150096................................................ 1.0067 20.03
150097................................................ 1.0922 18.31
150098................................................ 1.1583 14.30
150099................................................ ........ 19.05
150100................................................ 1.6560 17.45
150101................................................ 1.0932 17.56
150102................................................ 1.0786 11.50
150103................................................ 0.9709 17.31
150104................................................ 1.1262 17.26
150105................................................ 1.3363 19.17
150106................................................ 1.0512 18.91
150109................................................ 1.3950 18.23
150109................................................ 0.9960 14.44
150110................................................ 0.9833 18.58
150111................................................ 1.1623 16.17
150112................................................ 1.2432 19.82
150113................................................ 1.2363 19.30
150114................................................ 0.9759 16.96
150115................................................ 1.3380 17.06
150122................................................ 1.1564 19.35
150123................................................ 1.1155 15.16
150124................................................ 1.0883 15.07
150125................................................ 1.4626 20.31
150126................................................ 1.4875 20.33
150126................................................ 1.0382 15.85
150127................................................ 1.0281 22.81
150129................................................ 1.1879 23.39
150130................................................ 1.3446 16.19
150132................................................ 1.4200 19.37
150132................................................ 1.4200 19.37
150133................................................ 1.1908 16.49
150134................................................ 1.1980 17.06
150136................................................ 0.9556 19.28
160001................................................ 1.2605 19.03
160002................................................ 1.0936 15.37
160003................................................ 0.9983 15.77
160007................................................ 1.0218 15.66
160008................................................ 1.1414 14.97
160009................................................ 1.2218 16.09
160012................................................ 1.0466 16.54
160013................................................ 1.1370 17.06
160014................................................ 1.0250 15.09
160014................................................ 1.0321 14.26
160016................................................ 1.1679 18.37
160018................................................ 0.9632 14.16
160020................................................ 1.0694 13.91
160021................................................ 1.1170 15.49
160023................................................ 1.0888 14.20
160024................................................ 1.6094 18.95
160026................................................ 1.0266 18.66
160027................................................ 1.0851 15.74
160028................................................ 1.2340 20.44
160029................................................ 1.5289 20.40
160030................................................ 1.3882 17.99
160031................................................ 1.1181 15.28
160032................................................ 1.1544 16.18
160033................................................ 1.9173 18.37
160034................................................ 1.1493 14.51
160035................................................ 0.8438 15.92
160036................................................ 1.0544 18.91
160037................................................ 1.0584 18.40
160039................................................ 1.0389 17.63
160040................................................ 1.2661 16.83
160041................................................ 1.0648 15.58
160043................................................ 0.9893 15.63
160044................................................ 1.2182 16.04
160045................................................ 1.8186 20.12
160046................................................ 1.0239 14.77
160047................................................ 1.3703 16.93
160048................................................ 1.2473 13.14
160049................................................ 0.9262 13.36
160050................................................ 1.0709 16.42
160051................................................ 0.8978 14.27
160052................................................ 0.9936 17.55
160054................................................ 1.0281 15.71
160055................................................ 0.9846 14.06
160056................................................ 1.0679 15.38
160057................................................ 1.2435 17.41
160058................................................ 1.8383 20.34
160060................................................ 1.0430 15.95
160061................................................ 1.0815 17.57
160063................................................ 1.1620 16.30
160064................................................ 1.5348 19.94
160065................................................ 1.0510 16.51
160066................................................ 1.1016 16.26
160067................................................ 1.4226 17.85
160068................................................ 1.0237 15.85
160069................................................ 1.5362 18.49
160070................................................ 0.9937 15.66
160072................................................ 1.0339 14.19
160073................................................ 0.9954 15.05
160075................................................ 1.0796 17.89
160076................................................ 1.0993 17.31
160077................................................ 1.1152 11.40
160079................................................ 1.4125 17.71
160079................................................ 1.4017 16.15
160081................................................ 1.1531 16.51
160082................................................ 1.9254 18.80
160083................................................ 1.6684 18.41
160085................................................ 1.0030 18.55
160086................................................ 0.9493 16.46
160088................................................ 1.1546 17.53
160089................................................ 1.1915 16.74
160090................................................ 1.0124 16.60
160091................................................ 1.0383 12.19
160092................................................ 1.0124 15.80
160093................................................ 1.0155 15.95
160094................................................ 1.1043 16.56
160097................................................ 1.0774 15.21
160098................................................ 0.9397 15.54
160099................................................ 0.9650 13.79
160101................................................ 1.0852 17.87
160102................................................ 1.3435 18.36
160103................................................ 0.9416 17.15
160104................................................ 1.3010 19.76
160106................................................ 1.1089 16.66
160107................................................ 1.1508 16.56
160108................................................ 1.0237 15.42
160109................................................ 1.0167 16.49
160110................................................ 1.5117 19.93
160111................................................ 0.9983 13.17
160112................................................ 1.3773 16.28
160113................................................ 1.0930 14.58
[[Page 24774]]
160114................................................ 0.9786 14.95
160115................................................ 0.9774 15.76
160116................................................ 1.1196 16.69
160117................................................ 1.4123 17.29
160118................................................ 0.9961 15.84
160120................................................ 0.9938 12.56
160122................................................ 1.1131 18.52
160124................................................ 1.2998 17.16
160126................................................ 0.9654 17.74
160129................................................ 0.9727 15.89
160130................................................ 1.1286 15.45
160131................................................ 1.0444 14.69
160134................................................ 0.9506 13.32
160135................................................ 1.0170 16.33
160138................................................ 1.0149 15.71
160140................................................ 1.1324 18.80
160142................................................ 1.0194 16.14
160143................................................ 1.1242 15.92
160145................................................ 1.0697 15.17
160146................................................ 1.4409 13.50
160147................................................ 1.2762 18.39
160151................................................ 1.0545 15.74
160152................................................ 0.9384 15.22
160153................................................ 1.7613 19.69
170001................................................ 1.2074 17.52
170004................................................ 1.0753 13.06
170006................................................ 1.1961 19.31
170008................................................ 1.0034 13.90
170009................................................ 1.1438 19.59
170010................................................ 1.3587 17.90
170012................................................ 1.4141 16.76
170013................................................ 1.2829 17.89
170014................................................ 1.0333 17.34
170015................................................ 0.9812 16.34
170016................................................ 1.7067 18.60
170017................................................ 1.2014 17.87
170018................................................ 1.1012 14.36
170019................................................ 1.2360 16.56
170022................................................ 1.0526 17.85
170023................................................ 1.4684 19.36
170024................................................ 1.0663 13.06
170025................................................ 1.1917 16.37
170026................................................ 1.0818 13.89
170027................................................ 1.3172 16.39
170030................................................ 1.0591 15.24
170031................................................ 0.8922 13.47
170032................................................ 1.0128 14.48
170033................................................ 1.4150 16.05
170034................................................ 1.0335 15.02
170035................................................ 0.8966 15.62
170036................................................ ........ 14.17
170038................................................ 0.8998 14.21
170039................................................ 1.0943 14.30
170040................................................ 1.5837 17.97
170041................................................ 1.0521 11.47
170044................................................ 0.9951 14.78
170045................................................ 1.0889 12.11
170049................................................ 1.3499 18.64
170051................................................ 0.9890 14.16
170052................................................ 1.0435 14.62
170053................................................ 0.9336 9.03
170054................................................ 1.0324 12.77
170055................................................ 0.9801 14.99
170056................................................ 0.8854 14.87
170057................................................ ........ 15.09
170058................................................ 1.1572 18.17
170060................................................ 1.0218 17.23
170061................................................ 1.1583 14.14
170063................................................ 0.8974 11.49
170064................................................ ........ 12.42
170066................................................ 0.9451 14.48
170067................................................ 0.9987 12.71
170068................................................ 1.2647 15.82
170070................................................ 1.0543 13.37
170072................................................ 0.9012 13.34
170073................................................ 1.0417 16.47
170074................................................ 1.2016 14.40
170075................................................ 0.9266 11.26
170076................................................ 1.0220 13.58
170077................................................ 0.9136 13.11
170079................................................ 0.9666 14.21
170080................................................ 0.9657 12.20
170081................................................ 0.9118 12.51
170082................................................ 0.9428 12.39
170084................................................ 0.8978 12.16
170085................................................ 0.8828 14.51
170086................................................ 1.6770 19.85
170088................................................ 0.9319 11.37
170089................................................ 0.9738 18.08
170090................................................ 0.9616 11.27
170092................................................ ........ 12.85
170093................................................ 0.8913 12.79
170094................................................ 0.9571 17.71
170095................................................ 1.0123 15.75
170097................................................ 0.9071 15.66
170098................................................ 1.1366 14.10
170099................................................ 1.1582 13.55
170100................................................ ........ 14.47
170101................................................ 0.9709 13.16
170102................................................ 0.9675 13.35
170103................................................ 1.3238 16.66
170104................................................ 1.4841 19.76
170105................................................ 1.0598 15.93
170106................................................ 0.9341 14.68
170109................................................ 0.9347 16.87
170110................................................ 0.9851 15.55
170112................................................ 1.1373 13.39
170113................................................ 1.0737 13.25
170114................................................ 0.9511 14.51
170115................................................ 0.9965 13.03
170116................................................ 1.0601 15.76
170117................................................ 0.9782 15.28
170119................................................ 0.9547 13.97
170120................................................ 1.2724 15.91
170122................................................ 1.7580 18.62
170124................................................ 0.9913 10.21
170126................................................ 0.9316 12.13
170128................................................ 0.9622 14.99
170131................................................ ........ 13.10
170133................................................ 1.1289 16.90
170134................................................ 0.8746 12.90
170137................................................ 1.1809 17.42
170139................................................ 0.9898 13.28
170142................................................ 1.3140 17.32
170143................................................ 1.1148 15.88
170144................................................ 1.5078 16.09
170145................................................ 1.1143 16.75
170146................................................ 1.4429 19.97
170147................................................ 1.1965 16.28
170148................................................ 1.3707 17.25
170150................................................ 1.1488 15.43
170151................................................ 0.9381 13.37
170152................................................ 1.0039 13.68
170160................................................ 0.9959 13.31
170164................................................ 0.9827 15.25
170166................................................ 1.1079 17.57
170171................................................ 1.0545 13.81
170175................................................ 1.3046 16.60
170176................................................ 1.6707 20.32
170182................................................ 1.4297 14.20
170183................................................ 1.9808 19.09
170184................................................ ........ 27.01
180001................................................ 1.3847 19.52
180002................................................ 1.0822 18.13
180004................................................ 1.1128 15.99
180005................................................ 1.1971 20.63
180006................................................ 0.9090 11.23
180007................................................ 1.4645 17.20
180009................................................ 1.3630 20.81
180010................................................ 1.9327 17.55
180011................................................ 1.3163 16.93
180012................................................ 1.4400 18.74
180012................................................ 0.8766 13.61
180013................................................ 1.4541 17.35
180014................................................ 1.6943 19.54
180016................................................ 1.3332 18.84
180017................................................ 1.3056 15.17
180018................................................ 1.2982 18.92
180019................................................ 1.1910 16.76
180020................................................ 1.1105 17.78
180021................................................ 1.0495 15.16
180023................................................ 0.9502 15.22
180024................................................ 1.4092 15.33
180025................................................ 1.2023 17.17
180026................................................ 1.2026 14.16
180027................................................ 1.2506 14.89
180028................................................ 1.0909 19.35
180030................................................ 1.1726 17.02
180031................................................ 1.1189 13.79
180032................................................ 1.0597 16.09
180033................................................ 1.0978 13.77
180034................................................ 1.0888 17.32
180035................................................ 1.6441 19.45
180036................................................ 1.1569 19.12
180037................................................ 1.3126 19.85
180038................................................ 1.4604 16.19
180040*............................................... 1.9257 19.33
180041................................................ 1.1796 15.17
180042................................................ 1.1689 16.29
180043................................................ 1.1236 16.76
180044................................................ 1.1974 17.82
180045................................................ 1.4022 17.73
180046................................................ 1.0438 17.91
[[Page 24775]]
180047................................................ 0.9987 15.04
180048................................................ 1.2470 19.58
180049................................................ 1.3488 16.08
180050................................................ 1.2186 18.48
180051................................................ 1.3835 15.68
180053................................................ 1.0555 14.63
180054................................................ 1.0903 16.39
180055................................................ 1.2207 14.64
180056................................................ 1.1035 16.62
180058................................................ 1.0460 14.36
180059................................................ 0.8719 14.26
180060................................................ ........ 7.21
180063................................................ 1.0712 11.91
180064................................................ 1.1788 14.49
180065................................................ 1.0766 14.41
180066................................................ 1.0776 18.56
180067................................................ 1.8904 18.53
180069................................................ 1.1224 17.30
180070................................................ 1.1057 13.84
180072................................................ 1.1158 17.85
180075................................................ ........ 15.07
180078................................................ 1.0782 19.16
180079................................................ 1.1805 13.41
180080................................................ 1.0799 16.48
180087................................................ 1.2301 14.97
180088................................................ 1.6075 21.86
180088................................................ 1.4138 21.69
180092................................................ 1.2224 16.31
180093................................................ 1.4101 16.70
180094................................................ 1.0268 12.51
180095................................................ 1.1318 13.40
180099................................................ 1.0392 13.29
180101................................................ 1.1741 19.56
180102................................................ 1.4371 17.88
180103................................................ 2.3154 19.79
180104................................................ 1.5469 19.20
180105................................................ 0.8827 14.00
180108................................................ 0.8257 14.62
180115................................................ 0.9594 17.11
180116................................................ 1.2331 16.94
180117................................................ 1.1147 18.38
180118................................................ 0.9643 12.15
180120................................................ 1.0167 17.81
180121................................................ 1.1698 14.51
180122................................................ 1.0642 16.97
180123................................................ 1.3539 18.53
180124................................................ 1.3287 18.41
180125................................................ 1.1259 19.73
180126................................................ 1.1152 12.40
180127................................................ 1.2902 17.35
180128................................................ 1.0669 17.05
180129................................................ 0.9818 17.86
180130................................................ 1.4359 19.11
180132................................................ 1.2721 17.26
180133................................................ 1.3322 21.66
180134................................................ 1.0885 13.63
180136................................................ 1.8166 17.71
180138................................................ 1.1992 18.51
180139................................................ 1.0560 18.77
180140................................................ 0.9768 20.40
180141................................................ 1.8575 19.04
180141................................................ 1.1972 12.59
180142................................................ 1.7800 ......
190001................................................ 0.8866 16.91
190002................................................ 1.6874 18.84
190003................................................ 1.3295 22.15
190004................................................ 1.4230 17.54
190005................................................ 1.5174 16.71
190006................................................ 1.4666 17.73
190007................................................ 1.0552 13.60
190008................................................ 1.6186 16.89
190009................................................ 1.2882 14.21
190010................................................ 1.2081 17.02
190011................................................ 1.1424 15.17
190013................................................ 1.3002 16.57
190014................................................ 1.1875 17.02
190014................................................ 0.9519 12.03
190015................................................ 1.2666 17.44
190017................................................ 1.3398 15.79
190018................................................ 1.1056 16.98
190019................................................ 1.7887 17.40
190020................................................ 1.1956 17.31
190025................................................ 1.3076 16.07
190026................................................ 1.5552 17.21
190027................................................ 1.5165 16.19
190029................................................ 1.1492 17.11
190033................................................ 0.9722 10.74
190034................................................ 1.1705 16.68
190036*............................................... 1.6847 19.96
190037................................................ 0.9649 12.02
190039................................................ 1.4112 17.17
190040................................................ 1.3287 20.32
190041................................................ 1.6088 17.90
190043................................................ 1.0328 12.57
190044................................................ 1.1661 17.20
190046................................................ 1.4251 19.35
190048................................................ 1.1957 16.34
190049................................................ 0.9392 16.42
190050................................................ 1.0736 15.38
190053................................................ 1.1486 12.50
190054................................................ 1.2942 16.47
190059................................................ 0.8905 15.84
190060................................................ 1.3931 18.37
190064................................................ 1.5246 19.90
190065................................................ 1.4989 19.39
190071................................................ 0.8369 13.59
190077................................................ 0.8858 12.83
190078................................................ 1.1110 13.50
190079................................................ 1.3557 17.29
190081................................................ 0.8865 12.02
190083................................................ 1.0658 16.14
190086................................................ 1.3284 14.93
190088................................................ 1.2141 19.63
190089................................................ 1.1099 12.79
190090................................................ 1.0416 16.56
190092................................................ ........ 18.07
190095................................................ 0.9939 15.73
190098................................................ 1.5397 19.22
190099................................................ 1.1795 18.92
190102................................................ 1.6352 15.80
190103................................................ 0.9074 15.57
190106................................................ 1.1251 17.75
190109................................................ 1.2494 14.53
190110................................................ 0.9774 11.08
190111*............................................... 1.5870 20.05
190112................................................ 1.6970 19.21
190113................................................ 1.3935 18.99
190114................................................ 1.0147 12.91
190115................................................ 1.2775 20.49
190118................................................ 0.9963 12.95
190120................................................ 0.9962 13.69
190122*............................................... 1.2965 14.84
190124................................................ 1.6278 22.38
190125................................................ 1.4991 18.63
190128................................................ 1.1982 19.71
190130................................................ 0.9925 12.43
190131................................................ 1.2614 19.60
190133................................................ 1.0847 13.48
190134................................................ 1.0023 12.68
190135................................................ 1.4331 20.93
190136................................................ 0.9971 11.33
190138................................................ ........ 22.71
190142................................................ 0.9232 14.98
190144................................................ 1.1836 16.84
190145................................................ 0.9751 13.99
190146................................................ 1.5262 20.09
190147................................................ 0.9769 14.32
190148................................................ 0.9448 14.02
190149................................................ 0.9966 15.19
190151................................................ 1.0782 11.92
190152................................................ 1.5096 20.40
190155................................................ ........ 11.08
190156................................................ 0.9565 12.48
190158................................................ 1.2674 19.62
190160................................................ 1.2596 18.47
190161................................................ 1.0853 12.58
190162................................................ 1.2971 17.97
190164................................................ 1.1850 16.33
190167................................................ 1.1284 16.29
190170................................................ 0.9050 13.58
190173................................................ 1.3272 18.83
190175................................................ 1.4238 20.69
190176................................................ 1.6021 16.67
190177................................................ 1.7143 20.32
190178................................................ 0.9276 10.49
190182................................................ 1.3004 20.03
190183................................................ 1.1923 16.11
190184................................................ 0.9965 14.86
190185................................................ 1.3089 19.37
190186................................................ 0.9403 16.36
190189................................................ ........ 26.54
190190................................................ 0.9141 18.68
190191................................................ 1.1473 18.14
190196................................................ 0.9516 14.87
190197................................................ 1.1818 17.92
190199................................................ 1.0597 12.58
190200................................................ 1.4899 19.41
190201................................................ 1.0997 19.14
190202................................................ 1.1256 17.90
190203................................................ 1.4061 21.43
190204................................................ 1.4939 21.21
190205................................................ 1.9208 18.10
190206................................................ 1.6291 19.82
[[Page 24776]]
190207................................................ 1.2579 17.67
190208................................................ 0.8059 14.61
190218................................................ 1.0606 18.16
190223................................................ ........ 19.26
190227................................................ 1.0049 12.11
190231................................................ 1.5614 16.89
190235................................................ ........ 16.80
190236................................................ 1.4216 22.18
190237................................................ 2.4934 ......
190238................................................ 1.6330 ......
190239................................................ 1.1544 ......
190240................................................ 0.9642 ......
200001................................................ 1.3472 17.49
200002................................................ 1.1142 18.77
200003................................................ 1.0982 16.74
200006................................................ 1.0868 16.34
200007................................................ 1.0197 17.62
200008................................................ 1.2216 20.50
200009................................................ 1.8812 20.62
200012................................................ 1.1783 17.01
200013................................................ 1.1139 16.49
200015................................................ ........ 20.11
200016................................................ 1.0407 17.66
200017................................................ ........ 19.70
200018................................................ 1.2072 17.24
200019................................................ 1.2519 18.48
200020................................................ 1.1541 20.60
200021................................................ 1.1958 18.88
200023................................................ 0.8402 14.92
200024................................................ 1.4798 18.65
200025................................................ 1.2493 19.07
200026................................................ 0.9915 17.28
200027................................................ 1.2369 18.28
200028................................................ 0.9205 16.93
200031................................................ 1.2258 15.90
200032................................................ 1.3282 17.92
200033................................................ 1.7813 21.40
200034................................................ 1.2763 19.13
200037................................................ 1.2272 18.24
200038................................................ 1.1414 19.21
200039................................................ 1.2559 20.29
200040................................................ 1.1170 19.13
200041................................................ 1.1252 17.66
200043................................................ 0.8031 16.54
200050................................................ 1.2072 18.08
200051................................................ 0.9896 19.48
200052................................................ 0.9958 15.12
200055................................................ 1.0875 17.13
200062................................................ 0.9507 16.51
200063................................................ 1.2430 19.67
200066................................................ 1.1419 16.32
210001................................................ 1.4438 18.73
210002................................................ 2.0439 22.84
210003................................................ 1.6821 25.37
210004................................................ 1.3607 23.44
210005................................................ 1.2933 19.62
210006................................................ 1.1140 17.77
210007................................................ 1.8016 21.54
210008................................................ 1.3069 19.50
210009................................................ 1.8548 21.81
210010................................................ 1.1378 26.83
210011................................................ 1.3632 21.24
210012................................................ 1.6193 23.43
210013................................................ 1.3591 18.85
210015................................................ 1.3063 16.69
210016................................................ 1.8523 22.01
210017................................................ 1.2499 17.17
210018................................................ 1.2636 21.41
210019................................................ 1.6163 19.09
210022................................................ 1.4875 21.32
210023................................................ 1.4502 21.80
210024................................................ 1.6941 19.56
210025................................................ 1.3279 19.57
210026................................................ 1.3217 11.64
210027................................................ 1.2802 18.49
210028................................................ 1.1693 18.86
210029................................................ 1.2777 21.43
210030................................................ 1.2555 21.02
210031................................................ 1.3110 15.59
210032................................................ 1.1730 18.50
210033................................................ 1.2407 19.91
210034................................................ 1.3165 16.12
210035................................................ 1.3414 20.61
210037................................................ 1.2643 18.74
210038................................................ 1.4181 23.26
210039................................................ 1.1915 20.73
210040................................................ 1.3180 25.08
210043................................................ 1.2815 40.60
210044................................................ 1.3645 22.24
210045................................................ 1.0892 9.88
210048................................................ 1.2893 22.39
210049................................................ 1.1702 17.67
210051................................................ 1.4024 20.76
210054................................................ 1.3673 23.51
210055................................................ 1.3658 20.09
210056................................................ 1.3928 20.94
210057................................................ 1.3587 22.57
210058................................................ 1.5007 21.37
210059................................................ 1.1847 23.13
210060................................................ 1.2753 ......
210061................................................ 1.1313 20.02
220001................................................ 1.2879 26.32
220002................................................ 1.4678 22.58
220003................................................ 1.1104 19.14
220004................................................ ........ 20.01
220006................................................ 1.3867 22.04
220008................................................ 1.2973 21.89
220010................................................ 1.3481 22.06
220011................................................ 1.0947 23.85
220012................................................ 1.3117 28.24
220015................................................ 1.1691 21.73
220016................................................ 1.3445 21.30
220017................................................ 1.3512 24.90
220019................................................ 1.1561 19.13
220020................................................ 1.2448 20.00
220023................................................ 0.6351 18.76
220024................................................ 1.2167 21.59
220025................................................ 1.1442 19.94
220028*............................................... 1.4573 22.18
220029................................................ 1.1595 21.19
220030................................................ 1.1073 14.54
220031................................................ 1.9074 22.82
220033................................................ 1.2602 20.83
220035................................................ 1.3063 22.00
220036................................................ 1.6289 24.16
220038................................................ 1.3130 23.31
220041................................................ 1.1893 22.83
220042................................................ 1.2662 25.28
220046................................................ 1.3199 23.90
220049................................................ 1.2823 17.27
220050................................................ 1.1667 20.83
220051................................................ 1.1784 20.48
220052................................................ 1.2993 23.01
220053................................................ 1.1637 21.27
220055................................................ 1.2850 21.57
220055................................................ 1.2703 19.76
220057................................................ 1.3594 21.93
220060................................................ 1.2295 26.98
220062................................................ 0.5638 20.06
220063................................................ 1.2671 20.91
220064................................................ 1.2833 17.90
220065................................................ 1.3711 20.10
220066................................................ 1.3459 19.43
220067................................................ 1.2869 25.74
220068................................................ ........ 6.45
220070................................................ 1.2165 16.72
220071................................................ 1.9239 24.67
220073................................................ 1.3015 26.08
220074................................................ 1.3358 15.22
220075................................................ 1.7972 19.96
220076................................................ 1.2501 20.83
220077................................................ 1.8283 24.48
220079................................................ 1.0997 21.01
220080................................................ 1.3044 17.16
220081................................................ 0.9163 25.77
220082................................................ 1.2658 20.02
220083................................................ 1.1887 20.93
220084................................................ 1.2481 24.66
220086................................................ 1.7933 30.00
220088................................................ 1.6455 22.71
220089................................................ 1.2583 21.81
220090................................................ 1.2260 21.42
220092................................................ 1.1838 17.04
220094................................................ ........ 21.99
220095................................................ 1.1894 21.45
220098................................................ 1.3175 20.34
220098................................................ 1.2347 20.43
220100................................................ 1.3674 25.39
220101................................................ 1.4449 24.15
220104................................................ 1.4666 26.76
220105................................................ 1.2706 21.69
220106................................................ 1.2167 24.34
220107................................................ ........ 20.14
220108................................................ 1.1915 22.52
220110................................................ 2.1015 29.15
220111................................................ 1.2455 23.07
220116................................................ 1.9143 27.64
220118................................................ ........ 30.02
220119................................................ 1.2616 22.78
220123................................................ 1.0317 17.74
220126................................................ 1.2498 20.96
220128................................................ ........ 21.92
220133................................................ 0.7187 24.34
[[Page 24777]]
220135................................................ 1.2824 25.08
220153................................................ 1.0071 15.97
220154................................................ 0.9023 14.84
220162................................................ 1.4831 ......
220163................................................ 2.0302 27.35
220171................................................ 1.6811 23.43
230001................................................ 1.1539 19.20
230002................................................ 1.2731 21.91
230003................................................ 1.1409 19.61
230004................................................ 1.6874 22.42
230005................................................ 1.2532 19.40
230006................................................ 1.0501 18.47
230007................................................ ........ 19.43
230012................................................ 0.9650 18.67
230012................................................ 1.9036 23.94
230013................................................ 1.3748 20.12
230015................................................ 1.0768 20.43
230017................................................ 1.6133 20.40
230019................................................ 1.5299 19.05
230020................................................ 1.7464 21.04
230021................................................ 1.5000 18.57
230021................................................ 1.1691 18.89
230024................................................ 1.4282 27.96
230027................................................ 1.0357 18.03
230029................................................ 1.5743 21.12
230030................................................ 1.3405 17.29
230031................................................ 1.4291 17.00
230032*............................................... 1.7456 20.08
230034................................................ 1.2673 17.23
230035................................................ 1.0750 17.56
230035................................................ 1.6288 23.05
230036................................................ 1.2559 21.76
230037................................................ 1.1615 19.07
230038................................................ 1.7574 23.40
230040................................................ 1.1346 20.39
230041................................................ 1.2536 19.03
230042................................................ 1.2327 19.49
230046................................................ 1.9231 25.91
230047................................................ 1.3568 20.64
230053................................................ 1.5887 22.22
230054................................................ 1.8405 19.54
230055................................................ 1.1698 19.84
230056................................................ 0.8968 16.41
230058................................................ 1.1023 18.23
230059................................................ 1.4582 18.96
230060................................................ 1.3307 17.87
230062................................................ 0.9642 16.30
230063................................................ 1.2587 20.22
230065................................................ 1.3139 21.28
230066................................................ 1.3669 21.51
230069................................................ 1.1982 22.49
230070................................................ 1.6490 20.06
230071................................................ 1.1156 22.16
230075................................................ 1.5045 19.43
230076................................................ 1.4082 23.82
230077................................................ 2.0553 20.39
230078................................................ 1.1150 16.25
230078................................................ 1.1358 15.56
230080................................................ 1.2452 18.91
230081................................................ 1.2102 18.04
230082................................................ 1.1207 17.74
230085................................................ 1.2359 17.54
230086................................................ 0.9482 16.98
230087................................................ 1.0847 15.77
230089................................................ 1.2859 21.39
230092................................................ 1.3590 18.96
230093................................................ 1.2299 19.99
230095................................................ 1.1731 16.78
230096................................................ 1.1072 22.56
230097................................................ 1.6199 20.10
230099................................................ 1.1231 20.25
230100................................................ 1.1427 13.11
230101................................................ 1.0672 18.61
230103................................................ 1.0527 20.76
230104................................................ 1.5554 23.47
230105................................................ 1.7966 20.88
230106................................................ 1.1826 18.35
230107................................................ 0.9423 14.67
230108................................................ 1.2079 17.42
230110................................................ 1.3163 17.65
230113................................................ 0.8490 11.17
230115................................................ 1.0580 16.87
230116................................................ 0.8654 16.36
230118................................................ 1.1403 21.71
230119................................................ 1.3594 23.96
230120................................................ 1.1248 19.64
230121................................................ 1.2279 19.37
230122................................................ 1.3518 18.09
230125................................................ ........ 15.35
230128................................................ 1.4028 23.58
230130................................................ 1.6932 22.52
230132................................................ 1.3334 26.17
230133................................................ 1.2298 17.57
230134................................................ ........ 15.32
230135................................................ 1.2320 22.74
230137................................................ ........ 18.34
230142................................................ 1.2837 20.04
230143................................................ 1.2803 16.45
230144................................................ 1.1223 21.00
230145................................................ 1.1219 16.60
230146................................................ 1.2603 18.63
230147................................................ 1.4098 20.40
230149................................................ 1.1317 14.17
230151................................................ 1.4140 20.89
230153................................................ 1.0658 17.33
230154................................................ 0.8898 14.58
230155................................................ 1.0298 16.99
230156................................................ 1.7470 23.28
230157................................................ 1.1677 19.72
230159................................................ 1.0227 18.61
230162................................................ 0.9532 17.77
230165................................................ 1.9359 23.23
230167................................................ 1.7502 20.32
230169................................................ 1.3613 22.75
230171................................................ 1.0817 14.96
230172................................................ 1.1873 20.22
230174................................................ 1.3724 20.85
230175................................................ 2.3801 21.81
230176................................................ 1.2168 21.86
230178................................................ 0.9485 16.08
230180................................................ 1.1229 15.48
230184................................................ 1.2534 17.29
230188................................................ 1.1197 15.56
230189................................................ 0.9464 15.91
230190................................................ 0.8801 23.71
230191................................................ 0.9321 17.12
230193................................................ 1.3023 20.18
230195................................................ 1.3569 22.37
230197................................................ 1.4043 21.62
230199................................................ 1.0833 18.40
230201................................................ 1.2527 15.32
230204................................................ 1.3728 21.89
230205................................................ 0.9894 13.89
230207................................................ 1.2522 20.46
230208................................................ 1.3046 17.15
230211................................................ 0.9159 17.51
230212................................................ 1.0559 22.18
230213................................................ 0.9300 15.32
230216................................................ 1.5737 19.59
230217................................................ 1.2657 20.95
230219................................................ 0.8632 20.70
230221*............................................... ........ 21.55
230222................................................ 1.3904 20.79
230223................................................ 1.2692 21.50
230227................................................ 1.4208 21.21
230230................................................ 1.5877 22.53
230232................................................ ........ 12.64
230235................................................ 1.0880 15.95
230236*............................................... 1.3245 23.22
230239................................................ 1.1705 19.23
230241................................................ 1.1942 18.85
230244................................................ 1.4114 21.08
230253................................................ 0.9600 21.95
230254................................................ 1.2928 21.28
230257................................................ 0.9141 20.47
230259................................................ 1.1398 21.15
230264................................................ 1.6552 15.18
230269................................................ 1.3095 22.81
230270................................................ 1.2029 20.08
230273................................................ 1.5232 23.40
230275................................................ 0.5244 17.60
230276................................................ 0.5657 18.55
230277................................................ 1.2488 22.50
230278................................................ ........ 16.66
230279................................................ 0.6538 16.04
230280................................................ 1.0995 14.22
230283................................................ 2.2297 ......
240001................................................ 1.5271 22.84
240002................................................ 1.7570 23.02
240004*............................................... 1.5922 16.53
240005................................................ 0.8861 16.98
240006................................................ 1.1644 27.11
240007................................................ 1.0673 16.98
240008................................................ 1.1466 21.81
240009................................................ 0.9419 16.69
240010................................................ 1.9784 22.62
240011................................................ 1.1515 18.96
240013................................................ 1.2854 18.97
240014................................................ 1.0968 21.86
240016................................................ 1.3901 19.86
240017................................................ 1.1526 17.23
240018................................................ 1.2687 19.07
240019................................................ 1.1859 21.13
[[Page 24778]]
240020................................................ 1.1172 19.57
240021................................................ 0.9884 17.40
240022................................................ 1.1049 19.16
240023................................................ 0.9789 20.39
240025................................................ 1.0980 17.25
240027................................................ 1.0711 16.25
240028................................................ 1.1581 19.38
240029................................................ 1.1501 17.99
240030................................................ 1.2802 18.44
240031................................................ 0.9276 18.07
240036................................................ 1.5871 20.12
240037................................................ 1.0154 18.46
240038................................................ 1.5017 26.35
240040................................................ 1.2684 19.90
240041................................................ 1.1728 19.21
240043................................................ 1.2228 17.31
240044................................................ 1.1357 18.92
240045................................................ 1.1584 20.99
240047*............................................... 1.5726 21.86
240048................................................ ........ 23.31
240049................................................ ........ 22.13
240050................................................ 1.2114 24.50
240051................................................ 0.9654 18.23
240052................................................ 1.3024 19.22
240053................................................ 1.4855 21.29
240056................................................ 1.2541 22.29
240057................................................ 1.8364 23.24
240058................................................ 0.9292 14.91
240059................................................ 1.0456 21.96
240061................................................ 1.7666 24.44
240063................................................ 1.4484 23.54
240064................................................ 1.3259 20.76
240065................................................ 1.1496 12.55
240066................................................ 1.2838 22.05
240069................................................ 1.1917 19.18
240071................................................ 1.1069 19.19
240072................................................ 1.0236 18.00
240073................................................ 0.9003 15.63
240075................................................ 1.2015 21.19
240076................................................ 1.0725 21.07
240077................................................ 0.9002 14.95
240078................................................ 1.5426 22.71
240079................................................ 0.9545 17.82
240080*............................................... 1.6152 23.73
240082................................................ 1.1235 18.03
240083................................................ 1.2898 19.29
240084................................................ 1.3236 19.61
240085................................................ 1.0306 18.02
240086................................................ 1.0482 15.33
240087................................................ 1.1607 17.06
240088................................................ 1.4006 21.02
240089................................................ 0.9225 18.42
240090................................................ 1.1288 18.05
240093................................................ 1.2970 18.62
240094................................................ 0.9639 20.57
240096................................................ 0.9900 18.34
240096................................................ 1.2640 23.33
240097................................................ 1.1145 23.62
240098................................................ 0.9270 20.60
240099................................................ 1.0725 14.36
240099................................................ 1.6247 18.12
240100................................................ 1.2887 19.19
240101................................................ 1.2099 17.75
240102................................................ 0.9273 15.56
240103................................................ 1.2125 16.88
240103................................................ 1.2125 16.88
240103................................................ 1.2687 16.60
240104................................................ 1.1691 24.02
240105................................................ ........ 14.79
240106................................................ 1.3931 25.05
240107................................................ 0.9756 19.03
240108................................................ 0.9778 16.46
240109................................................ 0.9814 13.15
240110................................................ 0.9389 17.28
240111................................................ 0.9906 17.04
240112................................................ 0.9763 15.31
240114................................................ 0.9379 15.49
240115................................................ 1.6118 22.16
240116................................................ 0.9248 15.18
240117................................................ 1.1441 17.57
240119................................................ 0.8604 22.50
240121................................................ 0.9071 21.37
240122................................................ 1.0827 18.04
240123................................................ 1.0205 15.60
240124................................................ 0.9613 19.05
240125................................................ 0.9698 13.15
240127................................................ 1.0079 14.77
240128................................................ 1.1138 16.08
240129................................................ 0.9949 15.42
240130................................................ 0.9322 15.65
240132................................................ 1.2724 24.50
240133................................................ 1.2207 18.52
240135................................................ 0.9181 13.60
240137................................................ 1.1748 19.18
240138................................................ 0.9322 13.74
240139................................................ 0.9615 17.02
240141................................................ 1.1553 21.99
240142................................................ 1.0125 20.61
240142................................................ 0.9881 16.75
240143................................................ 0.9663 14.28
240144................................................ 1.0451 15.87
240145................................................ 0.9125 15.00
240145................................................ 1.5277 15.71
240146*............................................... 0.9085 16.79
240148................................................ 1.0240 11.48
240150................................................ 0.8795 12.83
240152................................................ 1.0247 20.20
240153................................................ 1.0015 15.61
240154................................................ 1.0211 17.06
240155................................................ 0.9166 20.42
240157................................................ 1.0227 14.69
240160................................................ 1.0601 16.60
240161................................................ 1.0376 15.42
240163................................................ 0.9706 17.87
240166................................................ 1.1526 16.39
240169................................................ 0.9599 18.62
240170................................................ 1.1056 17.65
240171................................................ 1.0083 16.72
240172................................................ 0.9741 14.91
240173................................................ 0.9979 16.74
240179................................................ 1.0343 16.65
240184................................................ 0.9677 14.40
240187................................................ 1.2492 17.51
240193................................................ 1.0038 16.30
240200................................................ 0.8955 14.73
240205................................................ 0.9180 ......
240206................................................ 0.8312 ......
240210*............................................... 1.2515 24.03
240211................................................ 0.9639 20.55
250002................................................ 0.8834 15.58
250003................................................ 0.9935 15.66
250004................................................ 1.5311 16.96
250006................................................ 0.9628 15.70
250007................................................ 1.2280 19.16
250008................................................ 1.0292 13.32
250009................................................ 1.2659 16.18
250010................................................ 1.0112 13.34
250012................................................ 0.9335 18.48
250015................................................ 1.0386 11.07
250017................................................ 1.0281 17.30
250018................................................ 0.9366 13.47
250019................................................ 1.4832 17.15
250020................................................ 0.9513 13.88
250021................................................ 0.8379 9.08
250023................................................ 0.8948 13.54
250024................................................ 0.8937 11.59
250025................................................ 1.1497 17.72
250027................................................ 0.9761 12.42
250029................................................ 0.8705 14.85
250030................................................ 0.9210 13.63
250031................................................ 1.2477 18.77
250032................................................ 1.2190 17.26
250033................................................ 1.0137 15.76
250034................................................ 1.5454 18.13
250035................................................ 0.8365 17.41
250036................................................ 0.9962 13.79
250037................................................ 0.8845 10.32
250038................................................ 0.9382 13.62
250039................................................ 0.9970 16.51
250040................................................ 1.3147 15.64
250042................................................ 1.2629 16.47
250043................................................ 0.8997 13.65
250045................................................ 1.2675 19.48
250045................................................ 1.6478 19.71
250047................................................ 0.9058 31.60
250049................................................ 0.8840 10.76
250050................................................ 1.2669 13.92
250051................................................ 0.9264 9.60
250057................................................ 1.1777 13.76
250058................................................ 1.1857 15.42
250059................................................ 1.0828 14.23
250060................................................ 0.7514 7.99
250061................................................ 0.8571 13.97
250063................................................ 0.8311 14.97
250065................................................ 0.8934 12.68
250066................................................ 0.9138 14.33
250067................................................ 1.1596 15.29
250068................................................ 0.8244 11.43
250069................................................ 1.2682 15.77
250071................................................ 0.8972 11.21
250072................................................ 1.4321 16.93
250077................................................ 0.9343 11.41
250078................................................ 1.5470 15.50
[[Page 24779]]
250079................................................ 0.8546 19.06
250081................................................ 1.2791 28.31
250082................................................ 1.4189 13.84
250083................................................ 0.9426 9.20
250084................................................ 1.0988 19.74
250085................................................ 0.9829 13.85
250088................................................ 0.9803 16.69
250089................................................ 1.0904 13.05
250093................................................ 1.1718 15.09
250094................................................ 1.3373 17.85
250095................................................ 0.9932 16.36
250096................................................ 1.2105 17.07
250097................................................ 1.2848 18.41
250098................................................ 0.9421 14.30
250099................................................ 1.2923 14.41
250101................................................ 0.8831 16.31
250102................................................ 1.5195 20.02
250104................................................ 1.4439 17.54
250105................................................ 0.9369 14.60
250107................................................ 0.8803 13.63
250109................................................ 0.8900 14.55
250109................................................ 1.7757 18.47
250112................................................ 0.9912 14.20
250117................................................ 1.0628 14.52
250119................................................ 1.0603 12.74
250120................................................ 1.0638 14.41
250122................................................ 1.1763 17.72
250123................................................ 1.2209 17.41
250124................................................ 0.9344 12.67
250125................................................ 1.2793 14.49
250126................................................ 0.9351 14.71
250127................................................ 0.9230 ......
250128................................................ 1.0367 13.00
250131................................................ 1.0826 10.28
250134................................................ 0.9667 17.98
250136................................................ 0.9182 18.05
250138................................................ 1.2054 17.60
250141................................................ 1.2067 17.12
250145................................................ 0.8696 11.40
250146................................................ 0.9386 13.28
250148................................................ 1.2354 11.98
250149................................................ 0.9690 12.98
250150................................................ 1.2560 ......
260001................................................ 1.6327 17.55
260002................................................ 1.4385 20.59
260003................................................ 1.1303 14.33
260004................................................ 0.9725 13.75
260004................................................ 1.4534 18.46
260006................................................ 1.5184 18.53
260008................................................ 0.9887 16.25
260009................................................ 1.2916 17.94
260011................................................ 1.5348 18.32
260012................................................ 1.0036 14.46
260013................................................ 1.1872 15.54
260015................................................ 1.1793 21.33
260017................................................ 1.1724 15.80
260018................................................ 0.8885 12.23
260019................................................ 1.1438 23.67
260020................................................ 1.8100 21.86
260020................................................ 1.0367 11.27
260021................................................ 1.4386 17.57
260022................................................ 1.2556 19.35
260023................................................ 1.4179 15.82
260024................................................ 0.9716 13.47
260025................................................ 1.3037 14.94
260027................................................ 1.6145 21.01
260029................................................ 1.1888 17.47
260030................................................ 1.1362 11.24
260031................................................ 1.5358 18.30
260032................................................ 1.7220 20.92
260034................................................ 1.0233 17.22
260035................................................ 1.0045 12.59
260036................................................ 1.0042 18.31
260039................................................ 1.0672 14.20
260040................................................ 1.6796 15.08
260042................................................ 1.2519 17.44
260044................................................ 1.0069 17.12
260047................................................ 1.6390 17.28
260048................................................ 1.2487 21.43
260050................................................ 1.0545 18.74
260052................................................ 1.3663 17.86
260053................................................ 1.1247 12.01
260054................................................ 1.3540 17.37
260055................................................ 0.9667 17.76
260057................................................ 1.0072 15.33
260059................................................ 1.2431 15.79
260061................................................ 1.1196 15.01
260062................................................ 1.1845 20.26
260063................................................ 1.0723 16.85
260064................................................ 1.3319 16.50
260066................................................ 1.0139 14.42
260067................................................ 0.8926 12.16
260068................................................ 1.6802 19.83
260070................................................ 1.0377 21.69
260073................................................ 1.0843 13.01
260074................................................ 1.2962 15.42
260077................................................ 1.7288 18.26
260078................................................ 1.1814 15.48
260079................................................ 1.0620 14.83
260080................................................ 0.9887 12.56
260081................................................ 1.6619 18.96
260082................................................ 1.1478 15.79
260085................................................ 1.5799 19.51
260086................................................ 0.9285 14.87
260091................................................ 1.6909 19.61
260094................................................ 1.1873 15.87
260095................................................ 1.3659 19.77
260096................................................ 1.5613 21.72
260097................................................ 1.1415 15.79
260100................................................ 1.0128 15.73
260102................................................ 0.9990 16.37
260103................................................ 1.3189 17.35
260104................................................ 1.7127 19.02
260105................................................ 1.8623 20.80
260108................................................ 1.8507 20.92
260109................................................ 0.9915 13.44
260110................................................ 1.6688 15.72
260113................................................ 1.2254 14.79
260115................................................ 1.2279 17.90
260116................................................ 1.1034 14.57
260119................................................ 1.2149 16.20
260120................................................ 1.1954 17.13
260122................................................ 1.0917 14.54
260123................................................ 1.0482 14.00
260127................................................ 1.0625 15.95
260129................................................ ........ 14.64
260131................................................ 1.2658 19.75
260134................................................ 1.1709 16.58
260137................................................ 1.7105 15.22
260138................................................ 1.9075 21.41
260141................................................ 1.9978 17.96
260142................................................ 1.1255 16.03
260143................................................ 0.9900 11.94
260147................................................ 0.9530 13.66
260148................................................ 0.9021 10.34
260158................................................ 1.0544 12.40
260159................................................ 1.0116 18.22
260160................................................ 1.1476 16.19
260162................................................ 1.5659 20.71
260163................................................ 1.2449 14.81
260164................................................ 0.9182 14.31
260166................................................ 1.2191 19.53
260172................................................ 0.9615 12.49
260173................................................ 1.0061 11.98
260175................................................ 1.1279 16.29
260176*............................................... 1.7243 19.59
260177................................................ 1.3381 20.75
260178................................................ 1.4663 21.20
260179................................................ 1.6090 20.76
260180................................................ 1.6591 18.54
260183................................................ 1.6570 17.65
260186................................................ 1.5847 18.06
260188................................................ 1.2749 18.58
260189................................................ 0.9425 10.75
260190................................................ 1.1964 18.16
260191................................................ 1.2874 19.34
260193................................................ 1.2224 20.51
260195................................................ 1.2469 15.95
260197................................................ 1.0913 16.37
260198................................................ 1.2980 17.64
260200................................................ 1.2109 18.88
260205................................................ 1.1102 ......
260206................................................ 2.6705 ......
270002................................................ 1.2837 17.19
270003................................................ 1.2133 22.13
270004................................................ 1.6933 29.28
270006................................................ 0.8808 16.19
270007................................................ 1.0011 13.17
270009................................................ 1.0272 17.75
270011................................................ 1.0451 19.82
270012................................................ 1.6015 23.08
270013................................................ ........ 20.40
270014................................................ 1.8492 18.48
270016................................................ 0.9184 19.77
270017................................................ 1.2649 19.58
270019................................................ 1.0264 12.78
270021................................................ 1.1688 16.65
270023................................................ 1.2657 20.40
270026................................................ 0.9058 16.07
270027................................................ 1.0591 9.78
270028................................................ 1.1731 17.21
270029................................................ 0.9220 17.89
270032................................................ 1.1300 17.03
[[Page 24780]]
270033................................................ 0.8642 16.46
270035................................................ 1.0008 17.65
270036................................................ 0.9192 14.08
270039................................................ 1.0442 15.35
270040................................................ 1.1242 19.19
270041................................................ 1.0456 16.78
270044................................................ 1.1398 13.46
270046................................................ ........ 17.10
270048................................................ 1.0107 15.84
270049................................................ 1.7664 21.17
270050................................................ 0.9917 18.04
270051................................................ 1.3153 20.23
270052................................................ 1.0056 14.80
270057................................................ 1.2986 20.01
270058................................................ 0.9229 14.07
270059................................................ 0.7512 15.60
270060................................................ 0.9524 14.02
270063................................................ 0.9338 14.23
270073................................................ 1.0809 15.53
270074................................................ 0.8747 ......
270075................................................ 0.8274 ......
270079................................................ 0.9338 17.80
270080................................................ 1.1410 11.35
270081................................................ 0.9579 15.52
270082................................................ 1.1020 16.13
270083................................................ 1.0098 20.82
270084................................................ 0.9151 16.66
280001................................................ 1.0632 17.89
280003................................................ 2.1214 22.00
280005................................................ 1.3518 18.75
280009................................................ 1.7680 18.70
280010................................................ 0.8073 16.54
280011................................................ 0.8552 13.96
280012................................................ ........ 16.41
280013................................................ 1.7249 22.18
280014................................................ 0.9006 15.24
280015................................................ 1.0730 14.64
280017................................................ 1.0693 14.19
280020................................................ 1.8118 19.40
280021................................................ 1.1765 16.69
280022................................................ 0.9681 15.71
280023................................................ 1.3951 21.30
280024................................................ 0.9612 13.91
280025................................................ 0.9725 14.27
280025................................................ 0.9215 13.56
280026................................................ 1.0478 16.06
280028................................................ 1.0763 15.89
280029................................................ 1.2096 19.46
280030*............................................... 1.7665 33.26
280031................................................ 0.9937 13.22
280032................................................ 1.3465 19.18
280033................................................ 1.0807 14.93
280034................................................ ........ 15.28
280035................................................ 0.9131 15.33
280037................................................ 1.0308 16.17
280038................................................ 1.0606 16.47
280039................................................ 1.0637 15.19
280040................................................ 1.7299 18.97
280041................................................ 0.9617 13.39
280042................................................ 1.0305 15.30
280043................................................ 0.9752 15.79
280045................................................ 1.0415 14.23
280046................................................ 1.0475 13.72
280046................................................ 0.9996 17.09
280047................................................ 1.1206 18.37
280048................................................ 1.1137 14.07
280049................................................ 1.0856 15.63
280050................................................ 0.8924 15.34
280052................................................ 1.0652 13.65
280054................................................ 1.2488 17.58
280055................................................ 0.9146 12.99
280056................................................ 0.9322 14.02
280057................................................ 0.9635 15.76
280058................................................ 1.2363 17.88
280060................................................ 1.6236 28.61
280061................................................ 1.4119 17.95
280062................................................ 1.1814 13.67
280064................................................ 1.0153 15.51
280065................................................ 1.2669 18.53
280066................................................ 1.0217 11.64
280068................................................ 0.9304 10.13
280070................................................ 0.9912 13.74
280073................................................ 0.9848 14.79
280074................................................ 0.9716 15.22
280075................................................ 1.1052 13.79
280076................................................ 1.0343 13.92
280077................................................ 1.3025 19.01
280077................................................ 1.3234 23.89
280079................................................ 1.0819 9.91
280080................................................ 1.0579 14.35
280081................................................ 1.7240 20.92
280082................................................ 1.0785 13.13
280083................................................ 1.0611 17.55
280084................................................ 0.9595 11.69
280085................................................ 0.8186 21.58
280088................................................ ........ 21.64
280089................................................ 0.8837 17.16
280090................................................ 0.8017 14.72
280091................................................ 1.0928 15.15
280092................................................ 0.9075 14.20
280092................................................ 1.2667 17.95
280094................................................ 0.9966 15.89
280097................................................ 1.0876 14.30
280098................................................ 0.8804 10.17
280101................................................ 1.0046 17.42
280102................................................ ........ 12.94
280104................................................ 0.9207 13.38
280105................................................ 1.2360 18.78
280106................................................ 1.0160 15.54
280107................................................ 1.1351 13.46
280108................................................ 1.0618 17.22
280109................................................ 0.9496 11.06
280110................................................ 0.9845 12.30
280111................................................ 1.2660 23.10
280115................................................ 0.9779 16.43
280117................................................ 1.0965 16.82
280118................................................ 0.9029 16.92
280119................................................ 0.9435 ......
280123................................................ ........ 20.77
280125................................................ 1.2266 ......
290001................................................ 1.6951 22.42
290002................................................ 0.9418 16.63
290003................................................ 1.6685 23.40
290005................................................ 1.3281 17.80
290006................................................ 1.2282 19.88
290007................................................ 1.6911 29.69
290008................................................ 1.2553 20.25
290009................................................ 1.6213 22.74
290010................................................ 1.1253 14.48
290011................................................ 1.0959 16.44
290012................................................ 1.3501 21.17
290014................................................ 1.0289 18.38
290015................................................ 0.9745 17.83
290016................................................ 1.1219 12.81
290019................................................ 1.3294 20.93
290020................................................ 0.9828 26.15
290021................................................ 1.6752 21.13
290022................................................ 1.5923 24.08
290027................................................ 0.8876 16.43
290029................................................ 0.9227 ......
290032................................................ 1.4102 22.79
290036................................................ 0.5760 18.61
290038................................................ 0.9313 23.14
290039................................................ 1.3278 25.80
290041................................................ 1.2669 ......
300001................................................ 1.4837 21.40
300003................................................ 2.0054 23.25
300005................................................ 1.3435 19.99
300006................................................ 1.1762 18.93
300007................................................ 1.0889 19.34
300008................................................ 1.2468 16.46
300009................................................ 1.0545 20.01
300010................................................ 1.2618 19.38
300011................................................ 1.3250 21.24
300011................................................ ........ 19.27
300013................................................ 1.1145 18.97
300014................................................ 1.2417 19.80
300015................................................ 1.1214 19.92
300016................................................ 1.2108 18.50
300017................................................ 1.3267 22.34
300018................................................ 1.3658 20.89
300019................................................ 1.2426 20.61
300020................................................ 1.3820 21.65
300021................................................ 1.0741 17.35
300022................................................ 1.1274 17.19
300023................................................ 1.3989 20.39
300028................................................ 1.2859 18.05
300029................................................ 1.3196 20.90
300033................................................ 1.0986 19.85
300034................................................ 2.1601 23.52
310001................................................ 1.7852 26.81
310002................................................ 1.8508 26.61
310003................................................ 1.2974 26.83
310005................................................ 1.2946 23.05
310006................................................ 1.2111 21.50
310008................................................ 1.3295 24.95
310009................................................ 1.3229 23.19
310010................................................ 1.2488 21.11
310011................................................ 1.2569 23.22
310012................................................ 1.6481 26.32
310013................................................ 1.3697 22.11
310014................................................ 1.6478 28.70
310015................................................ 2.0223 27.58
[[Page 24781]]
310016................................................ 1.2886 25.72
310017................................................ 1.3522 26.07
310018................................................ 1.0775 24.53
310019................................................ 1.6742 22.82
310020................................................ 1.3766 19.27
310021................................................ 1.5395 14.69
310022................................................ 1.3224 20.73
310024................................................ 1.3248 22.78
310025................................................ 1.1869 22.58
310026................................................ 1.2370 23.87
310027................................................ 1.3153 21.77
310028................................................ 1.2506 23.52
310029................................................ 1.9412 23.20
310031................................................ 2.7731 25.18
310032................................................ 1.3215 23.30
310034................................................ 1.2861 21.69
310036................................................ 1.1416 19.82
310037................................................ 1.3994 27.44
310038*............................................... 2.0125 25.33
310038*............................................... 2.0125 25.33
310038*............................................... 1.5187 17.94
310038*............................................... 1.5187 17.94
310039................................................ 1.2510 22.03
310040................................................ 1.2033 24.30
310041................................................ 1.3451 23.78
310042................................................ 1.2924 24.27
310043................................................ 1.1890 22.09
310044................................................ 1.3276 20.43
310045................................................ 1.4835 28.21
310047................................................ 1.3317 24.52
310048................................................ 1.2890 23.33
310049................................................ 1.2304 24.76
310050................................................ 1.2126 22.59
310051................................................ 1.3939 25.27
310052................................................ 1.3013 22.58
310054................................................ 1.3465 24.38
310057................................................ 1.3027 20.45
310058................................................ 1.1447 26.10
310060................................................ 1.1968 19.11
310061................................................ 1.2042 20.80
310063*............................................... 1.3466 21.90
310064................................................ 1.3576 22.05
310067................................................ 1.3003 22.27
310069................................................ 1.2634 24.17
310070................................................ 1.4213 25.04
310072................................................ 1.3710 22.22
310073................................................ 1.6733 25.62
310074................................................ 1.3502 24.46
310075................................................ 1.4191 26.46
310076................................................ 1.4966 28.90
310077................................................ 1.6653 25.06
310078................................................ 1.4152 23.48
310081................................................ 1.3497 23.89
310083................................................ 1.2748 23.68
310084................................................ 1.3299 24.09
310086................................................ 1.2171 21.44
310087................................................ 1.3363 20.89
310088................................................ 1.1986 22.34
310090................................................ 1.3887 24.24
310091................................................ 1.2672 21.64
310092................................................ 1.3184 22.34
310093................................................ 1.1947 21.23
310096................................................ 1.9874 26.30
310105................................................ 1.2351 24.49
310108................................................ 1.4307 23.23
310110................................................ 1.2698 20.05
310111................................................ 1.2535 21.72
310112................................................ 1.3035 22.52
310113................................................ 1.2899 22.95
310115................................................ 1.2997 20.07
310116................................................ 1.2877 25.24
310118................................................ 1.2498 23.69
310120................................................ 1.2025 21.69
310121................................................ ........ 18.74
320001................................................ 1.5282 17.85
320002................................................ 1.3475 18.74
320003................................................ 1.0738 15.35
320004................................................ 1.2912 17.12
320005................................................ 1.3136 19.87
320006*............................................... 1.3522 19.34
320009................................................ 1.5961 17.68
320011................................................ 1.1434 21.09
320012................................................ 1.0462 16.00
320013................................................ 1.1399 22.59
320014................................................ 1.0829 15.97
320016................................................ 1.1832 18.78
320017................................................ 1.1293 18.15
320019................................................ 1.5028 19.26
320021................................................ 1.8076 15.29
320022................................................ 1.2332 17.66
320023................................................ 1.0237 16.42
320030................................................ 1.1556 13.86
320031................................................ 0.9451 13.99
320032................................................ 0.9020 16.45
320033................................................ 1.1699 20.31
320035................................................ 1.0266 24.07
320037................................................ 1.1663 17.08
320038................................................ 1.2324 16.29
320046................................................ 1.4430 20.43
320048................................................ 1.4178 19.17
320057................................................ 0.9720 ......
320058................................................ 0.8862 ......
320059................................................ 1.0641 ......
320060................................................ 0.9268 ......
320061................................................ 1.1304 ......
320062................................................ 0.8542 ......
320063................................................ 1.2511 19.83
320065................................................ 1.2158 16.10
320067................................................ 0.8657 57.24
320068................................................ 0.8982 18.60
320069................................................ 0.9785 11.31
320070................................................ 0.9556 ......
320074................................................ 1.0897 18.65
320079................................................ 1.2128 19.42
330001................................................ 1.1867 25.21
330002................................................ 1.4494 28.92
330003................................................ 1.3431 17.65
330004................................................ 1.2951 19.59
330005................................................ 1.6834 24.28
330006................................................ 1.3333 25.46
330007................................................ 1.3686 18.65
330008................................................ 1.1791 17.76
330009................................................ 1.3308 30.42
330010................................................ 1.2833 14.74
330011................................................ 1.2963 17.63
330012................................................ 1.7216 29.82
330013................................................ 2.0344 19.11
330014................................................ 1.3868 27.44
330016................................................ 0.9933 17.41
330019................................................ 1.3623 32.45
330020................................................ 1.0286 14.55
330023................................................ 1.3016 24.27
330024................................................ 1.8309 33.55
330025................................................ 1.1142 16.03
330027................................................ 1.4665 32.50
330028................................................ 1.4110 27.08
330029................................................ 1.1574 16.56
330030................................................ 1.4176 15.06
330033................................................ 1.3126 16.75
330034................................................ 0.5350 30.78
330036................................................ 1.2759 24.32
330037................................................ 1.2231 16.00
330038................................................ 1.1805 16.01
330039................................................ ........ 12.47
330041................................................ 1.2877 30.42
330043................................................ 1.3072 27.15
330044................................................ 1.2664 18.70
330045................................................ 1.3750 27.17
330046................................................ 1.4572 31.91
330047................................................ 1.1976 17.53
330048................................................ 1.2590 17.62
330049................................................ 1.2689 19.31
330053................................................ 1.2232 15.67
330055................................................ 1.5716 28.99
330056................................................ 1.4640 30.21
330057................................................ 1.6852 18.34
330058................................................ 1.3123 16.98
330059................................................ 1.6000 31.58
330061................................................ 1.2766 25.07
330062................................................ 1.0980 15.28
330064................................................ 1.4278 32.87
330065................................................ 1.2356 18.37
330066................................................ 1.2664 19.12
330067................................................ 1.3300 20.94
330072................................................ 1.4065 30.35
330073................................................ 1.1715 15.88
330074................................................ 1.2824 18.18
330075................................................ 1.0926 17.26
330078................................................ 1.4535 17.49
330079................................................ 1.2821 16.76
330080................................................ 1.2129 24.70
330084................................................ 1.0650 23.03
330085................................................ 1.2897 18.78
330086................................................ 1.2267 30.69
330088................................................ 1.0497 25.62
330090................................................ 1.5603 18.68
330091................................................ 1.3782 18.53
330092................................................ 0.9905 12.65
330094................................................ 1.2369 17.72
330095................................................ 1.3277 18.34
330096................................................ 1.1197 16.60
330097................................................ 1.2448 16.96
330100................................................ 0.9996 28.11
[[Page 24782]]
330101................................................ 1.7924 29.22
330102................................................ 1.2990 17.25
330103................................................ 1.2013 16.48
330104................................................ 1.4136 28.77
330106................................................ 1.7000 35.87
330106................................................ 1.2141 17.58
330107................................................ 1.2746 28.08
330108................................................ 1.2381 17.08
330111................................................ 1.0714 15.20
330114................................................ 0.9051 18.24
330115................................................ 1.1308 16.56
330116................................................ 0.8461 24.23
330118................................................ 1.6337 20.76
330119................................................ 1.7045 34.75
330121................................................ 1.0146 14.77
330122................................................ 1.0120 21.20
330125................................................ 1.8884 22.57
330126................................................ 1.1356 22.70
330127................................................ 1.3758 28.67
330128................................................ 1.3080 26.63
330132................................................ 1.1999 14.70
330133................................................ 1.3624 32.28
330135................................................ 1.1989 18.33
330136................................................ 1.3313 17.26
330140................................................ 1.8200 19.50
330140................................................ 1.3693 29.22
330144................................................ 0.9879 12.52
330148................................................ 1.0686 15.04
330151................................................ 1.0943 13.97
330152................................................ 1.4603 29.48
330153................................................ 1.7146 17.40
330154................................................ 1.7635 ......
330157................................................ 1.3770 20.82
330159................................................ 1.2596 17.87
330160................................................ 1.4253 30.17
330162................................................ 1.2101 27.72
330163................................................ 1.2553 20.46
330164................................................ 1.3684 19.48
330166................................................ 1.0688 14.18
330167................................................ 1.7206 30.07
330169................................................ 1.4402 25.15
330171................................................ 1.3082 25.43
330177................................................ 0.9538 14.54
330179................................................ 0.8481 12.69
330180................................................ 1.2145 14.94
330181................................................ 1.3234 32.47
330182................................................ 2.5161 31.33
330184................................................ 1.3694 27.49
330185................................................ 1.2686 26.89
330188................................................ 1.2751 18.72
330189................................................ 1.1706 17.66
330191................................................ 1.3142 18.85
330193................................................ 1.3060 29.82
330194................................................ 1.8125 35.57
330194................................................ 1.3303 24.74
330196................................................ 1.2593 26.62
330197................................................ 1.1217 17.00
330198................................................ 1.3920 23.63
330199................................................ 1.3788 27.66
330201................................................ 1.6461 30.33
330202................................................ 1.3273 31.24
330203*............................................... 1.3894 19.24
330204................................................ 1.3574 26.81
330205................................................ 1.2183 19.46
330208................................................ 1.2533 25.82
330209................................................ 1.2122 24.88
330211................................................ 1.1003 19.10
330212................................................ 1.1260 21.18
330213................................................ 1.1307 18.51
330214................................................ 1.8224 32.20
330218................................................ 1.0787 21.71
330219................................................ 1.6427 20.48
330221................................................ 1.2963 30.00
330222................................................ 1.2742 17.71
330223................................................ 1.0460 17.28
330224................................................ 1.2634 20.89
330225................................................ 1.1993 25.80
330226................................................ 1.2803 17.67
330229................................................ 1.2988 16.25
330230................................................ 1.3375 28.86
330230................................................ 1.3883 30.32
330231................................................ 1.0207 26.61
330232................................................ 1.2609 19.50
330233................................................ 1.4708 33.48
330234................................................ 2.3386 32.95
330235................................................ 1.1656 19.45
330236................................................ 1.3899 29.54
330238................................................ 1.2178 14.80
330239................................................ 1.2090 17.28
330241................................................ 2.0171 22.60
330242................................................ 1.2839 24.74
330245................................................ 1.4700 17.28
330245................................................ 1.3066 17.65
330246................................................ 1.3232 26.51
330247*............................................... 0.8513 27.71
330249................................................ 1.1964 16.48
330250................................................ 1.2370 19.20
330252................................................ ........ 17.04
330254................................................ 1.1706 16.73
330258................................................ 1.2649 30.47
330259................................................ 1.4768 23.87
330261................................................ 1.3026 26.17
330263................................................ 1.0017 19.64
330264................................................ 1.1964 23.14
330265................................................ 1.3296 15.62
330267................................................ 1.3404 23.56
330268................................................ 0.9562 14.62
330270................................................ 2.0235 28.24
330273................................................ 1.2927 25.89
330275................................................ 1.3100 17.41
330275................................................ 1.5329 17.72
330276................................................ 1.1583 17.75
330277................................................ 1.1061 17.16
330279................................................ 1.2903 19.91
330285................................................ 1.8644 22.47
330286................................................ 1.3310 25.09
330290................................................ 1.7051 31.84
330293................................................ 1.1270 15.38
330304................................................ 1.2324 29.51
330306................................................ 1.3441 27.62
330307................................................ 1.3062 20.74
330308................................................ ........ 36.84
330327................................................ 0.8784 16.97
330331................................................ 1.3609 31.04
330332................................................ 1.2164 27.16
330333................................................ 1.2125 36.77
330333................................................ 1.1649 18.57
330336................................................ 1.3036 30.17
330338................................................ 1.2490 22.14
330339................................................ 0.9024 19.67
330340................................................ 1.1793 26.92
330350................................................ 1.7306 30.38
330353................................................ 1.3031 33.55
330354................................................ 1.5849 ......
330357................................................ 1.3385 34.68
330359................................................ ........ 29.29
330372................................................ 1.2176 22.50
330381................................................ 1.2997 29.24
330385................................................ 1.1314 26.39
330386................................................ 1.1741 24.67
330387................................................ 0.7617 ......
330389................................................ 1.7689 30.82
330390................................................ 1.3621 29.79
330393................................................ 1.7194 27.99
330394................................................ 1.5580 18.54
330395................................................ 1.3507 36.12
330396................................................ 1.1230 28.11
330397................................................ 1.3749 31.00
330399................................................ 1.2641 35.55
330400................................................ 0.8760 ......
340001................................................ 1.4552 18.47
340002................................................ 1.8350 18.79
340002................................................ 1.6766 19.97
340003................................................ 1.1378 21.97
340004................................................ 1.5051 17.89
340005................................................ 1.1264 14.09
340006................................................ 1.0454 15.57
340007................................................ 1.1632 17.17
340008................................................ 1.1038 18.38
340009................................................ ........ 20.50
340011................................................ 1.1008 14.92
340012................................................ 1.1768 16.66
340013................................................ 1.2426 17.43
340014................................................ 1.5356 19.86
340015................................................ 1.2423 19.01
340016................................................ 1.1688 16.40
340017................................................ 1.2562 19.22
340018................................................ 1.1436 15.16
340019................................................ 0.9955 11.80
340020................................................ 1.2435 16.75
340021................................................ 1.2560 19.67
340022................................................ 1.1245 16.72
340023................................................ 1.3399 15.75
340024................................................ 1.1416 16.64
340025................................................ 1.2473 16.82
340027................................................ 1.2113 17.30
340030................................................ 2.0492 20.05
340031................................................ 0.9575 12.39
340031................................................ 1.2347 19.73
340032................................................ 1.3541 20.47
340035................................................ 1.0956 18.10
340036................................................ 1.1309 16.97
340037................................................ 1.0053 15.53
[[Page 24783]]
340038................................................ 1.1024 17.01
340039................................................ 1.2595 20.01
340040................................................ 1.7834 20.07
340041................................................ 1.2546 18.97
340042................................................ 1.1890 16.63
340044................................................ 1.1035 16.37
340045................................................ 1.0223 12.42
340047*............................................... 1.8843 19.30
340048................................................ 0.6134 13.11
340049................................................ 0.7590 16.50
340051................................................ 1.2900 18.60
340051................................................ 1.8432 20.66
340052................................................ 0.9876 21.37
340053................................................ 1.6323 19.49
340054................................................ 1.1763 14.47
340055................................................ 1.2604 18.18
340060................................................ 1.0860 17.83
340061................................................ 1.7099 20.76
340063................................................ 1.0057 17.19
340064................................................ 1.1560 17.26
340065................................................ 1.3378 18.32
340067................................................ 1.0061 18.61
340068................................................ 1.2336 16.70
340069................................................ 1.8138 20.05
340070................................................ 1.2544 18.38
340071................................................ 1.1438 16.37
340072................................................ 1.1338 15.60
340073................................................ 1.3879 20.69
340075................................................ 1.2367 18.21
340080................................................ 0.9831 16.85
340084................................................ 1.1281 21.78
340085................................................ 1.1702 16.24
340087................................................ 1.1121 16.70
340088................................................ 1.2513 19.83
340089................................................ 0.9805 13.86
340090................................................ 1.1718 17.47
340093................................................ 1.0391 15.16
340094................................................ 1.3870 18.39
340096................................................ 1.1754 17.98
340097................................................ 1.1310 18.42
340098................................................ 1.5829 20.17
340099................................................ 1.1295 15.09
340101................................................ 1.0709 15.36
340104................................................ 0.8681 15.87
340105................................................ 1.3491 18.91
340106................................................ 1.1393 18.08
340107................................................ 1.2314 16.95
340109................................................ 1.3469 17.96
340111................................................ 1.1160 14.49
340112................................................ 0.9984 14.52
340113................................................ 1.8531 21.03
340114................................................ 1.6133 20.82
340115................................................ 1.5465 18.67
340116................................................ 1.8578 19.23
340119................................................ 1.2151 16.85
340120................................................ 1.1381 14.38
340121................................................ 1.0491 15.97
340123................................................ 1.1262 16.22
340124................................................ 1.1113 14.05
340125................................................ 1.4577 19.63
340126................................................ 1.3187 17.72
340127................................................ 1.3001 17.28
340130................................................ 1.3606 19.40
340131................................................ 1.5381 18.94
340132................................................ 1.2828 16.94
340133*............................................... 1.0724 14.35
340137................................................ 1.2697 ......
340138................................................ 1.0673 19.28
340141................................................ 1.7101 22.23
340142................................................ 1.1894 16.09
340143................................................ 1.4503 20.95
340144................................................ 1.2523 15.98
340145................................................ 1.3242 19.20
340146................................................ 1.0434 13.01
340147................................................ 1.2397 19.11
340148................................................ 1.3626 19.61
340151................................................ 1.2105 16.57
340155................................................ 1.3964 20.42
340156................................................ 0.7272 ......
340158................................................ 1.0734 17.26
340159................................................ 1.1779 16.80
340160................................................ 1.1654 15.53
340162................................................ ........ 16.64
340164................................................ 1.3649 19.68
340166................................................ 1.3051 19.22
340168................................................ 0.4822 14.75
340171................................................ 1.1342 20.05
340173................................................ 1.2028 20.21
350001................................................ 0.9646 15.10
350002................................................ 1.8458 17.28
350003................................................ 1.2077 17.43
350004................................................ 1.9288 17.90
350005................................................ 1.0897 16.03
350006................................................ 1.3848 16.62
350007................................................ 0.9036 13.28
350008................................................ 0.9721 21.70
350009................................................ 1.1842 18.28
350010................................................ 1.1308 15.28
350011................................................ 1.9255 18.49
350012................................................ 1.0794 12.73
350013................................................ 1.0590 16.68
350014................................................ 1.0303 15.79
350015................................................ 1.7237 15.87
350016................................................ ........ 11.63
350017................................................ 1.3344 17.78
350018................................................ 1.0338 13.64
350019................................................ 1.7223 19.40
350021................................................ 0.9859 12.69
350023................................................ 0.9505 13.34
350024................................................ 1.0054 14.37
350025................................................ 0.9807 16.24
350027................................................ 1.0099 17.12
350029................................................ 0.8409 12.80
350030................................................ 1.0670 17.35
350033................................................ 0.9292 14.90
350034................................................ 0.9296 18.32
350035................................................ 0.8734 10.16
350038................................................ 1.0785 18.74
350039................................................ 1.0406 17.31
350041................................................ 0.9448 14.68
350042................................................ 1.0516 16.75
350043................................................ 1.6090 17.16
350044................................................ 0.9036 10.53
350047................................................ 1.1408 17.93
350049................................................ 1.2037 14.53
350050................................................ 0.9242 10.57
350051................................................ 0.9872 17.53
350053................................................ 1.0058 13.94
350055................................................ 0.9910 12.37
350056................................................ 0.9210 14.67
350058................................................ 0.9553 14.35
350060................................................ 0.8626 9.60
350061................................................ 1.0444 14.59
350063................................................ 0.8913 ......
350064................................................ 0.8650 ......
350068................................................ 2.5336 ......
350069................................................ 1.1398 ......
360001................................................ 1.3040 17.61
360002................................................ 1.1823 17.40
360003................................................ 1.7502 22.03
360006................................................ 1.9071 22.09
360007................................................ 1.0921 17.10
360008................................................ 1.2559 18.28
360009................................................ 1.5436 17.53
360010................................................ 1.2815 18.09
360011................................................ 1.2938 18.95
360012................................................ 1.3003 19.22
360013................................................ 1.1471 20.81
360014................................................ 1.1215 19.88
360016................................................ 1.6714 18.71
360017................................................ 1.9258 22.50
360018*............................................... 1.6881 21.13
360019................................................ 1.2251 20.17
360020................................................ 1.4563 22.96
360024................................................ 1.3152 18.54
360025................................................ 1.3536 19.19
360026................................................ 1.3138 17.04
360027................................................ 1.4730 20.43
360028................................................ 1.4907 17.27
360029................................................ 1.1938 18.22
360030................................................ 1.3469 15.35
360031................................................ 1.1971 19.90
360032................................................ 1.1591 17.93
360034................................................ 1.3273 15.56
360035................................................ 1.6456 18.97
360036................................................ 1.3111 19.14
360037*............................................... 2.1426 22.52
360038................................................ 1.6235 19.09
360039................................................ 1.2937 17.52
360040................................................ 1.2913 18.12
360041................................................ 1.2871 18.42
360042................................................ 1.1662 16.12
360044................................................ 1.1478 16.79
360045................................................ 1.4244 21.18
360046................................................ 1.1481 19.32
360047................................................ 1.1315 15.34
360048*............................................... 1.8813 21.29
360049................................................ 1.2245 18.81
360050................................................ 1.2304 12.89
360051................................................ 1.6220 20.71
360052*............................................... 1.6960 19.75
360054................................................ 1.2429 16.19
360055................................................ 1.3166 23.27
[[Page 24784]]
360056................................................ 1.3960 18.36
360057................................................ 1.0590 13.81
360058................................................ 1.1936 17.92
360059................................................ 1.6088 20.39
360062................................................ 1.4087 20.31
360063................................................ 1.1347 22.79
360064................................................ 1.6113 20.64
360065................................................ 1.2531 19.45
360066................................................ 1.6390 20.03
360067................................................ 1.1463 14.57
360068................................................ 1.7916 21.92
360069................................................ 1.1347 17.88
360070................................................ 1.7820 17.55
360071................................................ 1.4177 23.80
360072................................................ 1.2731 17.97
360074*............................................... 1.2996 18.32
360075................................................ 1.3460 19.25
360076................................................ 1.3579 19.59
360077................................................ 1.6157 20.82
360078................................................ 1.2427 20.79
360079*............................................... 1.8438 22.00
360080................................................ 1.1427 16.66
360081................................................ 1.3387 19.64
360082................................................ 1.2779 22.86
360083................................................ ........ 18.46
360084................................................ 1.6077 20.09
360085................................................ 1.8767 20.73
360086................................................ 1.4308 17.04
360087................................................ 1.4296 20.04
360088................................................ 1.3224 22.31
360089................................................ 1.1349 20.56
360090................................................ 1.2682 20.40
360091................................................ 1.3213 21.03
360092................................................ 1.1373 15.91
360093................................................ 1.1774 18.57
360094................................................ 1.3412 18.31
360095................................................ 1.2596 18.71
360096................................................ 1.0736 17.16
360098................................................ 1.4620 18.34
360099................................................ 0.9911 16.43
360100................................................ 1.2362 17.66
360101................................................ 1.3303 22.31
360102................................................ 1.2046 16.41
360103................................................ ........ 22.66
360104................................................ 1.1889 ......
360106................................................ 1.1909 16.18
360107................................................ 1.2449 14.54
360108................................................ 1.0519 16.51
360109................................................ 1.1015 19.52
360112................................................ 1.9154 22.68
360113................................................ 1.3257 22.27
360114................................................ 1.0880 17.13
360115................................................ 1.3591 18.19
360116................................................ 1.1091 18.08
360118................................................ 1.3515 18.60
360121................................................ 1.2071 21.42
360123................................................ 1.2382 19.13
360125................................................ 1.1479 18.17
360126................................................ 1.2125 20.46
360126................................................ 1.8377 ......
360127................................................ 1.1473 16.92
360128................................................ 1.1568 15.58
360129................................................ 0.9446 15.42
360130................................................ 1.0122 15.34
360131................................................ 1.3308 18.29
360132................................................ 1.4132 18.27
360133................................................ 1.6508 19.03
360134................................................ 1.7520 20.24
360136................................................ 1.0180 17.85
360137................................................ 1.7424 20.26
360140................................................ 0.9460 19.13
360141................................................ 1.6432 22.85
360142................................................ 1.0527 17.32
360143................................................ 1.3343 20.44
360144................................................ 1.2946 21.92
360145................................................ 1.6897 19.39
360147................................................ 1.2436 16.59
360148................................................ 1.1482 18.89
360149................................................ 1.2611 18.79
360150................................................ 1.3025 20.63
360150................................................ 1.3486 14.24
360151................................................ 1.3908 17.49
360152................................................ 1.5270 22.00
360153................................................ 1.1281 14.89
360154................................................ 1.0435 13.78
360155................................................ 1.3677 20.90
360156................................................ 1.2714 17.92
360159................................................ 1.1769 20.71
360161*............................................... 1.3552 19.43
360162................................................ 1.0718 18.32
360163................................................ 1.8472 20.38
360164................................................ ........ 16.16
360165................................................ 1.1740 19.48
360166................................................ ........ 16.98
360170................................................ 1.4424 17.18
360172................................................ 1.3450 18.47
360172................................................ 1.0594 11.46
360174................................................ 1.2393 19.09
360175................................................ 1.1888 20.41
360176................................................ 1.1416 15.55
360177................................................ 1.3276 19.41
360178................................................ 1.3155 17.40
360179................................................ 1.4147 18.82
360180................................................ 2.1660 22.09
360184................................................ 0.5560 19.35
360185................................................ 1.2279 18.67
360186................................................ 1.0613 20.86
360187................................................ 1.4008 18.02
360188................................................ 0.9300 17.53
360188................................................ 1.3145 19.84
360189................................................ 1.0999 17.37
360192................................................ 1.3351 21.00
360193................................................ ........ 17.67
360194................................................ 1.1660 17.69
360195................................................ 1.1446 19.02
360197................................................ 1.1572 19.42
360200................................................ 0.9136 17.76
360203................................................ 1.1642 15.61
360204................................................ 1.2012 19.35
360210................................................ 1.1861 20.28
360211................................................ 1.2583 19.58
360212................................................ 1.3502 20.23
360213................................................ 1.2562 18.33
360218................................................ 1.3312 18.41
360230................................................ 1.5295 21.44
360231................................................ 1.1521 13.56
360234................................................ 1.3657 22.06
360236................................................ 1.2693 19.57
360239................................................ 1.2655 19.86
360241................................................ 0.4070 22.08
360243................................................ 0.6871 13.58
360244................................................ ........ 10.55
360245................................................ 0.7435 15.06
360247................................................ 0.4015 18.11
360248................................................ ........ 21.65
370001................................................ 1.7396 21.23
370002................................................ 1.2252 14.08
370004................................................ 1.1874 16.77
370005................................................ 0.9385 17.38
370006................................................ 1.1866 12.54
370007................................................ 1.1476 17.00
370008................................................ 1.3755 17.30
370011................................................ 1.0368 14.64
370012................................................ 0.8370 10.80
370013................................................ 1.8507 18.04
370014................................................ 1.1884 19.63
370015................................................ 1.1919 17.91
370016................................................ 1.3306 16.64
370017................................................ 1.1140 12.98
370019................................................ 1.3158 16.88
370020................................................ 1.2742 13.48
370021................................................ 0.8613 11.26
370022................................................ 1.3170 17.90
370023................................................ 1.2564 16.82
370025................................................ 1.3094 16.40
370026................................................ 1.4938 16.90
370028................................................ 1.8978 19.71
370029................................................ 1.1615 13.89
370030................................................ 1.1993 15.47
370032................................................ 1.5960 16.70
370033................................................ 1.0434 12.39
370034................................................ 1.2300 14.51
370034................................................ 1.1035 13.64
370035................................................ 1.7244 18.96
370037................................................ 1.7347 17.75
370038................................................ 0.9601 12.81
370039................................................ 1.1556 16.27
370040................................................ 1.0121 14.34
370041................................................ 0.9415 17.41
370042................................................ 0.8490 14.61
370043................................................ 0.9307 16.08
370045................................................ 1.0379 12.44
370046................................................ 0.9834 18.15
370047................................................ 1.4255 15.67
370048................................................ 1.2037 17.44
370051................................................ 0.9449 12.18
370054................................................ 1.3630 16.56
370056................................................ 1.5715 18.88
370057................................................ 1.0250 14.66
370059................................................ 1.1266 16.46
370060................................................ 1.0540 15.12
370063................................................ 1.1044 17.06
370064................................................ 0.9378 9.78
[[Page 24785]]
370065................................................ 0.9995 16.56
370071................................................ 1.0274 14.95
370072................................................ 0.8645 26.05
370076................................................ 1.2553 12.86
370077................................................ ........ 17.62
370078................................................ 1.6857 17.24
370079................................................ 0.9312 13.60
370080................................................ 0.9515 14.34
370082................................................ 0.8548 13.57
370083................................................ 0.9662 11.49
370084................................................ 1.0191 21.75
370085................................................ 0.8886 11.88
370086................................................ 1.1148 13.56
370089................................................ 1.2157 14.50
370091................................................ 1.6647 17.58
370092................................................ 0.9950 14.68
370093................................................ 1.7953 18.57
370094................................................ 1.4453 18.38
370095................................................ 0.9872 14.13
370097................................................ 1.3458 15.72
370099................................................ 1.1231 16.17
370100................................................ 0.9784 17.10
370103................................................ 0.9071 15.90
370105................................................ 1.9589 21.06
370106................................................ 1.5282 18.62
370108................................................ 0.9670 12.24
370112................................................ 1.0284 15.25
370113................................................ 1.2334 16.20
370114................................................ 1.6444 15.98
370121................................................ 1.0409 19.55
370122................................................ 1.0451 12.15
370123................................................ 1.4513 16.36
370125................................................ 0.9024 13.55
370126................................................ 0.9646 18.24
370131................................................ 0.9766 16.24
370133................................................ 1.0621 10.47
370138................................................ 1.0490 16.02
370139................................................ 1.0965 13.30
370140................................................ 1.0464 15.23
370141................................................ 1.3716 6.09
370146................................................ 1.0935 12.56
370148................................................ 1.4521 ......
370149................................................ 1.3479 16.72
370153................................................ 1.1151 15.32
370154................................................ 1.0475 16.29
370158................................................ 1.0197 15.09
370159................................................ 1.2547 15.49
370163................................................ 0.9790 14.56
370165................................................ 1.2623 13.22
370166................................................ 1.0457 17.82
370169................................................ 1.0462 11.80
370170................................................ 1.0246 ......
370171................................................ 1.0343 ......
370172................................................ 0.8992 ......
370173................................................ 1.0625 ......
370174................................................ 0.7213 ......
370176................................................ 1.2190 16.03
370177................................................ 0.9910 11.88
370178................................................ 0.9838 11.64
370179................................................ 0.9498 19.27
370180................................................ 0.9870 ......
370183................................................ 1.0383 7.62
370186................................................ 0.9785 13.35
370190................................................ 1.4695 13.70
370192................................................ 1.4803 16.74
370196................................................ 0.8822 ......
370197................................................ ........ 21.57
370198................................................ 1.4366 ......
370199................................................ 1.0307 ......
370200................................................ 1.1673 ......
380001................................................ 1.3046 22.03
380002................................................ 1.2175 19.48
380003................................................ 1.1750 24.74
380004................................................ 1.7385 23.16
380005................................................ 1.1745 23.24
380006................................................ 1.2246 20.54
380007................................................ 1.6509 24.16
380008................................................ 1.0680 21.19
380009................................................ 1.7977 25.28
380010................................................ 1.0413 19.75
380011................................................ 1.1006 21.14
380013................................................ 1.1883 20.10
380014................................................ 1.6527 23.48
380017................................................ 1.9295 23.68
380018................................................ 1.8300 22.08
380019................................................ 1.2442 20.77
380020................................................ 1.4525 21.35
380021................................................ 1.2077 20.64
380022................................................ 1.1107 21.61
380023................................................ 1.1378 19.24
380025................................................ 1.2975 24.67
380026................................................ 1.1414 19.27
380027................................................ 1.2810 20.16
380029................................................ 1.1411 18.57
380031................................................ 0.9370 22.83
380033................................................ 1.7968 22.62
380035................................................ 1.3525 21.65
380036................................................ 1.0858 19.33
380037................................................ 1.2271 21.23
380038................................................ 1.2457 25.58
380039................................................ 1.2601 22.12
380040................................................ 1.2922 21.64
380042................................................ 1.0121 19.81
380047................................................ 1.6765 21.95
380048................................................ 1.0418 18.38
380050................................................ 1.4266 18.25
380051................................................ 1.6342 21.24
380052................................................ 1.2506 17.77
380055................................................ ........ 21.25
380056................................................ 1.0970 17.16
380060................................................ 1.4584 23.48
380061................................................ 1.5207 22.63
380062................................................ 1.2197 18.52
380063................................................ ........ 19.36
380064................................................ 1.3207 19.87
380065................................................ 1.3101 22.17
380066................................................ 1.3211 20.42
380068................................................ ........ 22.76
380069................................................ 1.0679 19.58
380070................................................ 1.3454 24.71
380071................................................ 1.2327 20.47
380072................................................ 0.9961 16.32
380075................................................ 1.4249 22.17
380078................................................ 1.1368 19.10
380081................................................ 1.0229 20.59
380082................................................ 1.2627 22.58
380083................................................ 1.1660 21.81
380084................................................ 1.2367 23.64
380087................................................ 1.2347 16.75
380088................................................ 1.0722 19.52
380089................................................ 1.2780 23.74
380090................................................ 1.2983 27.09
380091................................................ 1.2616 22.83
390001................................................ 1.5197 16.39
390002................................................ 1.3158 18.08
390003................................................ 1.2403 17.24
390004................................................ 1.3978 18.82
390005................................................ 1.0949 15.36
390006*............................................... 1.8485 18.13
390009*............................................... 1.7387 20.16
390010................................................ 1.2504 17.42
390011................................................ 1.2787 18.07
390012................................................ 1.2197 20.00
390013................................................ 1.2401 19.33
390015................................................ 1.1331 12.94
390016................................................ 1.2482 17.95
390017................................................ 1.1848 16.22
390018................................................ 1.2431 18.98
390019................................................ 1.0762 16.40
390022................................................ 1.3535 22.86
390024................................................ 1.1793 25.03
390026................................................ 1.2757 22.18
390027................................................ 1.7878 27.37
390028*............................................... 1.8892 18.48
390030................................................ 1.2187 18.40
390031................................................ 1.2151 18.69
390032................................................ 1.2603 18.15
390035................................................ 1.2652 18.51
390036................................................ 1.5396 18.78
390039................................................ 1.1414 16.54
390040................................................ 0.9484 15.12
390041................................................ 1.2691 19.58
390042................................................ 1.5798 21.10
390043................................................ 1.1762 16.36
390044................................................ 1.6420 19.50
390045................................................ 1.7171 18.75
390046................................................ 1.6108 20.42
390047*............................................... 1.7435 23.61
390048................................................ 1.1520 18.38
390049................................................ 1.6125 21.02
390049................................................ 1.7948 24.39
390050................................................ 2.1150 21.43
390050................................................ 1.2393 20.86
390051................................................ 2.1342 26.05
390052................................................ 1.1532 17.10
390054................................................ 1.2344 17.50
390055................................................ 1.8882 25.85
390056................................................ 1.1202 17.17
390057................................................ 1.3145 19.74
390058................................................ 1.2840 19.25
390060................................................ 1.2088 13.63
390061................................................ 1.4935 16.95
390062................................................ 1.2449 16.45
[[Page 24786]]
390063................................................ 1.8347 19.51
390065................................................ 1.2323 20.00
390066................................................ 1.2608 18.70
390067................................................ 1.8041 20.18
390068................................................ 1.3029 17.55
390069................................................ 1.2663 19.76
390070................................................ 1.4168 20.07
390071................................................ 1.1082 16.23
390072................................................ 1.0501 15.56
390073................................................ 1.6668 20.64
390074................................................ 1.2477 16.60
390075................................................ 1.3927 17.27
390076................................................ 1.2793 21.43
390078................................................ 1.1506 18.23
390079................................................ 1.7570 17.76
390080................................................ 1.2902 18.82
390081................................................ 1.2995 23.99
390083................................................ 1.2055 ......
390084................................................ 1.2684 16.35
390086................................................ 1.1376 17.25
390088................................................ 1.3701 22.85
390090................................................ 1.8017 20.68
390091................................................ 1.1279 18.36
390093................................................ 1.1549 16.61
390095................................................ 1.2035 13.05
390096................................................ 1.4931 19.25
390097................................................ 1.2755 21.52
390100................................................ 1.6536 19.89
390101................................................ 1.2027 17.10
390102................................................ 1.3963 19.51
390103................................................ 1.0916 17.71
390104................................................ 1.0666 16.17
390106................................................ 1.1160 16.28
390107................................................ 1.3258 19.18
390108................................................ 1.4022 21.43
390109................................................ 1.2016 14.66
390110................................................ 1.5961 19.51
390111................................................ 1.9406 26.03
390112................................................ 1.2965 14.04
390113................................................ 1.2515 17.53
390114................................................ 1.2347 23.03
390115................................................ 1.3973 24.42
390116................................................ 1.2899 20.60
390117................................................ 1.1722 16.90
390118................................................ 1.2135 16.90
390119*............................................... 1.3898 18.48
390121................................................ 1.3957 18.64
390122................................................ 1.0603 17.46
390123................................................ 1.2758 20.44
390125................................................ 1.2067 15.94
390126................................................ 1.2899 20.94
390127................................................ 1.2286 21.88
390128................................................ 1.2202 19.99
390130................................................ 1.1343 17.33
390131................................................ 1.3302 16.83
390132................................................ 1.2935 21.10
390136................................................ 1.1431 17.61
390137................................................ 1.5156 16.54
390138................................................ 1.3212 18.86
390139................................................ 1.5084 22.94
390142*............................................... 1.6088 27.22
390145................................................ 1.3880 20.34
390146................................................ 1.2154 17.70
390147................................................ 1.2654 21.11
390150................................................ 1.1815 19.66
390151................................................ 1.2305 20.51
390152................................................ 1.1114 19.15
390153................................................ 1.2214 23.14
390154................................................ 1.2689 15.85
390156................................................ 1.4094 20.88
390157................................................ 1.3940 19.83
390158................................................ ........ 21.69
390160................................................ 1.2380 20.67
390161................................................ 1.1893 12.37
390162................................................ 1.5191 21.01
390163................................................ 1.2262 15.64
390164*............................................... 2.1709 21.74
390166................................................ 1.1125 19.96
390166................................................ 1.1125 19.96
390167................................................ ........ 22.91
390168................................................ 1.2596 18.99
390169................................................ 1.3383 18.99
390170................................................ 1.8481 22.99
390173................................................ 1.2222 17.82
390174*............................................... 1.6754 23.61
390176................................................ 1.1817 17.36
390178................................................ 1.3114 17.47
390179................................................ 1.3111 21.16
390180................................................ 1.4554 25.02
390181................................................ 1.0732 17.09
390183................................................ 1.1620 18.28
390184................................................ 1.1309 20.75
390185................................................ 1.2171 17.65
390189................................................ 1.1411 18.67
390191................................................ 1.1707 16.20
390192................................................ 1.1740 16.32
390193................................................ 1.1938 16.50
390194................................................ 1.1395 20.15
390195................................................ 1.8245 23.69
390196................................................ 1.5792 ......
390197................................................ 1.2825 18.99
390197................................................ 1.3365 11.12
390198*............................................... 1.2667 15.51
390199................................................ 1.2670 16.66
390200................................................ 0.9701 13.59
390201................................................ 1.2646 20.50
390203................................................ 1.3562 22.06
390204................................................ 1.2728 20.85
390206................................................ 1.4000 16.78
390206................................................ 1.4000 16.78
390209................................................ 1.0811 16.96
390211................................................ 1.2184 17.88
390213................................................ 1.1284 17.17
390215................................................ 1.2563 20.84
390217................................................ 1.2232 19.29
390219................................................ 1.3072 22.71
390220................................................ 1.1652 18.52
390222................................................ 1.3140 20.91
390223................................................ 1.7334 22.13
390224................................................ 0.8802 15.91
390225................................................ 1.1951 18.17
390226................................................ 1.6039 22.46
390228................................................ 1.2976 19.81
390231................................................ 1.5675 22.40
390231................................................ 1.1916 9.56
390233................................................ 1.3507 18.20
390235................................................ 1.4144 23.54
390236................................................ 1.2254 17.03
390237................................................ 1.5705 19.89
390238................................................ 1.2725 1.27
390238................................................ 1.1545 10.04
390242................................................ ........ 18.10
390244................................................ 0.9245 14.41
390245................................................ 1.3199 20.15
390246................................................ 1.1920 17.75
390247................................................ 1.0511 20.67
390249................................................ 0.9293 10.73
390256................................................ 1.8901 23.84
390258................................................ 1.4575 21.36
390258................................................ 1.3348 22.53
390260................................................ 1.0990 21.19
390262................................................ 1.9276 18.62
390263................................................ 1.4224 23.62
390265................................................ 1.2935 19.51
390266................................................ 1.2118 16.24
390267................................................ 1.2589 20.79
390268................................................ 1.3375 21.02
390270................................................ 1.3851 17.83
390272................................................ 0.4768 ......
390277................................................ 0.4015 27.10
390278................................................ 0.6660 18.99
390283................................................ 1.2887 ......
390284................................................ 1.3639 ......
400001................................................ 1.2182 9.86
400002................................................ 1.6803 9.31
400003................................................ 1.3589 10.13
400004................................................ 1.1421 8.48
400005................................................ 1.1211 7.85
400006................................................ 1.1593 8.22
400007................................................ 1.2021 7.86
400009................................................ 1.0530 8.37
400010................................................ 0.8902 11.66
400011................................................ 1.0733 7.44
400012................................................ 1.3428 7.81
400013................................................ 1.2616 8.21
400014................................................ 1.3935 9.54
400015................................................ 1.3307 10.33
400016................................................ 1.3663 12.07
400017................................................ 1.1570 8.57
400018................................................ 1.2817 9.45
400019................................................ 1.6576 10.13
400021................................................ 1.4432 11.68
400024................................................ 0.9500 7.56
400026................................................ 0.9640 7.12
400027................................................ 1.1026 8.49
400028................................................ 1.2500 8.40
400031................................................ 1.2515 9.78
400032................................................ 1.2212 9.42
400048................................................ 1.0249 9.47
400061................................................ 1.7094 16.08
400079................................................ 1.2218 ......
400087................................................ 1.4156 9.83
400094................................................ 0.9947 5.15
[[Page 24787]]
400098................................................ 1.3998 8.17
400102................................................ 1.1591 7.73
400103................................................ 1.3870 10.59
400104................................................ 1.2767 9.68
400105................................................ 1.2171 10.06
400106................................................ 1.2574 8.51
400109................................................ 1.4773 10.18
400110................................................ 1.1292 10.52
400112................................................ 1.0540 9.97
400113................................................ 1.1575 9.48
400114................................................ 1.0784 6.41
400115................................................ 1.0386 9.13
400118................................................ 1.2392 8.70
400120................................................ 1.2554 9.74
400121................................................ 0.9964 7.11
400122................................................ 1.0235 8.48
400123................................................ 1.2031 9.00
400124................................................ 2.8358 11.16
400125................................................ 1.0022 ......
410004................................................ 1.2575 22.06
410005................................................ 1.3735 21.26
410006................................................ 1.3057 21.68
410007................................................ 1.6365 20.98
410008................................................ 1.2136 22.62
410009................................................ 1.2941 24.08
410010................................................ 1.1611 27.14
410011................................................ 1.2705 24.37
410012................................................ 1.9068 21.33
410013................................................ 1.2981 25.01
420002................................................ 1.5015 20.20
420004................................................ 1.8164 19.41
420005................................................ 1.1323 15.99
420006................................................ 1.1199 18.24
420007................................................ 1.5710 17.43
420009................................................ 1.1697 17.25
420010................................................ 1.1774 17.91
420011................................................ 1.2438 14.99
420014................................................ 1.0197 16.72
420015................................................ 1.3348 17.18
420016................................................ 0.9571 18.15
420018................................................ 1.8110 19.73
420019................................................ 1.2145 15.55
420020................................................ 1.1846 20.16
420023................................................ 1.4298 20.97
420026................................................ 1.8901 21.90
420027................................................ 1.3308 18.08
420030................................................ 1.2081 17.82
420031................................................ 0.8622 13.07
420033................................................ 1.1653 21.09
420036................................................ 1.2907 19.80
420037................................................ 1.1948 21.96
420038................................................ 1.3155 16.15
420039................................................ 1.0701 16.96
420042................................................ ........ 14.66
420043................................................ 1.1867 18.36
420048................................................ 1.2366 29.62
420049................................................ 1.2046 19.23
420051................................................ 1.6466 18.25
420053................................................ 1.1427 16.48
420054................................................ 1.2398 16.55
420055................................................ 1.0585 16.18
420056................................................ 1.1158 14.85
420057................................................ 1.1156 14.50
420059................................................ 0.9738 19.13
420061................................................ 1.1761 17.78
420062................................................ 1.1904 18.92
420064................................................ 1.1038 16.15
420065................................................ 1.3912 19.06
420066................................................ 0.9834 15.52
420067................................................ 1.2163 18.30
420068................................................ 1.3854 17.21
420069................................................ 1.0602 16.40
420070................................................ 1.2331 17.45
420071................................................ 1.3510 18.29
420072................................................ 0.9129 12.34
420073................................................ 1.2802 19.20
420074................................................ 1.0257 13.80
420075................................................ 0.9395 16.29
420078*............................................... 1.8578 20.68
420079................................................ 1.5179 18.77
420080................................................ 1.3722 24.83
420082................................................ 1.5853 18.88
420083................................................ 1.3596 20.41
420085................................................ 1.4116 18.33
420086................................................ 1.4340 19.31
420087................................................ 1.5959 17.43
420088................................................ 1.0878 17.09
420089................................................ 1.2941 21.66
420091................................................ 1.2732 18.57
420093................................................ 1.0353 16.77
420094................................................ ........ 32.68
430004................................................ 0.9973 17.85
430005................................................ 1.3588 15.92
430007................................................ 1.0895 14.06
430008................................................ 1.0971 16.54
430010................................................ 1.1605 16.11
430011................................................ 1.2930 16.42
430012................................................ 1.3230 17.56
430013................................................ 1.2073 17.24
430014................................................ 1.3653 18.56
430015................................................ 1.2134 16.41
430016................................................ 1.8711 18.97
430018................................................ 0.8815 15.15
430022................................................ 0.8616 12.95
430023................................................ 0.8729 11.64
430024................................................ 0.9364 13.99
430026................................................ ........ 10.85
430027................................................ 1.7681 18.32
430028................................................ 1.0724 16.78
430029................................................ 0.9602 15.10
430031................................................ 0.9138 12.46
430033................................................ 0.9935 14.64
430034................................................ 0.9461 12.85
430036................................................ 0.9551 13.78
430037................................................ 0.9633 15.95
430038................................................ 1.0095 11.94
430040................................................ 1.0511 13.37
430041................................................ 0.9140 12.62
430043................................................ 1.1323 13.43
430044................................................ 0.9084 16.45
430047................................................ 1.0274 17.06
430048................................................ 1.2378 17.26
430049................................................ 0.8812 14.44
430051................................................ 0.9318 17.03
430054................................................ 0.9648 13.50
430056................................................ 0.8301 10.74
430057................................................ 0.8972 15.15
430060................................................ 1.0902 8.64
430062................................................ ........ 10.89
430064................................................ 1.0191 12.74
430065................................................ ........ 12.77
430066................................................ 0.9635 13.44
430073................................................ 1.0646 14.98
430076................................................ 0.9475 12.25
430076................................................ 1.3562 15.61
430077................................................ 1.6605 17.72
430079................................................ 1.0029 12.98
430081................................................ 0.8954 ......
430082................................................ 0.8549 ......
430083................................................ 0.9273 ......
430084................................................ 0.8155 ......
430085................................................ 0.7910 ......
430087................................................ ........ 10.45
430089................................................ 0.8333 17.01
430090................................................ 1.3320 ......
430091................................................ 1.4528 ......
430092................................................ 2.2007 ......
430093................................................ 0.9966 ......
440001................................................ 1.1722 15.01
440002................................................ 1.6649 24.36
440003................................................ 1.2128 17.47
440006................................................ 1.4058 20.39
440007................................................ 1.0032 7.77
440008................................................ 0.9784 14.04
440009................................................ 1.1552 15.46
440010................................................ 0.9307 13.59
440011................................................ 1.3832 17.16
440012................................................ 1.7143 18.79
440014................................................ 1.0046 14.61
440015................................................ 1.7923 21.09
440016................................................ 1.0334 14.94
440017................................................ 1.7422 20.93
440018................................................ 1.2965 18.21
440019................................................ 1.7372 28.22
440020................................................ 1.1314 14.70
440022................................................ ........ 19.02
440023................................................ 1.1030 14.14
440024................................................ 1.2947 18.10
440025................................................ 1.1538 15.28
440026................................................ 0.8073 22.92
440029................................................ 1.2585 18.52
440030................................................ 1.2098 15.57
440031................................................ 1.0300 14.30
440031................................................ 1.5024 19.61
440032................................................ 1.0048 13.60
440033................................................ 1.1602 14.04
440034................................................ 1.5621 17.93
440035................................................ 1.2301 18.16
440039................................................ 1.8871 16.52
440040................................................ 0.9687 17.50
440041................................................ 1.0284 13.63
440046................................................ 1.2336 16.83
440047................................................ 0.9254 17.00
[[Page 24788]]
440048................................................ 1.8710 18.14
440049................................................ 1.6635 15.23
440050................................................ 1.3867 16.76
440051................................................ 0.9145 14.91
440052................................................ 1.0633 16.27
440053................................................ 1.3201 17.69
440054................................................ 1.1349 12.31
440056................................................ 1.1422 14.25
440057................................................ 1.0340 12.72
440058................................................ 1.2124 18.86
440059................................................ 1.4182 17.53
440060................................................ 1.1653 15.86
440061................................................ 1.1496 16.48
440063................................................ 1.6724 18.29
440064................................................ 1.0863 17.38
440065................................................ 1.2816 18.69
440067................................................ 1.2422 28.28
440068................................................ 1.2251 17.45
440070................................................ 1.0077 15.04
440071................................................ 1.3615 16.17
440073................................................ 1.2785 18.56
440078................................................ 1.0266 13.09
440081................................................ 1.0950 17.97
440082................................................ 2.0471 19.61
440083................................................ 0.9670 59.16
440084................................................ 1.2064 13.37
440091................................................ 1.6371 19.72
440100................................................ 1.0065 13.95
440102................................................ 1.1313 13.96
440103................................................ 1.1144 19.21
440104................................................ 1.7388 22.39
440105................................................ 1.7270 16.03
440109................................................ 1.0889 14.25
440110................................................ 1.1002 15.92
440111*............................................... 1.4426 21.12
440114................................................ 1.0554 13.61
440115................................................ 1.0675 12.97
440115................................................ 1.4538 16.64
440120................................................ 1.6404 18.30
440125................................................ 1.5584 16.11
440130................................................ 1.1384 16.67
440131................................................ 1.1174 14.68
440132................................................ 1.1314 15.91
440133................................................ 1.5479 21.70
440135................................................ 1.2196 35.34
440137................................................ 1.0844 14.70
440141................................................ 0.9706 12.48
440142................................................ 1.0003 13.01
440143................................................ 1.0461 17.33
440144................................................ 1.2139 16.67
440145................................................ 0.9559 13.66
440147................................................ 1.7001 22.01
440148................................................ 1.1231 17.64
440149................................................ 1.0945 13.89
440150................................................ 1.3319 13.04
440151................................................ 1.1148 15.43
440152................................................ 2.0165 17.84
440153................................................ 1.1547 16.10
440157................................................ 1.0819 9.02
440159................................................ 1.1218 17.62
440161................................................ 1.8684 20.39
440162................................................ ........ 14.41
440166................................................ 1.6849 18.14
440168................................................ 1.0561 17.15
440173................................................ 1.6008 18.47
440174................................................ 1.0302 17.01
440175................................................ 1.0716 17.29
440176................................................ 1.3816 18.75
440180................................................ 1.2237 17.01
440181................................................ 0.9662 11.85
440182................................................ 0.9596 18.91
440183................................................ 1.5917 19.43
440184................................................ 1.2536 18.06
440185................................................ 1.1857 18.73
440186................................................ 1.0479 18.28
440187................................................ 1.1048 14.46
440189................................................ 1.4799 16.19
440192................................................ 1.0810 19.97
440193................................................ 1.2265 18.40
440194................................................ 1.2532 19.21
440197................................................ 1.3616 23.08
440200................................................ 1.0421 15.85
440203................................................ 0.9727 16.61
440206................................................ 0.9468 13.75
440209................................................ ........ 14.75
440210................................................ 0.8584 12.33
440211................................................ 0.7073 ......
440212................................................ 1.3679 ......
440213................................................ 2.6309 ......
440214................................................ 1.3295 ......
450002*............................................... 1.5334 19.92
450004................................................ 1.1433 15.28
450005................................................ 1.1877 15.66
450007................................................ 1.2689 15.75
450008................................................ 1.2584 15.75
450010................................................ 1.4340 16.08
450011................................................ 1.5214 17.66
450014................................................ 1.1172 18.22
450015*............................................... 1.6355 16.44
450016................................................ 1.6644 17.31
450018................................................ 1.4434 19.81
450020................................................ 0.9601 16.97
450021................................................ 1.8595 22.03
450024................................................ 1.4525 16.10
450024................................................ 1.6146 15.16
450025................................................ 1.7316 16.44
450028................................................ 1.5003 18.28
450029................................................ 1.6807 17.69
450031................................................ 1.4829 20.90
450032................................................ 1.3571 15.24
450033................................................ 1.7144 20.86
450034................................................ 1.5651 18.91
450035................................................ 1.4731 16.91
450037................................................ 1.5577 18.65
450039*............................................... 1.4262 18.83
450040................................................ 1.5483 17.52
450042................................................ 1.7715 17.01
450044................................................ 1.6187 17.61
450046*............................................... 1.3251 16.99
450047................................................ 1.1488 12.50
450050................................................ 0.9407 13.00
450051................................................ 1.5714 20.08
450052................................................ 1.0002 13.53
450053................................................ 1.1028 17.31
450054*............................................... 1.6343 21.98
450055................................................ 1.1125 14.81
450056................................................ 1.6257 19.22
450058................................................ 1.6338 16.98
450059................................................ 1.3021 14.21
450063................................................ 0.9097 13.81
450064................................................ 1.4200 15.43
450065................................................ 1.0265 19.61
450068................................................ 1.9331 22.90
450072................................................ 1.1764 17.34
450073................................................ 1.1207 16.62
450076................................................ 1.7329 ......
450078................................................ 0.8770 13.49
450079................................................ 1.5311 19.49
450080................................................ 1.1778 16.19
450081................................................ 1.0574 16.17
450082................................................ 0.9688 13.30
450083................................................ 1.8071 20.18
450085................................................ 1.0524 14.22
450087................................................ 1.4467 21.44
450090................................................ 1.1231 13.91
450092................................................ 1.2254 15.68
450094................................................ 1.3268 19.20
450096................................................ 1.4156 16.63
450097................................................ 1.3392 18.27
450098................................................ 1.0981 15.48
450099................................................ 1.1515 22.88
450101................................................ 1.4797 15.29
450102................................................ 1.7275 17.15
450104................................................ 1.1833 15.96
450107................................................ 1.5329 20.74
450108................................................ 1.0388 13.53
450109................................................ 0.9217 12.77
450110................................................ ........ 21.44
450111................................................ 1.2306 19.27
450112................................................ 1.2588 12.04
450113................................................ 1.3241 15.15
450118................................................ 1.6610 15.83
450119................................................ 1.4076 18.32
450121................................................ 1.5363 17.37
450123................................................ 1.1893 19.19
450124................................................ 1.6632 20.61
450126................................................ 1.3278 17.45
450128................................................ 1.1963 15.62
450130................................................ 1.5006 17.86
450131................................................ 1.2640 17.62
450132................................................ 1.6184 14.38
450133................................................ 1.6016 19.64
450137................................................ 1.5728 23.96
450140................................................ 0.9222 18.07
450143................................................ 1.0314 13.28
450144................................................ 1.0945 16.30
450145................................................ 0.8669 14.84
450146................................................ 0.9518 13.75
450147................................................ 1.3039 14.90
450148................................................ 1.2199 16.91
450149................................................ 1.4914 24.00
450150................................................ 0.9050 12.56
450151................................................ 1.1034 14.84
[[Page 24789]]
450152................................................ 1.2307 17.33
450153................................................ 1.5443 24.00
450154................................................ 1.1796 11.36
450155................................................ 1.0303 23.77
450157................................................ 1.0679 14.62
450160................................................ 0.9623 8.75
450162................................................ 1.2163 22.12
450163................................................ 1.0057 16.98
450164................................................ 1.1844 19.21
450165................................................ 1.0389 15.16
450166................................................ 0.9373 10.28
450169................................................ ........ 15.88
450170................................................ 0.9628 13.96
450176................................................ 1.2927 16.30
450177................................................ 1.2044 15.38
450178................................................ 1.0248 16.76
450181................................................ 1.0084 14.02
450184................................................ 1.4589 19.47
450185................................................ 1.0264 13.06
450187................................................ 1.1969 17.14
450188................................................ 0.9950 13.78
450191................................................ 1.0176 18.80
450192................................................ 1.1764 21.53
450193................................................ 2.0194 22.73
450194................................................ 1.3017 19.15
450196................................................ 1.4365 16.49
450200................................................ 1.4455 17.38
450201................................................ 1.0178 17.05
450203................................................ 1.1592 18.66
450209................................................ 1.5655 18.66
450210................................................ 1.0520 14.23
450211................................................ 1.3626 16.69
450213................................................ 1.7288 17.44
450214................................................ 1.3280 17.25
450217................................................ 0.9354 11.69
450219................................................ 1.0891 15.42
450221................................................ 1.1920 16.99
450222................................................ 1.4941 18.38
450224................................................ 1.3678 22.83
450229................................................ 1.5725 16.39
450231................................................ 1.6282 13.25
450234................................................ 1.0450 13.26
450235................................................ 1.0681 13.42
450236................................................ 1.1453 15.68
450237................................................ 1.5262 17.40
450239................................................ 1.0080 13.64
450241................................................ 0.9562 13.66
450243................................................ 0.9422 12.31
450246................................................ 1.0110 18.31
450249................................................ 1.0667 11.63
450250................................................ 0.9906 14.91
450253................................................ 1.1234 15.35
450258................................................ 1.0358 13.23
450259................................................ ........ 17.85
450264................................................ 0.8807 13.89
450269................................................ 0.9963 14.16
450270................................................ 1.0793 9.86
450271................................................ 1.2394 15.39
450272................................................ 1.2614 17.91
450276................................................ 1.0966 12.71
450278................................................ 0.8254 13.79
450280................................................ 1.5815 19.01
450283................................................ 1.0413 13.89
450286................................................ ........ 12.12
450288................................................ 1.1566 15.67
450289................................................ 1.4681 18.08
450293................................................ 0.9461 14.43
450296................................................ 1.3456 20.66
450299................................................ 1.5412 17.97
450303................................................ 0.9624 11.59
450306................................................ 1.0914 13.32
450307................................................ 0.7995 16.23
450309................................................ 1.0981 11.91
450315................................................ 0.9788 20.80
450320................................................ 1.2431 19.63
450321................................................ 0.9220 13.09
450322................................................ 0.5973 12.33
450324................................................ 1.5343 17.87
450327................................................ 0.9680 15.98
450330................................................ 1.1267 18.42
450334................................................ 0.9752 12.27
450337................................................ 0.9932 17.42
450340................................................ 1.4589 15.85
450341................................................ 1.0144 19.27
450346................................................ 1.5017 14.22
450347................................................ 1.2197 17.54
450348................................................ 1.1296 12.94
450352................................................ 1.1887 17.50
450353................................................ 1.1374 15.00
450355................................................ 1.0444 14.32
450358................................................ 2.0739 18.73
450362................................................ 1.0903 14.71
450369................................................ 1.0535 15.17
450370................................................ 1.2082 15.44
450371................................................ 1.2448 11.90
450372................................................ 1.2359 18.76
450373................................................ 1.1042 17.60
450374................................................ 0.8698 12.69
450378................................................ 1.1823 23.06
450379................................................ 1.5578 20.28
450381................................................ 0.9504 13.57
450388................................................ 1.7801 17.56
450389................................................ 1.2887 18.15
450393................................................ 1.2516 15.73
450395................................................ 1.0414 13.48
450400................................................ 1.3751 11.53
450411................................................ 0.9314 13.56
450417................................................ 1.0236 13.85
450418................................................ 1.3841 20.58
450419................................................ 1.2162 14.50
450422................................................ 1.0412 24.33
450423................................................ 1.5371 19.44
450424................................................ 1.2463 17.09
450429................................................ 1.1179 10.12
450431................................................ 1.5626 34.88
450438................................................ 1.1330 14.95
450446................................................ 0.7612 21.97
450447................................................ 1.3910 16.35
450451................................................ 1.1844 18.35
450457................................................ 1.8463 19.35
450460................................................ 1.0034 16.62
450462................................................ 1.7354 19.83
450464................................................ 0.9328 10.87
450465................................................ 1.3057 15.22
450467................................................ 1.0766 15.02
450469................................................ 1.3918 22.10
450473................................................ 1.0190 14.19
450475................................................ 1.0903 16.25
450484................................................ 1.4886 19.59
450488................................................ 1.3273 18.73
450489................................................ 0.9699 12.93
450497................................................ 1.1188 11.89
450498................................................ 0.9736 0.87
450508................................................ 1.3853 19.37
450514................................................ 1.0764 22.28
450517................................................ 0.9583 12.86
450518................................................ 1.5216 18.98
450523................................................ 1.4806 20.26
450530................................................ 1.1943 22.91
450534................................................ 0.9671 22.77
450535................................................ 1.2284 21.26
450537................................................ 1.3420 20.83
450538................................................ ........ 19.69
450539................................................ 1.2651 14.25
450544*............................................... 1.1442 19.38
450545................................................ 1.3928 16.97
450547................................................ 1.0633 13.81
450551................................................ 1.1045 24.23
450558................................................ 1.7912 20.15
450559................................................ ........ 11.50
450561................................................ ........ 16.82
450563................................................ 1.2647 30.37
450565................................................ 1.2567 16.45
450570................................................ 1.1346 17.71
450571................................................ 1.4908 16.80
450573................................................ 0.9885 15.61
450574................................................ 0.9302 14.24
450575................................................ 1.1445 19.06
450578................................................ 0.9365 16.87
450580................................................ 1.1534 15.36
450583................................................ 1.0350 15.50
450583................................................ 1.1976 21.38
450584................................................ 1.1771 12.42
450586................................................ 1.0584 12.79
450587................................................ 1.1745 17.11
450591................................................ 1.1460 17.92
450596................................................ 1.2182 14.82
450597................................................ 0.9687 16.18
450603................................................ 0.7880 12.77
450604................................................ 1.3023 14.47
450605................................................ 1.1873 20.15
450609................................................ 0.8938 10.73
450610................................................ 1.4674 16.49
450614................................................ 0.9889 13.25
450615................................................ 1.0755 14.75
450617................................................ 1.3306 19.54
450620................................................ 1.1230 12.27
450623................................................ 1.1390 21.83
450626................................................ 1.0109 18.56
450628................................................ 1.0152 16.83
450630................................................ 1.5199 19.19
450631................................................ 1.6593 17.56
450632................................................ 0.9391 11.63
[[Page 24790]]
450633................................................ 1.5493 19.26
450634................................................ 1.5955 20.29
450638................................................ 1.5280 21.11
450639................................................ 1.4800 20.14
450639................................................ 1.1078 14.71
450641................................................ 1.0511 13.50
450643................................................ 1.2200 17.43
450643................................................ 1.8171 18.65
450644................................................ 1.4350 20.79
450644................................................ 1.2078 17.67
450646................................................ 1.4571 19.99
450647................................................ 1.8915 22.10
450648................................................ 1.0015 12.59
450649................................................ 1.0322 15.37
450651................................................ 1.6801 20.31
450652................................................ 0.9063 15.24
450653................................................ 1.0888 19.28
450654................................................ 0.9486 13.41
450656................................................ 1.3894 18.56
450658................................................ 0.9605 15.15
450659................................................ 1.4874 20.56
450661................................................ 1.1066 20.22
450662................................................ 1.4702 18.42
450665................................................ 0.8639 13.60
450666................................................ 1.3180 19.35
450668................................................ 1.6257 18.50
450669................................................ 1.3474 22.28
450670................................................ 1.3446 18.20
450672................................................ 1.5857 21.04
450673................................................ 1.0157 13.84
450674................................................ 1.1515 20.62
450675................................................ 1.3677 23.26
450677................................................ 1.3317 18.71
450678................................................ 1.4729 20.75
450681................................................ 1.3177 ......
450683................................................ 1.2745 19.95
450684................................................ 1.2398 22.85
450686................................................ 1.5933 14.85
450688................................................ 1.3163 20.90
450690................................................ 1.3862 16.37
450694................................................ 1.1409 18.03
450696................................................ 1.3358 17.57
450697................................................ 1.3692 15.93
450698................................................ 0.9124 14.40
450700................................................ 0.9465 15.12
450702................................................ 1.5056 21.01
450703................................................ 1.1321 18.80
450704................................................ 1.2418 21.62
450705................................................ 0.8800 22.32
450705................................................ 1.7726 20.82
450709................................................ 1.1858 17.96
450711................................................ 1.6329 17.93
450712................................................ 0.5447 16.89
450713................................................ 1.4868 23.11
450715................................................ 1.4311 19.11
450716................................................ 1.2675 19.99
450716................................................ 1.3205 16.71
450717................................................ 1.2910 19.45
450718................................................ 1.1993 19.07
450723................................................ 1.4195 20.55
450724................................................ 1.2576 20.07
450725................................................ ........ 19.56
450727................................................ 1.0735 17.75
450728................................................ 0.8255 12.93
450730................................................ 1.3987 20.88
450733................................................ 1.4711 20.37
450735................................................ 0.8297 8.00
450742................................................ 1.2724 20.74
450743................................................ 1.4594 14.65
450746................................................ 0.9226 18.45
450747................................................ 1.3312 17.38
450749................................................ 1.0333 12.95
450750................................................ 1.0162 14.72
450751................................................ 1.2148 22.25
450754................................................ 0.9405 14.89
450757................................................ 0.8760 13.96
450761................................................ 0.9449 11.14
450763................................................ 1.0029 17.56
450766................................................ 2.0829 18.19
450769................................................ 0.8529 13.62
450770................................................ 0.9940 15.51
450771................................................ 1.9141 17.74
450774................................................ 1.6697 16.52
450775................................................ 1.3635 19.97
450776................................................ 1.0096 10.19
450777................................................ 0.9775 19.59
450779................................................ 1.2926 22.97
450780................................................ 1.7465 15.28
450785................................................ 0.9897 18.55
450788................................................ 1.5030 20.78
450794................................................ ........ 18.40
450795................................................ 0.9920 14.17
450796................................................ 3.3883 ......
450797................................................ 0.7701 18.59
450798................................................ 0.7662 9.22
450801................................................ 1.4574 16.35
450802................................................ 1.4444 18.90
450803................................................ 1.0998 16.20
450804................................................ 1.7558 20.19
450807................................................ 0.8919 13.23
450808................................................ 1.9103 45.47
450809................................................ 1.5476 12.09
450810................................................ 0.9739 ......
450811................................................ 2.4111 18.38
450812................................................ ........ 20.74
450813................................................ 0.9720 ......
450815................................................ 2.5623 ......
450817................................................ 0.6826 ......
450818................................................ 1.1788 ......
450819................................................ 1.2321 ......
450820................................................ 1.0337 ......
450822................................................ 1.2194 ......
460001................................................ 1.7791 20.63
460003................................................ 1.6039 20.60
460005................................................ 1.6610 17.58
460006................................................ 1.3361 19.65
460007................................................ 1.3066 20.57
460008................................................ 1.3692 23.97
460009*............................................... 1.8478 21.14
460010................................................ 2.0938 21.25
460013................................................ 1.4314 18.21
460014................................................ 1.2150 16.70
460015................................................ 1.2389 19.99
460016................................................ 0.9921 18.08
460017................................................ 1.4000 6.88
460018................................................ 0.9273 16.86
460019................................................ 1.0515 16.83
460020................................................ 0.9556 17.03
460021................................................ 1.3838 20.26
460022................................................ 0.9569 18.21
460023................................................ 1.1748 21.33
460024................................................ ........ 13.03
460025................................................ 0.8253 12.51
460026................................................ 1.0648 17.34
460027................................................ 0.9545 20.85
460029................................................ 1.0958 17.45
460030................................................ 1.1965 17.22
460032................................................ 0.9812 19.55
460033................................................ 0.9710 15.72
460035................................................ 0.9482 10.14
460036................................................ 1.0012 22.38
460037................................................ 0.9093 18.77
460039................................................ 1.0603 24.48
460041................................................ 1.3034 21.69
460042................................................ 1.3720 17.85
460043................................................ 0.9896 23.90
460044................................................ 1.1363 20.69
460046................................................ ........ 17.11
460047................................................ 1.6725 20.94
460049................................................ 1.9835 18.82
460051................................................ 1.1533 20.98
460052................................................ 1.4619 ......
470001................................................ 1.3024 19.61
470003................................................ 1.8178 22.10
470004................................................ 1.0690 18.10
470005................................................ 1.2301 21.51
470006................................................ 1.2402 18.39
470008................................................ 1.2583 19.41
470010................................................ 1.0674 19.47
470011................................................ 1.1523 21.20
470012................................................ 1.2771 18.52
470015................................................ 1.2008 19.26
470018................................................ 1.2257 20.77
470020................................................ 0.9900 18.99
470023................................................ 1.3178 20.34
470024................................................ 1.1530 20.41
490001................................................ 1.1947 24.76
490002................................................ 1.0751 12.74
490003................................................ 0.6419 18.00
490004................................................ 1.2734 18.67
490005................................................ 1.5964 16.91
490006................................................ 1.2135 15.23
490007................................................ 2.0980 18.43
490009................................................ 1.9433 22.95
490010................................................ 1.0335 18.58
490011................................................ 1.4669 18.20
490012................................................ 1.1951 13.78
490013................................................ 1.2469 16.93
490014................................................ 1.5363 24.56
490015................................................ 1.5153 19.36
490017................................................ 1.3909 15.07
490018................................................ 1.3011 17.67
490019................................................ 1.1928 16.93
[[Page 24791]]
490020................................................ 1.2250 17.67
490021................................................ 1.3802 19.45
490022................................................ 1.5525 21.01
490023................................................ 1.2187 18.87
490024................................................ 1.6719 16.89
490027................................................ 1.1135 14.46
490030................................................ 1.1907 10.50
490031................................................ 1.0746 15.82
490032*............................................... 1.7258 25.58
490033................................................ 1.1993 18.33
490037................................................ 1.2001 15.97
490038................................................ 1.2145 15.71
490040................................................ 1.4731 22.35
490041................................................ 1.2784 16.55
490042................................................ 1.2285 15.27
490043................................................ 1.3526 20.68
490044................................................ 1.3206 17.63
490045................................................ 1.2191 19.63
490046................................................ 1.5460 18.61
490047................................................ 1.1059 17.16
490048................................................ 1.5709 17.89
490050................................................ 1.4272 22.71
490052................................................ 1.6374 16.94
490053................................................ 1.3173 15.69
490054................................................ 1.0322 15.55
490057................................................ 1.5692 19.07
490059................................................ 1.5895 20.22
490060................................................ 1.0646 19.20
490063................................................ 1.7720 27.25
490066................................................ 1.3206 17.88
490067................................................ 1.2570 17.19
490069................................................ 1.4162 13.29
490071................................................ 1.4080 19.47
490074................................................ ........ 13.34
490075................................................ 1.3803 19.19
490077................................................ 1.2281 19.79
490079................................................ 1.3125 16.44
490079................................................ 1.3236 23.38
490083................................................ ........ 16.64
490084................................................ 1.1288 16.38
490085................................................ 1.1577 16.40
490088................................................ 1.1207 20.76
490089................................................ 1.0686 15.86
490090................................................ 1.1204 16.35
490091................................................ 1.2337 19.83
490092................................................ 1.2211 12.97
490093................................................ 1.4392 16.48
490094................................................ 1.0907 16.79
490097................................................ 1.2114 15.86
490098................................................ 1.2065 14.70
490099................................................ 0.9562 16.88
490100................................................ ........ 17.22
490101................................................ 1.2299 24.85
490104................................................ 0.6981 28.49
490105................................................ 0.5822 18.25
490106................................................ 0.8713 16.91
490107................................................ 1.3325 22.41
490107................................................ 1.2448 21.42
490108................................................ 0.8976 19.75
490109................................................ 0.8779 21.16
490110................................................ 1.3090 15.84
490111................................................ 1.2008 17.34
490112................................................ 1.6550 20.52
490112................................................ 0.9491 21.43
490113................................................ 1.3260 23.08
490114................................................ 1.1579 16.91
490115................................................ 1.1607 17.10
490116................................................ 1.1694 16.44
490117................................................ 1.1533 13.84
490119................................................ 1.3405 17.87
490122................................................ 1.3606 23.62
490123................................................ 1.1354 16.85
490124................................................ 1.0889 19.36
490126................................................ 1.3233 17.07
490127................................................ 1.0414 14.48
490129................................................ 1.0562 27.47
490130................................................ 1.3109 16.28
490132................................................ 1.0184 17.02
500001................................................ 1.4839 21.30
500002................................................ 1.4064 21.04
500003................................................ 1.3996 24.31
500005................................................ 1.7494 23.48
500007................................................ 1.3375 22.43
500007................................................ 1.7377 27.24
500008................................................ 1.9429 24.19
500011................................................ 1.3347 25.18
500012................................................ 1.5545 22.28
500014................................................ 1.5643 23.93
500015................................................ 1.3297 23.24
500016................................................ 1.4969 23.90
500019................................................ 1.3825 22.37
500019................................................ 1.0542 16.63
500021................................................ 1.4811 24.46
500023................................................ 1.2084 27.19
500024................................................ 1.6908 28.85
500025................................................ 1.9076 23.96
500026................................................ 1.4496 23.35
500027*............................................... 1.6837 25.11
500028................................................ 1.0717 18.86
500029................................................ 0.9116 17.15
500030................................................ 1.4523 24.13
500031................................................ 1.2466 23.37
500033................................................ 1.3324 21.39
500036................................................ 1.3903 21.89
500037................................................ 1.1389 19.69
500039................................................ 1.3777 23.32
500042................................................ 1.4121 22.13
500043................................................ 1.0020 20.25
500044................................................ 1.9366 23.11
500045................................................ 1.0116 22.10
500048................................................ 0.9588 19.01
500049................................................ 1.4726 22.95
500050................................................ 1.3485 20.97
500051................................................ 1.6734 24.48
500052................................................ 1.1378 ......
500053................................................ 1.3294 22.05
500054................................................ 1.8773 22.90
500055................................................ 1.1299 22.88
500057................................................ 1.3026 18.04
500058................................................ 1.4858 23.40
500059................................................ 1.0767 22.54
500060................................................ 1.3734 23.58
500061................................................ 1.0038 20.40
500062................................................ 1.0655 19.46
500064................................................ 1.6399 24.53
500068................................................ 1.0553 18.70
500069................................................ 1.1143 20.63
500071................................................ 1.2830 19.38
500072................................................ 1.2022 24.46
500074................................................ 1.1040 17.83
500077................................................ 1.3318 22.93
500079................................................ 1.3197 22.98
500080................................................ 0.8124 13.80
500084................................................ 1.2783 17.76
500085................................................ 0.9278 28.61
500086................................................ 1.2605 22.31
500088................................................ 1.2964 23.71
500089................................................ 1.0388 17.94
500090................................................ 0.8380 16.33
500092................................................ 1.0142 17.40
500094................................................ 0.8826 18.11
500096................................................ 0.9385 20.96
500097................................................ 1.0798 19.71
500098................................................ 1.0464 16.38
500101................................................ 1.0138 19.45
500102................................................ 0.9022 20.33
500104................................................ 1.2658 22.58
500106................................................ 0.9351 18.71
500107................................................ 1.2050 17.30
500107................................................ 1.2050 17.30
500107................................................ 1.4730 20.61
500110................................................ 1.2039 21.41
500118................................................ 1.1500 22.92
500118................................................ 1.2716 18.35
500119................................................ 1.3565 21.57
500122................................................ 1.2754 21.91
500123................................................ 0.9512 19.58
500124................................................ 1.3682 24.15
500129................................................ 1.6395 23.60
500132................................................ 0.9695 19.42
500134................................................ 0.6470 20.96
500138................................................ 3.6799 ......
500139................................................ 1.4685 20.88
500140................................................ ........ 1.00
500141................................................ 1.3697 22.94
500143................................................ 0.5986 17.60
500146................................................ ........ 17.85
510001................................................ 1.9505 17.87
510002................................................ 1.2866 17.34
510005................................................ 1.0195 14.43
510006................................................ 1.2718 17.53
510007*............................................... 1.5744 20.25
510008................................................ 1.2176 17.29
510012................................................ 1.0090 20.21
510013................................................ 1.1010 16.62
510015................................................ 0.9623 14.56
510016................................................ ........ 14.52
510018................................................ 1.0667 16.48
510020................................................ 1.0824 12.65
510022................................................ 1.8964 19.84
510023................................................ 1.2383 15.94
510024................................................ 1.5822 18.80
510026................................................ 1.0565 13.46
[[Page 24792]]
510027................................................ 0.9592 17.58
510028................................................ 1.0482 20.73
510029................................................ 1.2825 17.05
510029................................................ 1.1570 15.37
510030................................................ 1.0525 18.31
510030................................................ 1.1257 17.66
510031................................................ 1.4148 18.49
510033................................................ 1.2896 18.81
510035................................................ 1.2262 18.65
510036................................................ 0.9851 13.20
510038................................................ 1.0644 14.34
510039................................................ 1.3991 16.04
510043................................................ 0.9349 14.29
510046................................................ 1.2728 17.73
510047................................................ 1.2608 19.12
510048................................................ 1.1326 20.37
510050................................................ 1.7469 16.57
510053................................................ 1.0811 15.59
510055................................................ 1.2272 22.84
510058................................................ 1.2791 17.98
510059................................................ 1.9378 16.77
510060................................................ 1.0503 15.66
510061................................................ 1.0234 14.22
510062................................................ 1.2784 17.63
510065................................................ ........ 13.72
510066................................................ ........ 12.72
510067................................................ 1.2058 18.11
510068................................................ 1.2072 16.29
510070................................................ 1.2966 16.36
510071................................................ 1.3310 16.24
510072................................................ 1.0568 17.66
510077................................................ 1.1382 16.41
510080................................................ 1.1488 14.80
510081................................................ 1.0777 13.00
510082................................................ 1.1599 13.38
510084................................................ 1.0387 12.48
510086................................................ 1.1038 13.79
510088................................................ 1.0373 ......
520003................................................ 1.0889 16.43
520004................................................ 1.1781 18.17
520006................................................ 1.0164 20.44
520007................................................ 1.0498 13.11
520008................................................ 1.6388 23.11
520009................................................ 1.6963 18.51
520010................................................ 1.1567 20.34
520011................................................ 1.1930 20.38
520013................................................ 1.3708 21.64
520014................................................ 1.1081 16.40
520015................................................ 1.1985 18.32
520016................................................ 0.9785 13.29
520017................................................ 1.1935 19.32
520018................................................ 1.1169 18.64
520019................................................ 1.3094 18.31
520021................................................ 1.4602 19.46
520024................................................ 1.0420 14.61
520025................................................ 1.0655 18.11
520026................................................ 1.0229 19.81
520027................................................ 1.2629 18.86
520028................................................ 1.3300 19.14
520029................................................ 0.8925 16.75
520030................................................ 1.7397 20.01
520031................................................ 1.0727 18.71
520032................................................ 1.2635 17.84
520033................................................ 1.2390 18.77
520034................................................ 1.1068 16.69
520035................................................ 1.3242 17.10
520037................................................ 1.7020 20.05
520038................................................ 1.3352 17.71
520039................................................ 0.9971 19.60
520040................................................ 1.5273 20.48
520044................................................ 1.4160 17.79
520045................................................ 1.6446 19.67
520047................................................ 0.9370 17.87
520048................................................ 1.4946 18.61
520049................................................ 2.0474 19.57
520051*............................................... 1.8401 19.06
520053................................................ 1.1887 16.49
520054................................................ 1.0540 15.99
520057................................................ 1.1966 18.32
520058................................................ 1.1064 18.13
520059................................................ 1.4353 19.85
520060................................................ 1.4753 17.05
520062................................................ 1.2495 17.80
520063................................................ 1.1851 20.77
520064................................................ 1.5705 21.46
520066................................................ 1.4668 22.24
520068................................................ 0.9622 18.08
520069................................................ 1.2302 17.00
520070................................................ 1.5249 17.82
520071................................................ 1.2534 18.75
520074................................................ 1.0579 19.57
520075................................................ 1.4850 19.09
520076................................................ 1.1802 16.51
520077................................................ 0.9304 15.54
520078................................................ 1.6347 20.13
520082................................................ 1.1943 16.74
520083................................................ 1.7211 25.85
520084................................................ 1.0805 18.95
520087................................................ 1.6998 19.39
520088................................................ 1.2750 20.15
520090................................................ 1.2589 18.00
520091................................................ 1.2781 20.07
520092................................................ 1.0851 17.56
520094................................................ 0.7814 19.78
520095................................................ 1.2912 18.51
520096................................................ 1.3837 19.30
520097................................................ 1.3186 19.57
520098*............................................... 1.7679 20.03
520100................................................ 1.2558 18.38
520101................................................ 1.0673 17.85
520102................................................ 1.1747 19.83
520103................................................ 1.3291 21.23
520107................................................ 1.2651 20.54
520109................................................ 1.0080 18.63
520110................................................ 1.2429 20.03
520111................................................ 1.0771 17.24
520112................................................ 1.1370 18.18
520113................................................ 1.2753 20.59
520114................................................ 1.0715 17.38
520115................................................ 1.2443 17.38
520116................................................ 1.2746 18.57
520117................................................ 1.0104 17.42
520118................................................ 0.9267 12.44
520120................................................ 0.9639 15.62
520121................................................ 0.9809 17.58
520122................................................ 0.9984 16.76
520123................................................ 0.9687 17.41
520124................................................ 1.0565 16.39
520130................................................ 1.0658 14.49
520131................................................ 1.0212 18.80
520132................................................ 1.2099 17.28
520134................................................ 1.1056 17.61
520135................................................ 0.9696 14.47
520136*............................................... 1.5145 19.85
520138................................................ 1.8811 20.56
520139................................................ 1.2600 21.28
520140................................................ 1.6657 20.99
520141................................................ ........ 16.95
520142................................................ 0.8561 17.70
520144................................................ 1.0159 16.62
520145................................................ 0.9104 17.24
520146................................................ 1.0606 15.73
520148................................................ 1.1740 16.93
520149................................................ 0.8682 13.30
520151................................................ 1.0569 18.08
520152................................................ 1.1284 21.33
520153................................................ 0.9014 15.45
520154................................................ 1.1279 17.92
520156................................................ 1.1295 19.84
520157................................................ 1.1386 17.28
520159................................................ 0.9313 18.74
520160................................................ 1.7788 18.84
520161................................................ 0.9970 18.57
520170................................................ 1.1959 22.45
520171................................................ 0.9550 15.73
520173................................................ 1.1310 19.81
520177................................................ 1.7167 21.29
520178................................................ 1.0405 17.04
520187................................................ 0.6853 ......
530002................................................ 1.1871 17.59
530003................................................ 0.8651 15.78
530004................................................ 0.9408 16.19
530005................................................ 1.1117 15.15
530006................................................ 1.1073 19.34
530007................................................ 1.0694 18.06
530008................................................ 1.2168 19.71
530009................................................ 0.9868 19.45
530010................................................ 1.2449 18.93
530011................................................ 1.1582 17.44
530012................................................ 1.6193 19.48
530014................................................ 1.4152 17.32
530015................................................ 1.2824 22.65
530016................................................ 1.2295 17.71
530017................................................ 0.9391 13.71
530018................................................ 0.9886 17.87
530019................................................ 0.9196 16.76
530022................................................ 1.1517 17.88
530023................................................ 0.8312 20.75
530025................................................ 1.3777 20.32
530026................................................ 1.1298 18.92
530027................................................ 0.8284 29.77
530029................................................ 1.0012 17.97
530031................................................ 0.8249 13.38
[[Page 24793]]
530032................................................ 0.9898 20.21
------------------------------------------------------------------------
Table 4A.--Wage Index and Capital Geographic Adjustment Factor (GAF) -
for Urban Areas
------------------------------------------------------------------------
Wage
Urban area (constituent counties) index GAF
------------------------------------------------------------------------
0040 Abilene, TX................................... 0.8269 0.8780
Taylor, TX
0060 Aguadilla, PR................................. 0.4559 0.5840
Aguada, PR
Aguadilla, PR
Moca, PR
0080 Akron, OH..................................... 1.0277 1.0189
Portage, OH
Summit, OH
0120 \2\ Albany, GA................................ 0.8189 0.8721
Dougherty, GA
Lee, GA
0160 \2\ Albany-Schenectady-Troy, NY............... 0.8633 0.9042
Albany, NY
Montgomery, NY
Rensselaer, NY
Saratoga, NY
Schenectady, NY
Schoharie, NY
0200 \2\ Albuquerque, NM........................... 0.8613 0.9028
Bernalillo, NM
Sandoval, NM
Valencia, NM
0220 Alexandria, LA................................ 0.7988 0.8574
Rapides, LA
0240 Allentown-Bethlehem-Easton, PA................ 0.9754 0.9831
Carbon, PA
Lehigh, PA
Northampton, PA
0280 Altoona, PA................................... 0.9422 0.9600
Blair, PA
0320 Amarillo, TX.................................. 0.8150 0.8693
Potter, TX
Randall, TX
0380 Anchorage, AK................................. 1.3143 1.2058
Anchorage, AK
0440 Ann Arbor, MI................................. 1.1565 1.1047
Lenawee, MI
Livingston, MI
Washtenaw, MI
0450 Anniston, AL.................................. 0.8548 0.8981
Calhoun, AL
0460 Appleton-Oshkosh-Neenah, WI................... 0.8944 0.9264
Calumet, WI
Outagamie, WI
Winnebago, WI
0470 Arecibo, PR................................... 0.4737 0.5995
Arecibo, PR
Camuy, PR
Hatillo, PR
0480 Asheville, NC................................. 0.8978 0.9288
Buncombe, NC
Madison, NC
0500 Athens, GA.................................... 0.9556 0.9694
Clarke, GA
Madison, GA
Oconee, GA
0520 \1\ Atlanta, GA............................... 1.0119 1.0081
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......................... 1.1076 1.0725
Atlantic, NJ
Cape May, NJ
0600 Augusta-Aiken, GA-SC.......................... 0.9117 0.9387
Columbia, GA
McDuffie, GA
Richmond, GA
Aiken, SC
Edgefield, SC
0640 \2\ Austin-San Marcos, TX..................... 0.9511 0.9663
Bastrop, TX
Caldwell, TX
Hays, TX
Travis, TX
Williamson, TX
0680 \2\ Bakersfield, CA........................... 1.0153 1.0105
Kern, CA
0720 \1\ Baltimore, MD............................. 1.0176 1.0120
Anne Arundel, MD
Baltimore, MD
Baltimore City, MD
Carroll, MD
Harford, MD
Howard, MD
Queen Anne's, MD
0733 Bangor, ME.................................... 0.9706 0.9798
Penobscot, ME
0743 Barnstable-Yarmouth, MA....................... 1.3013 1.1976
Barnstable, MA
0760 Baton Rouge, LA............................... 0.8796 0.9159
Ascension, LA
East Baton Rouge, LA
Livingston, LA
West Baton Rouge, LA
0840 Beaumont-Port Arthur, TX...................... 0.8555 0.8986
Hardin, TX
Jefferson, TX
Orange, TX
0860 Bellingham, WA................................ 1.1509 1.1010
Whatcom, WA
0870 \2\ Benton Harbor, MI......................... 0.8904 0.9236
Berrien, MI
0875 \1\ Bergen-Passaic, NJ........................ 1.1861 1.1240
Bergen, NJ
Passaic, NJ
0880 Billings, MT.................................. 1.1802 1.1201
Yellowstone, MT
0920 Biloxi-Gulfport-Pascagoula, MS................ 0.8030 0.8605
Hancock, MS
Harrison, MS
Jackson, MS
0960 Binghamton, NY................................ 0.8701 0.9091
Broome, NY
Tioga, NY
1000 Birmingham, AL................................ 0.9010 0.9311
Blount, AL
Jefferson, AL
St. Clair, AL
Shelby, AL
1010 Bismarck, ND.................................. 0.7973 0.8563
Burleigh, ND
Morton, ND
1020 Bloomington, IN............................... 0.8680 0.9076
Monroe, IN
1040 Bloomington-Normal, IL........................ 0.9084 0.9363
McLean, IL
1080 Boise City, ID................................ 0.9178 0.9430
Ada, ID
Canyon, ID
1123 \1\ Boston-Worcester-Lawrence-Lowell-Brockton, 1.1247 1.0838
MA-NH..............................................
Bristol, MA
Essex, MA
Middlesex, MA
Norfolk, MA
Plymouth, MA
Suffolk, MA
Worcester, MA
Hillsborough, NH
Merrimack, NH
Rockingham, NH
Strafford, NH
[[Page 24794]]
1125 Boulder-Longmont, CO.......................... 1.0045 1.0031
Boulder, CO
1145 Brazoria, TX................................. 0.8592 0.9013
Brazoria, TX
1150 Bremerton, WA................................. 1.1122 1.0755
Kitsap, WA
1240 Brownsville-Harlingen-San Benito, TX.......... 0.9243 0.9475
Cameron, TX
1260 Bryan-College Station, TX..................... 0.8453 0.8913
Brazos, TX
1280 \1\ Buffalo-Niagara Falls, NY................. 0.9586 0.9715
Erie, NY
Niagara, NY
1303 Burlington, VT................................ 1.0455 1.0309
Chittenden, VT
Franklin, VT
Grand Isle, VT
1310 Caguas, PR.................................... 0.4555 0.5836
Caguas, PR
Cayey, PR
Cidra, PR
Gurabo, PR
San Lorenzo, PR
1320 Canton-Massillon, OH.......................... 0.8722 0.9106
Carroll, OH
Stark, OH
1350 Casper, WY.................................... 0.9292 0.9510
Natrona, WY
1360 Cedar Rapids, IA.............................. 0.9110 0.9382
Linn, IA
1400 Champaign-Urbana, IL.......................... 0.9255 0.9484
Champaign, IL
1440 Charleston-North Charleston, SC............... 0.8997 0.9302
Berkeley, SC
Charleston, SC
Dorchester, SC
1480 Charleston, WV................................ 0.9187 0.9436
Kanawha, WV
Putnam, WV
1520 \1\ Charlotte-Gastonia-Rock Hill, NC-SC....... 0.9522 0.9670
Cabarrus, NC
Gaston, NC
Lincoln, NC
Mecklenburg, NC
Rowan, NC
Stanly, NC
Union, NC
York, SC
1540 Charlottesville, VA........................... 1.0681 1.0461
Albemarle, VA
Charlottesville City, VA
Fluvanna, VA
Greene, VA
1560 Chattanooga, TN-GA............................ 0.9892 0.9926
Catoosa, GA
Dade, GA
Walker, GA
Hamilton, TN
Marion, TN
1580 \2\ Cheyenne, WY.............................. 0.8891 0.9227
Laramie, WY
1600 \1\ Chicago, IL............................... 1.0858 1.0580
Cook, IL
DeKalb, IL
DuPage, IL
Grundy, IL
Kane, IL
Kendall, IL
Lake, IL
McHenry, IL
Will, IL
1620 Chico-Paradise, CA............................ 1.0381 1.0259
Butte, CA
1640 \1\ Cincinnati, OH-KY-IN...................... 0.9477 0.9639
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............... 0.8413 0.8884
Christian, KY
Montgomery, TN
1680 \1\ Cleveland-Lorain-Elyria, OH............... 0.9724 0.9810
Ashtabula, OH
Cuyahoga, OH
Geauga, OH
Lake, OH
Lorain, OH
Medina, OH
1720 Colorado Springs, CO.......................... 0.9311 0.9523
El Paso, CO
1740 Columbia, MO.................................. 0.8982 0.9291
Boone, MO
1760 Columbia, SC.................................. 0.9452 0.9621
Lexington, SC
Richland, SC
1800 Columbus, GA-AL............................... 0.8565 0.8994
Russell, AL
Chattahoochee, GA
Harris, GA
Muscogee, GA
1840 \1\ Columbus, OH.............................. 0.9802 0.9864
Delaware, OH
Fairfield, OH
Franklin, OH
Licking, OH
Madison, OH
Pickaway, OH
1880 Corpus Christi, TX............................ 0.9318 0.9528
Nueces, TX
San Patricio, TX
1900 \2\ Cumberland, MD-WV (Maryland Hospitals).... 0.9096 0.9372
Allegany, MD
Mineral, WV
1900 Cumberland, MD-WV (West Virginia Hospitals)... 0.8890 0.9226
Allegany, MD
Mineral, WV
1920 \1\ Dallas, TX................................ 0.9230 0.9466
Collin, TX
Dallas, TX
Denton, TX
Ellis, TX
Henderson, TX
Hunt, TX
Kaufman, TX
Rockwall, TX
1950 Danville, VA.................................. 0.9153 0.9412
Danville City, VA
Pittsylvania, VA
1960 Davenport-Moline-Rock Island, IA-IL........... 0.8795 0.9158
Scott, IA
Henry, IL
Rock Island, IL
2000 Dayton-Springfield, OH........................ 0.9388 0.9577
Clark, OH
Greene, OH
Miami, OH
Montgomery, OH
2020 \2\ Daytona Beach, FL......................... 0.9074 0.9356
Flagler, FL
Volusia, FL
2030 Decatur, AL................................... 0.9983 0.9988
Lawrence, AL
Morgan, AL
2040 Decatur, IL................................... 0.8413 0.8884
Macon, IL
2080 \1\ Denver, CO................................ 1.0247 1.0168
Adams, CO
Arapahoe, CO
Denver, CO
Douglas, CO
Jefferson, CO
2120 Des Moines, IA................................ 0.8849 0.9197
Dallas, IA
Polk, IA
Warren, IA
2160 \1\ Detroit, MI............................... 1.0463 1.0315
Lapeer, MI
[[Page 24795]]
Macomb, MI
Monroe, MI
Oakland, MI
St. Clair, MI
Wayne, MI
2180 Dothan, AL.................................... 0.7916 0.8521
Dale, AL
Houston, AL
2190 Dover, DE..................................... 0.9426 0.9603
Kent, DE
2200 Dubuque, IA................................... 0.8606 0.9023
Dubuque, IA
2240 Duluth-Superior, MN-WI........................ 1.0278 1.0190
St. Louis, MN
Douglas, WI
2281 Dutchess County, NY........................... 0.9837 0.9888
Dutchess, NY
2290 Eau Claire, WI................................ 0.9049 0.9339
Chippewa, WI
Eau Claire, WI
2320 El Paso, TX................................... 0.8983 0.9292
El Paso, TX
2330 Elkhart-Goshen, IN............................ 0.9142 0.9404
Elkhart, IN
2335 \2\ Elmira, NY................................ 0.8633 0.9042
Chemung, NY
2340 Enid, OK...................................... 0.8034 0.8608
Garfield, OK
2360 Erie, PA...................................... 0.9078 0.9359
Erie, PA
2400 Eugene-Springfield, OR........................ 1.0761 1.0515
Lane, OR
2440 \2\ Evansville-Henderson, IN-KY (IN Hospitals) 0.8480 0.8932
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
2440 Evansville-Henderson, IN-KY (KY Hospital)..... 0.8380 0.8860
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
2520 Fargo-Moorhead, ND-MN......................... 0.8707 0.9095
Clay, MN
Cass, ND
2560 Fayetteville, NC.............................. 0.8673 0.9071
Cumberland, NC
2580 Fayetteville-Springdale-Rogers, AR............ 0.7852 0.8474
Benton, AR
Washington, AR
2620 Flagstaff, AZ-UT.............................. 1.0453 1.0308
Coconino, AZ
Kane, UT
2640 Flint, MI..................................... 1.1132 1.0762
Genesee, MI
2650 Florence, AL.................................. 0.8007 0.8588
Colbert, AL
Lauderdale, AL
2655 Florence, SC.................................. 0.8706 0.9095
Florence, SC
2670 Fort Collins-Loveland, CO..................... 1.0406 1.0276
Larimer, CO
2680 \1\ Ft. Lauderdale, FL........................ 1.0239 1.0163
Broward, FL
2700 \2\ Fort Myers-Cape Coral, FL................. 0.9074 0.9356
Lee, FL
2710 Fort Pierce-Port St. Lucie, FL................ 1.0240 1.0164
Martin, FL
St. Lucie, FL
2720 Fort Smith, AR-OK............................. 0.7923 0.8526
Crawford, AR
Sebastian, AR
Sequoyah, OK
2750 \2\ Fort Walton Beach, FL..................... 0.9074 0.9356
Okaloosa, FL
2760 Fort Wayne, IN................................ 0.8941 0.9262
Adams, IN
Allen, IN
De Kalb, IN
Huntington, IN
Wells, IN
Whitley, IN
2800 \1\ Forth Worth-Arlington, TX................. 0.9003 0.9306
Hood, TX
Johnson, TX
Parker, TX
Tarrant, TX
2840 Fresno, CA.................................... 1.0371 1.0253
Fresno, CA
Madera, CA
2880 Gadsden, AL................................... 0.8842 0.9192
Etowah, AL
2900 Gainesville, FL............................... 1.0181 1.0124
Alachua, FL
2920 Galveston-Texas City, TX...................... 0.9569 0.9703
Galveston, TX
2960 Gary, IN...................................... 0.9449 0.9619
Lake, IN
Porter, IN
2975 Glens Falls, NY............................... 0.8693 0.9085
Warren, NY
Washington, NY
2980 Goldsboro, NC................................. 0.8418 0.8888
Wayne, NC
2985 Grand Forks, ND-MN............................ 0.9190 0.9438
Polk, MN
Grand Forks, ND
2995 Grand Junction, CO............................ 0.9291 0.9509
Mesa, CO
3000 \1\ Grand Rapids-Muskegon-Holland, MI......... 1.0169 1.0115
Allegan, MI
Kent, MI
Muskegon, MI
Ottawa, MI
3040 Great Falls, MT............................... 1.0626 1.0425
Cascade, MT
3060 Greeley, CO................................... 0.9449 0.9619
Weld, CO
3080 Green Bay, WI................................. 0.9305 0.9519
Brown, WI
3120 \1\ Greensboro-Winston-Salem-High Point, NC... 0.9122 0.9390
Alamance, NC
Davidson, NC
Davie, NC
Forsyth, NC
Guilford, NC
Randolph, NC
Stokes, NC
Yadkin, NC
3150 Greenville, NC................................ 0.9570 0.9704
Pitt, NC
3160 Greenville-Spartanburg-Anderson, SC........... 0.9199 0.9444
Anderson, SC
Cherokee, SC
Greenville, SC
Pickens, SC
Spartanburg, SC
3180 \2\ Hagerstown, MD............................ 0.9096 0.9372
Washington, MD
3200 Hamilton-Middletown, OH....................... 0.9080 0.9360
Butler, OH
3240 Harrisburg-Lebanon-Carlisle, PA............... 0.9896 0.9929
Cumberland, PA
Dauphin, PA
Lebanon, PA
Perry, PA
3283 \1\ \2\ Hartford, CT.......................... 1.2692 1.1773
Hartford, CT
Litchfield, CT
Middlesex, CT
Tolland, CT
3285 Hattiesburg, MS............................... 0.7453 0.8177
Forrest, MS
Lamar, MS
3290 Hickory-Morganton-Lenoir, NC.................. 0.9255 0.9484
Alexander, NC
Burke, NC
Caldwell, NC
Catawba, NC
3320 Honolulu, HI.................................. 1.1600 1.1070
[[Page 24796]]
Honolulu, HI
3350 Houma, LA..................................... 0.7916 0.8521
Lafourche, LA
Terrebonne, LA
3360 \1\ Houston, TX............................... 0.9286 0.9505
Chambers, TX
Fort Bend, TX
Harris, TX
Liberty, TX
Montgomery, TX
Waller, TX
3400 Huntington-Ashland, WV-KY-OH.................. 0.9851 0.9898
Boyd, KY
Carter, KY
Greenup, KY
Lawrence, OH
Cabell, WV
Wayne, WV
3440 Huntsville, AL................................ 0.8912 0.9242
Limestone, AL
Madison, AL
3480 \1\ Indianapolis, IN.......................... 0.9876 0.9915
Boone, IN
Hamilton, IN
Hancock, IN
Hendricks, IN
Johnson, IN
Madison, IN
Marion, IN
Morgan, IN
Shelby, IN
3500 Iowa City, IA................................. 0.9705 0.9797
Johnson, IA
3520 Jackson, MI................................... 0.8930 0.9254
Jackson, MI
3560 Jackson, MS................................... 0.8519 0.8960
Hinds, MS
Madison, MS
Rankin, MS
3580 Jackson, TN................................... 1.0953 1.0643
Madison, TN
Chester, TN
3600 \1\ \2\ Jacksonville, FL...................... 0.9074 0.9356
Clay, FL
Duval, FL
Nassau, FL
St. Johns, FL
3605 \2\ Jacksonville, NC.......................... 0.8349 0.8838
Onslow, NC
3610 \2\ Jamestown, NY............................. 0.8633 0.9042
Chautauqua, NY
3620 Janesville-Beloit, WI......................... 0.9703 0.9796
Rock, WI
3640 Jersey City, NJ............................... 1.1718 1.1147
Hudson, NJ
3660 Johnson City-Kingsport-Bristol, TN-VA......... 0.8935 0.9258
Carter, TN
Hawkins, TN
Sullivan, TN
Unicoi, TN
Washington, TN
Bristol City, VA
Scott, VA
Washington, VA
3680 \2\ Johnstown, PA............................. 0.8488 0.8938
Cambria, PA
Somerset, PA
3700 Jonesboro, AR................................. 0.7324 0.8079
Craighead, AR
3710 Joplin, MO.................................... 0.7756 0.8403
Jasper, MO
Newton, MO
3720 Kalamazoo-Battlecreek, MI..................... 1.0095 1.0065
Calhoun, MI
Kalamazoo, MI
Van Buren, MI
3740 Kankakee, IL.................................. 0.8349 0.8838
Kankakee, IL
3760 \1\ Kansas City, KS-MO........................ 0.9301 0.9516
Johnson, KS
Leavenworth, KS
Miami, KS
Wyandotte, KS
Cass, MO
Clay, MO
Clinton, MO
Jackson, MO
Lafayette, MO
Platte, MO
Ray, MO
3800 \2\ Kenosha, WI............................... 0.8842 0.9192
Kenosha, WI
3810 Killeen-Temple, TX............................ 1.0031 1.0021
Bell, TX
Coryell, TX
3840 Knoxville, TN................................. 0.9315 0.9526
Anderson, TN
Blount, TN
Knox, TN
Loudon, TN
Sevier, TN
Union, TN
3850 Kokomo, IN.................................... 0.9075 0.9357
Howard, IN
Tipton, IN
3870 La Crosse, WI-MN.............................. 0.9024 0.9321
Houston, MN
La Crosse, WI
3880 Lafayette, LA................................. 0.8160 0.8700
Acadia, LA
Lafayette, LA
St. Landry, LA
St. Martin, LA
3920 Lafayette, IN................................. 0.8898 0.9232
Clinton, IN
Tippecanoe, IN
3960 Lake Charles, LA.............................. 0.7901 0.8510
Calcasieu, LA
3980 \2\ Lakeland-Winter Haven, FL................. 0.9074 0.9356
Polk, FL
4000 Lancaster, PA................................. 0.8944 0.9264
Lancaster, PA
4040 Lansing-East Lansing, MI...................... 1.0091 1.0062
Clinton, MI
Eaton, MI
Ingham, MI
4080 Laredo, TX.................................... 0.8407 0.8880
Webb, TX
4100 \2\ Las Cruces, NM............................ 0.8613 0.9028
Dona Ana, NM
4120 \1\ Las Vegas, NV-AZ.......................... 1.1182 1.0795
Mohave, AZ
Clark, NV
Nye, NV
4150 Lawrence, KS.................................. 0.8306 0.8806
Douglas, KS
4200 Lawton, OK.................................... 0.8475 0.8929
Comanche, OK
4243 Lewiston-Auburn, ME........................... 0.8971 0.9283
Androscoggin, ME
4280 Lexington, KY................................. 0.8683 0.9078
Bourbon, KY
Clark, KY
Fayette, KY
Jessamine, KY
Madison, KY
Scott, KY
Woodford, KY
4320 Lima, OH...................................... 0.8995 0.9300
Allen, OH
Auglaize, OH
4360 Lincoln, NE................................... 0.9768 0.9841
Lancaster, NE
4400 Little Rock-North Little Rock, AR............. 0.8698 0.9089
Faulkner, AR
Lonoke, AR
Pulaski, AR
Saline, AR
4420 Longview-Marshall, TX......................... 0.8828 0.9182
Gregg, TX
Harrison, TX
Upshur, TX
4480 \1\ Los Angeles-Long Beach, CA................ 1.1903 1.1267
Los Angeles, CA
4520 Louisville, KY-IN............................. 0.9296 0.9512
Clark, IN
Floyd, IN
Harrison, IN
Scott, IN
Bullitt, KY
Jefferson, KY
Oldham, KY
4600 Lubbock, TX................................... 0.8438 0.8902
[[Page 24797]]
Lubbock, TX
4640 Lynchburg, VA................................. 0.9048 0.9338
Amherst, VA
Bedford, VA
Bedford City, VA
Campbell, VA
Lynchburg City, VA
4680 Macon, GA..................................... 0.8615 0.9029
Bibb, GA
Houston, GA
Jones, GA
Peach, GA
Twiggs, GA
4720 Madison, WI................................... 1.0096 1.0066
Dane, WI
4800 \2\ Mansfield, OH............................. 0.8722 0.9106
Crawford, OH
Richland, OH
4840 Mayaguez, PR.................................. 0.4862 0.6103
Anasco, PR
Cabo Rojo, PR
Hormigueros, PR
Mayaguez, PR
Sabana Grande, PR
San German, PR
4880 McAllen-Edinburg-Mission, TX.................. 0.8152 0.8694
Hidalgo, TX
4890 Medford-Ashland, OR.......................... 1.0600 1.0407
Jackson, OR
4900 Melbourne-Titusville-Palm Bay, FL............. 0.9390 0.9578
Brevard, Fl
4920 \1\ Memphis, TN-AR-MS......................... 0.8070 0.8634
Crittenden, AR
DeSoto, MS
Fayette, TN
Shelby, TN
Tipton, TN
4940 Merced, CA....................................
Merced, CA 1.0615 1.0417
5000 \1\ Miami, FL................................. 1.0314 1.0214
Dade, FL
5015 \1\ Middlesex-Somerset-Hunterdon, NJ.......... 1.1028 1.0693
Hunterdon, NJ
Middlesex, NJ
Somerset, NJ
5080 \1\ Milwaukee-Waukesha, WI.................... 0.9840 0.9890
Milwaukee, WI
Ozaukee, WI
Washington, WI
Waukesha, WI
5120 \1\ Minneapolis-St. Paul, MN-WI............... 1.0630 1.0427
Anoka, MN
Carver, MN
Chicago, MN
Dakota, MN
Hennepin, MN
Isanti, MN
Ramsey, MN
Scott, MN
Sherburne, MN
Washington, MN
Wright, MN
Pierce, WI
St. Croix, WI
5140 Missoula, MT.................................. 0.9281 0.9502
Missoula, MT
5160 Mobile, AL.................................... 0.8301 0.8803
Baldwin, AL
Mobile, AL
5170 Modesto, CA................................... 1.0183 1.0125
Stanislaus, CA
5190 \1\ Monmouth-Ocean, NJ........................ 1.1371 1.0920
Monmouth, NJ
Ocean, NJ
5200 Monroe, LA.................................... 0.8304 0.8805
Ouachita, LA
5240 \2\ Montgomery, AL............................ 0.7542 0.8243
Autauga, AL
Elmore, AL
Montgomery, AL
5280 Muncie, IN.................................... 1.0869 1.0587
Delaware, IN
5330 Myrtle Beach, SC.............................. 0.8647 0.9052
Horry, SC
5345 Naples, FL.................................... 1.0234 1.0160
Collier, FL
5360 \1\ Nashville, TN............................. 0.9140 0.9403
Cheatham, TN
Davidson, TN
Dickson, TN
Robertson, TN
Rutherford TN
Sumner, TN
Williamson, TN
Wilson, TN
5380 \1\ Nassau-Suffolk, NY........................ 1.3274 1.2140
Nassau, NY
Suffolk, NY
5483 \1\ \2\ New Haven-Bridgeport-Stamford- 1.2692 1.1773
Waterbury-Danbury, CT..............................
Fairfield, CT
New Haven, CT
5523 \2\ New London-Norwich, CT.................... 1.2692 1.1773
New London, CT
5560 \1\ New Orleans, LA........................... 0.9073 0.9356
Jefferson, LA
Orleans, LA
Plaquemines, LA
St. Bernard, LA
St. Charles, LA
St. James, LA
St. John The Baptist, LA
St. Tammany, LA
5600 \1\ New York, NY.............................. 1.4302 1.2777
Bronx, NY
Kings, NY
New York, NY
Putnam, NY
Queens, NY
Richmond, NY
Rockland, NY
Westchester, NY
5640 \1\ Newark, NJ................................ 1.0873 1.0590
Essex, NJ
Morris, NJ
Sussex, NJ
Union, NJ
Warren, NJ
5660 Newburgh, NY-PA............................... 1.1019 1.0687
Orange, NY
Pike, PA
5720 \1\ Norfolk-Virginia Beach-Newport News, VA-NC 0.8378 0.8859
Currituck, NC
Chesapeake City, VA
Gloucester, VA
Hampton City, VA
Isle of Wight, VA
James City, VA
Mathews, VA
Newport News City, VA
Norfolk City, VA
Poquoson City, VA
Portsmouth City, VA
Suffolk City, VA
Virginia Beach City VA
Williamsburg City, VA
York, VA
5775 \1\ Oakland, CA............................... 1.5199 1.3320
Alameda, CA
Contra Costa, CA
5790 Ocala, FL..................................... 0.9712 0.9802
Marion, FL
5800 Odessa-Midland, TX............................ 0.8016 0.8595
Ector, TX
Midland, TX
5880 \1\ Oklahoma City, OK......................... 0.8705 0.9094
Canadian, OK
Cleveland, OK
Logan, OK
McClain, OK
Oklahoma, OK
Pottawatomie, OK
5910 Olympia, WA.................................. 1.2750 1.1810
Thurston, WA
5920 Omaha, NE-IA.................................. 1.0722 1.0489
Pottawattamie, IA
Cass, NE
[[Page 24798]]
Douglas, NE
Sarpy, NE
Washington, NE
5945 \1\ Orange County, CA......................... 1.1539 1.1030
Orange, CA
5960 \1\ Orlando, FL............................... 0.9997 0.9998
Lake, FL
Orange, FL
Osceola, FL
Seminole, FL
5990 \2\ Owensboro, KY............................. 0.8129 0.8677
Daviess, KY
6015 Panama City, FL.............................. 0.9266 0.9491
Bay, FL
6020 Parkersburg-Marietta, WV-OH (West Virginia 0.8500 0.8947
Hospitals).........................................
Washington, OH
Wood, WV
6020 \2\ Parkersburg-Marietta, WV-OH (Ohio 0.8722 0.9106
Hospitals).........................................
Washington, OH
Wood, WV
6080 \2\ Pensacola, FL............................. 0.9074 0.9356
Escambia, FL
Santa Rosa, FL
6120 Peoria-Pekin, IL.............................. 0.8495 0.8943
Peoria, IL
Tazewell, IL
Woodford, IL
6160 \1\ Philadelphia, PA-NJ....................... 1.1077 1.0726
Burlington, NJ
Camden, NJ
Gloucester, NJ
Salem, NJ
Bucks, PA
Chester, PA
Delaware, PA
Montgomery, PA
Philadelphia, PA
6200 \1\ Phoenix-Mesa, AZ.......................... 0.9546 0.9687
Maricopa, AZ
Pinal, AZ
6240 Pine Bluff, AR................................ 0.7689 0.8353
Jefferson, AR
6280 \1\ Pittsburgh, PA............................ 0.9537 0.9681
Allegheny, PA
Beaver, PA
Butler, PA
Fayette, PA
Washington, PA
Westmoreland, PA
6323 Pittsfield, MA................................ 1.0767 1.0519
Berkshire, MA
6340 Pocatello, ID................................. 0.9068 0.9352
Bannock, ID
6360 Ponce, PR..................................... 0.5026 0.6243
Guayanilla, PR
Juana Diaz, PR
Penuelas, PR
Ponce, PR
Villalba, PR
Yauco, PR
6403 Portland, ME.................................. 0.9552 0.9691
Cumberland, ME
Sagadahoc, ME
York, ME
6440 \1\ Portland-Vancouver, OR-WA................. 1.1091 1.0735
Clackamas, OR
Columbia, OR
Multnomah, OR
Washington, OR
Yamhill, OR
Clark, WA
6483 \1\ Providence-Warwick-Pawtucket, RI.......... 1.0789 1.0534
Bristol, RI
Kent, RI
Newport, RI
Providence, RI
Washington, RI
6520 Provo-Orem, UT................................ 0.9786 0.9853
Utah, UT
6560 Pueblo, CO.................................... 0.8943 0.9264
Pueblo, CO
6580 \2\ Punta Gorda, FL........................... 0.9074 0.9356
Charlotte, FL
6600 Racine, WI.................................... 0.9310 0.9522
Racine, WI
6640 \1\ Raleigh-Durham-Chapel Hill, NC............ 0.9631 0.9746
Chatham, NC
Durham, NC
Franklin, NC
Johnston, NC
Orange, NC
Wake, NC
6660 Rapid City, SD................................ 0.8449 0.8910
Pennington, SD
6680 Reading, PA................................... 0.9526 0.9673
Berks, PA
6690 Redding, CA................................... 1.1392 1.0934
Shasta, CA
6720 Reno, NV...................................... 1.0763 1.0516
Washoe, NV
6740 Richland-Kennewick-Pasco, WA.................. 1.1338 1.0898
Benton, WA
Franklin, WA
6760 Richmond-Petersburg, VA....................... 1.0053 1.0036
Charles City County, VA
Chesterfield, VA
Colonial Heights City, VA
Dinwiddie, VA
Goochland, VA
Hanover, VA
Henrico, VA
Hopewell City, VA
New Kent, VA
Petersburg City, VA
Powhatan, VA
Prince George, VA
Richmond City, VA
6780 \1\ Riverside-San Bernardino, CA.............. 1.0622 1.0422
Riverside, CA
San Bernardino, CA
6800 Roanoke, VA................................... 0.8224 0.8747
Botetourt, VA
Roanoke, VA
Roanoke City, VA
Salem City, VA
6820 Rochester, MN................................. 1.1056 1.0712
Olmsted, MN
6840 \1\ Rochester, NY............................. 0.9448 0.9619
Genesee, NY
Livingston, NY
Monroe, NY
Ontario, NY
Orleans, NY
Wayne, NY
6880 Rockford, IL.................................. 0.8861 0.9205
Boone, IL
Ogle, IL
Winnebago, IL
6895 Rocky Mount, NC............................... 0.8823 0.9178
Edgecombe, NC
Nash, NC
6920 \1\ Sacramento, CA............................ 1.2482 1.1640
El Dorado, CA
Placer, CA
Sacramento, CA
6960 Saginaw-Bay City-Midland, MI.................. 0.9422 0.9600
Bay, MI
Midland, MI
Saginaw, MI
6980 St. Cloud, MN................................. 0.9650 0.9759
Benton, MN
Stearns, MN
7000 St. Joseph, MO................................ 0.8836 0.9187
Andrew, MO
Buchanan, MO
7040 \1\ St. Louis, MO-IL.......................... 0.9186 0.9435
Clinton, IL
Jersey, IL
Madison, IL
Monroe, IL
St. Clair, IL
Franklin, MO
Jefferson, MO
Lincoln, MO
St. Charles, MO
St. Louis, MO
St. Louis City, MO
Warren, MO
7080 \2\ Salem, OR................................. 1.0071 1.0049
[[Page 24799]]
Marion, OR
Polk, OR
7120 Salinas, CA................................... 1.4706 1.3023
Monterey, CA
7160 \1\ Salt Lake City-Ogden, UT.................. 0.9884 0.9920
Davis, UT
Salt Lake, UT
Weber, UT
7200 San Angelo, TX................................ 0.7870 0.8487
Tom Green, TX
7240 \1\ San Antonio, TX........................... 0.8271 0.8781
Bexar, TX
Comal, TX
Guadalupe, TX
Wilson, TX
7320 \1\ San Diego, CA............................. 1.1943 1.1293
San Diego, CA
7360 \1\ San Francisco, CA......................... 1.3976 1.2576
Marin, CA
San Francisco, CA
San Mateo, CA
7400 \1\ San Jose, CA.............................. 1.3714 1.2415
Santa Clara, CA
7440 \1\ San Juan-Bayamon, PR...................... 0.4740 0.5998
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.... 1.0576 1.0391
San Luis Obispo, CA
7480 Santa Barbara-Santa Maria-Lompoc, CA.......... 1.0927 1.0626
Santa Barbara, CA
7485 Santa Cruz-Watsonville, CA.................... 1.4068 1.2633
Santa Cruz, CA
7490 Santa Fe, NM.................................. 0.9115 0.9385
Los Alamos, NM
Santa Fe, NM
7500 Santa Rosa, CA............................... 1.3127 1.2048
Sonoma, CA
7510 Sarasota-Bradenton, FL........................ 0.9928 0.9951
Manatee, FL
Sarasota, FL
7520 Savannah, GA.................................. 0.9892 0.9926
Bryan, GA
Chatham, GA
Effingham, GA
7560 \2\ Scranton-Wilkes-Barre-Hazleton, PA........ 0.8488 0.8938
Columbia, PA
Lackawanna, PA
Luzerne, PA
Wyoming, PA
7600 \1\ Seattle-Bellevue-Everett, WA.............. 1.1390 1.0932
Island, WA
King, WA
Snohomish, WA
7610 \2\ Sharon, PA................................ 0.8488 0.8938
Mercer, PA
7620 \2\ Sheboygan, WI............................. 0.8842 0.9192
Sheboygan, WI
7640 Sherman-Denison, TX........................... 0.9213 0.9454
Grayson, TX
7680 Shreveport-Bossier City, LA.................. 0.9142 0.9404
Bossier, LA
Caddo, LA
Webster, LA
7720 Sioux City, IA-NE............................. 0.8051 0.8620
Woodbury, IA
Dakota, NE
7760 Sioux Falls, SD............................... 0.8778 0.9146
Lincoln, SD
Minnehaha, SD
7800 South Bend, IN................................ 0.9893 0.9927
St. Joseph, IN
7840 Spokane, WA................................... 1.0891 1.0602
Spokane, WA
7880 Springfield, IL............................... 0.8772 0.9142
Menard, IL
Sangamon, IL
7920 Springfield, MO............................... 0.8003 0.8585
Christian, MO
Greene, MO
Webster, MO
8003 Springfield, MA............................... 0.9914 0.9941
Hampden, MA
Hampshire, MA
8050 State College, PA............................. 0.9249 0.9479
Centre, PA
8080 \2\ Steubenville-Weirton, OH-WV (Ohio 0.8722 0.9106
Hospitals).........................................
Jefferson, OH
Brooke, WV
Hancock, WV
8080 Steubenville-Weirton, OH-WV (West Virginia 0.8702 0.9092
Hospitals).........................................
Jefferson, OH
Brooke, WV
Hancock, WV
8120 Stockton-Lodi, CA............................. 1.0623 1.0423
San Joaquin, CA
8140 \2\ Sumter, SC................................ 0.8541 0.8976
Sumter, SC
8160 Syracuse, NY.................................. 0.9527 0.9674
Cayuga, NY
Madison, NY
Onondaga, NY
Oswego, NY
8200 Tacoma, WA.................................... 1.1755 1.1171
Pierce, WA
8240 \2\ Tallahassee, FL........................... 0.9074 0.9356
Gadsden, FL
Leon, FL
8280 \1\ Tampa-St. Petersburg-Clearwater, FL....... 0.9260 0.9487
Hernando, FL
Hillsborough, FL
Pasco, FL
Pinellas, FL
8320 Terre Haute, IN............................... 0.8673 0.9071
Clay, IN
Vermillion, IN
Vigo, IN
8360 Texarkana, AR-Texarkana, TX................... 0.8206 0.8734
Miller, AR
Bowie, TX
8400 Toledo, OH.................................... 0.9810 0.9870
Fulton, OH
Lucas, OH
Wood, OH
8440 Topeka, KS.................................... 0.9195 0.9441
Shawnee, KS
8480 Trenton, NJ................................... 1.0051 1.0035
Mercer, NJ
8520 Tucson, AZ.................................... 0.8831 0.9184
Pima, AZ
8560 Tulsa, OK..................................... 0.7852 0.8474
Creek, OK
Osage, OK
Rogers, OK
Tulsa, OK
Wagoner, OK
[[Page 24800]]
8600 Tuscaloosa, AL................................ 0.7994 0.8579
Tuscaloosa, AL
8640 Tyler, TX..................................... 0.8572 0.8999
Smith, TX
8680 \2\ Utica-Rome, NY............................ 0.8633 0.9042
Herkimer, NY
Oneida, NY
8720 Vallejo-Fairfield-Napa, CA.................... 1.2783 1.1831
Napa, CA
Solano, CA
8735 Ventura, CA................................... 1.0983 1.0663
Ventura, CA
8750 Victoria, TX.................................. 0.8062 0.8628
Victoria, TX
8760 Vineland-Millville-Bridgeton, NJ.............. 1.0623 1.0423
Cumberland, NJ
8780 Visalia-Tulare-Porterville, CA................ 1.0409 1.0278
Tulare, CA
8800 Waco, TX...................................... 0.7561 0.8258
McLennan, TX
8840 \1\ Washington, DC-MD-VA-WV................... 1.1118 1.0753
District of Columbia, DC
Calvert, MD
Charles, MD
Frederick, MD
Montgomery, MD
Prince Georges, MD
Alexandria City, VA
Arlington, VA
Clarke, VA
Culpeper, VA
Fairfax, VA
Fairfax City, VA
Falls Church City, VA
Fauquier, VA
Fredericksburg City, VA
King George, VA
Loudoun, VA
Manassas City, VA
Manassas Park City, VA
Prince William, VA
Spotsylvania, VA
Stafford, VA
Warren, VA
Berkeley, WV
Jefferson, WV
8920 Waterloo-Cedar Falls, IA...................... 0.9039 0.9332
Black Hawk, IA
8940 Wausau, WI.................................... 0.9545 0.9686
Marathon, WI
8960 \1\ West Palm Beach-Boca Raton, FL............ 1.0167 1.0114
Palm Beach, FL
9000 \2\ Wheeling, WV-OH (West Virginia Hospitals). 0.8206 0.8734
Belmont, OH
Marshall, WV
Ohio, WV
9000 \2\ Wheeling, WV-OH (Ohio Hospitals).......... 0.8722 0.9106
Belmont, OH
Marshall, WV
Ohio, WV
9040 Wichita, KS................................... 0.9117 0.9387
Butler, KS
Harvey, KS
Sedgwick, KS
9080 Wichita Falls, TX............................. 0.7730 0.8384
Archer, TX
Wichita, TX
9140 Williamsport, PA.............................. 0.8611 0.9027
Lycoming, PA
9160 Wilmington-Newark, DE-MD...................... 1.1388 1.0931
New Castle, DE
Cecil, MD
9200 Wilmington, NC................................ 0.9962 0.9974
New Hanover, NC
Brunswick, NC
9260 \2\ Yakima, WA................................ 1.0474 1.0322
Yakima, WA
9270 Yolo, CA...................................... 1.0591 1.0401
Yolo, CA
9280 York, PA...................................... 0.9348 0.9549
York, PA
9320 Youngstown-Warren, OH......................... 1.0098 1.0067
Columbiana, OH
Mahoning, OH
Trumbull, OH
9340 Yuba City, CA................................. 1.0770 1.0521
Sutter, CA
Yuba, CA
9360 Yuma, AZ...................................... 1.0024 1.0016
Yuma, AZ
------------------------------------------------------------------------
\1\ Large Urban Area.
\2\ Hospitals geographically located in the area are assigned the
statewide rural wage index for FY 2000.
Table 4B.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Rural Areas
------------------------------------------------------------------------
Wage
Nonurban area index GAF
------------------------------------------------------------------------
Alabama............................................. 0.7542 0.8243
Alaska.............................................. 1.2181 1.1447
Arizona............................................. 0.8610 0.9026
Arkansas............................................ 0.7290 0.8054
California.......................................... 1.0153 1.0105
Colorado............................................ 0.8852 0.9199
Connecticut......................................... 1.2692 1.1773
Delaware............................................ 0.9259 0.9486
Florida............................................. 0.9074 0.9356
Georgia............................................. 0.8189 0.8721
Hawaii.............................................. 1.0812 1.0549
Idaho............................................... 0.8715 0.9101
Illinois............................................ 0.8121 0.8672
Indiana............................................. 0.8480 0.8932
Iowa................................................ 0.8000 0.8583
Kansas.............................................. 0.7512 0.8221
Kentucky............................................ 0.8129 0.8677
Louisiana........................................... 0.7519 0.8226
Maine............................................... 0.8706 0.9095
Maryland............................................ 0.9096 0.9372
Massachusetts....................................... 0.9914 0.9941
Michigan............................................ 0.8904 0.9236
Minnesota........................................... 0.8753 0.9128
Mississippi......................................... 0.7453 0.8177
Missouri............................................ 0.7701 0.8362
Montana............................................. 0.8528 0.8967
Nebraska............................................ 0.8075 0.8638
Nevada.............................................. 0.9633 0.9747
New Hampshire....................................... 0.9978 0.9985
New Jersey \1\...................................... ........ ........
New Mexico.......................................... 0.8613 0.9028
New York............................................ 0.8633 0.9042
North Carolina...................................... 0.8349 0.8838
North Dakota........................................ 0.7750 0.8398
Ohio................................................ 0.8722 0.9106
Oklahoma............................................ 0.7345 0.8095
Oregon.............................................. 1.0071 1.0049
Pennsylvania........................................ 0.8488 0.8938
Puerto Rico......................................... 0.4379 0.5681
Rhode Island \1\.................................... ........ ........
South Carolina...................................... 0.8541 0.8976
South Dakota........................................ 0.7663 0.8334
Tennessee........................................... 0.7743 0.8393
Texas............................................... 0.7008 0.7839
Utah................................................ 0.8219 0.8743
Vermont............................................. 0.9524 0.9672
Virginia............................................ 0.7938 0.8537
Washington.......................................... 1.0474 1.0322
West Virginia....................................... 0.8206 0.8734
Wisconsin........................................... 0.8842 0.9192
Wyoming............................................. 0.8891 0.9227
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.
Table 4C.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Hospitals That are Reclassified
------------------------------------------------------------------------
Wage
Area index GAF
------------------------------------------------------------------------
Abilene, TX......................................... 0.8269 0.8780
Akron, OH........................................... 1.0091 1.0062
Albany, GA.......................................... 0.8189 0.8721
Alexandria, LA...................................... 0.7988 0.8574
Amarillo, TX........................................ 0.8150 0.8693
Anchorage, AK....................................... 1.3143 1.2058
Ann Arbor, MI....................................... 1.1437 1.0963
Atlanta, GA......................................... 1.0119 1.0081
Austin-San Marcos, TX............................... 0.9511 0.9663
[[Page 24801]]
Baltimore, MD....................................... 1.0176 1.0120
Baton Rouge, LA..................................... 0.8796 0.9159
Beaumont-Port Arthur, TX............................ 0.8555 0.8986
Bergen-Passaic, NJ.................................. 1.1861 1.1240
Billings, MT........................................ 1.1496 1.1002
Biloxi-Gulfport-Pascagoula, MS...................... 0.8030 0.8605
Binghamton, NY...................................... 0.8701 0.9091
Birmingham, AL...................................... 0.9010 0.9311
Bismarck, ND........................................ 0.7973 0.8563
Boise City, ID...................................... 0.9178 0.9430
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH.... 1.1247 1.0838
Burlington, VT...................................... 1.0046 1.0031
Caguas, PR.......................................... 0.4555 0.5836
Champaign-Urbana, IL................................ 0.9255 0.9484
Charleston-North Charleston, SC..................... 0.8997 0.9302
Charleston, WV...................................... 0.8950 0.9268
Charlotte-Gastonia-Rock Hill, NC-SC................. 0.9522 0.9670
Chattanooga, TN-GA.................................. 0.9586 0.9715
Chicago, IL......................................... 1.0858 1.0580
Cincinnati, OH-KY-IN................................ 0.9477 0.9639
Clarksville-Hopkinsville, TN-KY..................... 0.8413 0.8884
Cleveland-Lorain-Elyria, OH......................... 0.9724 0.9810
Columbia, MO........................................ 0.8815 0.9173
Columbia, SC........................................ 0.9308 0.9521
Columbus, GA-AL..................................... 0.8379 0.8859
Columbus, OH........................................ 0.9660 0.9766
Corpus Christi, TX.................................. 0.9172 0.9425
Dallas, TX.......................................... 0.9230 0.9466
Danville, VA........................................ 0.8795 0.9158
Davenport-Moline-Rock Island,
IA-IL............................................. 0.8694 0.9086
Dayton-Springfield, OH.............................. 0.9284 0.9504
Denver, CO.......................................... 1.0247 1.0168
Des Moines, IA...................................... 0.8849 0.9197
Dothan, AL.......................................... 0.7916 0.8521
Dover, DE........................................... 1.0618 1.0419
Duluth-Superior, MN-WI.............................. 1.0278 1.0190
Elkhart-Goshen, IN.................................. 0.9142 0.9404
Eugene-Springfield, OR.............................. 1.0761 1.0515
Evansville-Henderson, IN-KY......................... 0.8480 0.8932
Fargo-Moorhead, ND-MN (ND and SD Hospitals)......... 0.8707 0.9095
Fargo-Moorhead, ND-MN (MN Hospital)................. 0.8753 0.9128
Fayetteville, NC.................................... 0.8673 0.9071
Flagstaff, AZ-UT.................................... 0.9960 0.9973
Fort Collins-Loveland, CO........................... 1.0301 1.0205
Fort Pierce-Port St. Lucie, FL...................... 1.0240 1.0164
Fort Smith, AR-OK................................... 0.7774 0.8416
Fort Walton Beach, FL............................... 0.9005 0.9307
Forth Worth-Arlington, TX........................... 0.9003 0.9306
Fresno, CA.......................................... 1.0371 1.0253
Gadsden, AL......................................... 0.8842 0.9192
Gainesville, FL..................................... 1.0042 1.0029
Goldsboro, NC....................................... 0.8418 0.8888
Grand Forks, ND-MN.................................. 0.9190 0.9438
Grand Rapids-Muskegon-Holland, MI................... 1.0062 1.0042
Great Falls, MT..................................... 1.0626 1.0425
Greeley, CO......................................... 0.9292 0.9510
Green Bay, WI....................................... 0.9305 0.9519
Greensboro-Winston-Salem-High Point, NC............. 0.9122 0.9390
Greenville, NC...................................... 0.9313 0.9524
Greenville-Spartanburg-Anderson, SC................. 0.9199 0.9444
Hagerstown, MD...................................... 0.8943 0.9264
Harrisburg-Lebanon-Carlisle, PA..................... 0.9787 0.9854
Hartford, CT........................................ 1.1220 1.0820
Hickory-Morganton-Lenoir, NC........................ 0.9255 0.9484
Honolulu, HI........................................ 1.1600 1.1070
Houston, TX......................................... 0.9286 0.9505
Huntington-Ashland, WV-KY-OH........................ 0.9563 0.9699
Huntsville, AL...................................... 0.8912 0.9242
Indianapolis, IN.................................... 0.9876 0.9915
Iowa City, IA....................................... 0.9556 0.9694
Jackson, MS......................................... 0.8519 0.8960
Jackson, TN......................................... 1.0339 1.0231
Jacksonville, FL.................................... 0.8993 0.9299
Johnson City-Kingsport-Bristol, TN-VA............... 0.8935 0.9258
Jonesboro, AR....................................... 0.7324 0.8079
Joplin, MO.......................................... 0.7756 0.8403
Kalamazoo-Battlecreek, MI........................... 1.0095 1.0065
Kansas City, KS-MO.................................. 0.9301 0.9516
Knoxville, TN....................................... 0.9315 0.9526
Kokomo, IN.......................................... 0.9075 0.9357
Lafayette, LA....................................... 0.8160 0.8700
Lansing-East Lansing, MI............................ 0.9980 0.9986
Las Vegas, NV-AZ.................................... 1.1182 1.0795
Lexington, KY....................................... 0.8683 0.9078
Lincoln, NE......................................... 0.9535 0.9679
Little Rock-North Little Rock, AR................... 0.8498 0.8945
Longview-Marshall, TX............................... 0.8618 0.9032
Los Angeles-Long Beach, CA.......................... 1.1903 1.1267
Louisville, KY-IN................................... 0.9296 0.9512
Macon, GA........................................... 0.8615 0.9029
Madison, WI......................................... 1.0096 1.0066
Memphis, TN-AR-MS................................... 0.8070 0.8634
Merced, CA.......................................... 1.0615 1.0417
Milwaukee-Waukesha, WI.............................. 0.9840 0.9890
Minneapolis-St. Paul, MN-WI......................... 1.0630 1.0427
Missoula, MT........................................ 0.9281 0.9502
Monmouth-Ocean, NJ.................................. 1.0829 1.0561
Monroe, LA.......................................... 0.8143 0.8688
Montgomery, AL...................................... 0.7542 0.8243
Myrtle Beach, SC.................................... 0.8465 0.8922
Nashville, TN....................................... 0.9008 0.9310
New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT. 1.2692 1.1773
New London-Norwich, CT.............................. 1.0860 1.0581
New Orleans, LA..................................... 0.9073 0.9356
New York, NY........................................ 1.4302 1.2777
Newark, NJ.......................................... 1.0873 1.0590
Newburgh, NY-PA..................................... 1.0805 1.0545
Norfolk-Virginia Beach-Newport News, VA-NC.......... 0.8378 0.8859
Oakland, CA......................................... 1.5199 1.3320
Oklahoma City, OK................................... 0.8705 0.9094
Omaha, NE-IA........................................ 1.0722 1.0489
Orange County, CA................................... 1.1539 1.1030
Orlando, FL......................................... 0.9997 0.9998
Peoria-Pekin, IL.................................... 0.8495 0.8943
Philadelphia, PA-NJ................................. 1.1077 1.0726
Phoenix-Mesa, AZ.................................... 0.9546 0.9687
Pittsburgh, PA...................................... 0.9537 0.9681
Pocatello, ID....................................... 0.8715 0.9101
Portland, ME........................................ 0.9552 0.9691
Portland-Vancouver, OR-WA........................... 1.1091 1.0735
Provo-Orem, UT...................................... 0.9786 0.9853
Raleigh-Durham-Chapel Hill, NC...................... 0.9631 0.9746
Roanoke, VA......................................... 0.8224 0.8747
Rockford, IL........................................ 0.8861 0.9205
Sacramento, CA...................................... 1.2482 1.1640
Saginaw-Bay City-Midland, MI........................ 0.9422 0.9600
St. Cloud, MN....................................... 0.9650 0.9759
St. Louis, MO-IL.................................... 0.9186 0.9435
Salt Lake City-Ogden, UT............................ 0.9884 0.9920
San Diego, CA....................................... 1.1943 1.1293
Santa Fe, NM........................................ 0.9115 0.9385
Santa Rosa, CA...................................... 1.3127 1.2048
Seattle-Bellevue-Everett, WA........................ 1.1390 1.0932
Sharon, PA.......................................... 0.8488 0.8938
Sherman-Denison, TX................................. 0.8782 0.9149
Sioux City, IA-NE................................... 0.8051 0.8620
South Bend, IN...................................... 0.9791 0.9856
Springfield, MO..................................... 0.8003 0.8585
Syracuse, NY........................................ 0.9527 0.9674
Tallahassee, FL..................................... 0.8545 0.8979
Tampa-St. Petersburg-Clearwater, FL................. 0.9260 0.9487
Texarkana, AR-Texarkana, TX......................... 0.8206 0.8734
Toledo, OH.......................................... 0.9810 0.9870
Tulsa, OK........................................... 0.7852 0.8474
Tuscaloosa, AL...................................... 0.7994 0.8579
Tyler, TX........................................... 0.8572 0.8999
[[Page 24802]]
Vallejo-Fairfield-Napa, CA.......................... 1.2291 1.1517
Victoria, TX........................................ 0.8062 0.8628
Waco, TX............................................ 0.7561 0.8258
Washington, DC-MD-VA-WV............................. 1.1118 1.0753
Waterloo-Cedar Falls, IA............................ 0.9039 0.9332
Wausau, WI.......................................... 0.9545 0.9686
West Palm Beach-Boca Raton, FL...................... 1.0167 1.0114
Wichita, KS......................................... 0.8857 0.9202
Rural Colorado...................................... 0.8852 0.9199
Rural Florida....................................... 0.9074 0.9356
Rural Illinois...................................... 0.8121 0.8672
Rural Louisiana..................................... 0.7519 0.8226
Rural Michigan...................................... 0.8904 0.9236
Rural Minnesota..................................... 0.8753 0.9128
Rural Missouri...................................... 0.7701 0.8362
Rural Montana....................................... 0.8528 0.8967
Rural Oregon........................................ 1.0071 1.0049
Rural Pennsylvania (NY Hospital).................... 0.8633 0.9042
Rural Tennessee..................................... 0.7743 0.8393
Rural Texas (OK Hospital)........................... 0.7345 0.8095
Rural Virginia (KY Hospital)........................ 0.8129 0.8677
Rural Washington.................................... 1.0370 1.0252
Rural Wyoming....................................... 0.8891 0.9227
------------------------------------------------------------------------
Table 4D.--Average Hourly Wage for Urban Areas
------------------------------------------------------------------------
Average
Urban area hourly
wage
------------------------------------------------------------------------
Abilene, TX.................................................. 17.3384
Aguadilla, PR................................................ 9.5600
Akron, OH.................................................... 21.5487
Albany, GA................................................... 15.2742
Albany-Schenectady-Troy, NY.................................. 18.0615
Albuquerque, NM.............................................. 17.5627
Alexandria, LA............................................... 16.6620
Allentown-Bethlehem-Easton, PA............................... 21.7512
Altoona, PA.................................................. 19.7557
Amarillo, TX................................................. 16.8825
Anchorage, AK................................................ 27.2347
Ann Arbor, MI................................................ 24.2486
Anniston, AL................................................. 17.9235
Appleton-Oshkosh-Neenah, WI.................................. 18.7525
Arecibo, PR.................................................. 9.9315
Asheville, NC................................................ 18.8257
Athens, GA................................................... 20.0661
Atlanta, GA.................................................. 21.2165
Atlantic-Cape May, NJ........................................ 22.9089
Augusta-Aiken, GA-SC......................................... 19.1161
Austin-San Marcos, TX........................................ 19.9429
Bakersfield, CA.............................................. 20.3276
Baltimore, MD................................................ 21.3358
Bangor, ME................................................... 20.3521
Barnstable-Yarmouth, MA...................................... 27.2846
Baton Rouge, LA.............................................. 18.4438
Beaumont-Port Arthur, TX..................................... 17.9374
Bellingham, WA............................................... 24.1321
Benton Harbor, MI............................................ 17.9119
Bergen-Passaic, NJ........................................... 25.2711
Billings, MT................................................. 24.7467
Biloxi-Gulfport-Pascagoula, MS............................... 16.6634
Binghamton, NY............................................... 18.2442
Birmingham, AL............................................... 18.8910
Bismarck, ND................................................. 16.4329
Bloomington, IN.............................................. 18.1990
Bloomington-Normal, IL....................................... 19.0474
Boise City, ID............................................... 19.1895
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH............. 23.5756
Boulder-Longmont, CO......................................... 21.0610
Brazoria, TX................................................. 18.0160
Bremerton, WA................................................ 23.3211
Brownsville-Harlingen-San Benito, TX......................... 19.3812
Bryan-College Station, TX.................................... 17.7233
Buffalo-Niagara Falls, NY.................................... 20.0987
Burlington, VT............................................... 21.9214
Caguas, PR................................................... 9.5514
Canton-Massillon, OH......................................... 18.5824
Casper, WY................................................... 19.4829
Cedar Rapids, IA............................................. 19.1010
Champaign-Urbana, IL......................................... 19.4065
Charleston-North Charleston, SC.............................. 18.7959
Charleston, WV............................................... 19.2624
Charlotte-Gastonia-Rock Hill, NC-SC.......................... 19.9662
Charlottesville, VA.......................................... 22.3946
Chattanooga, TN-GA........................................... 20.7419
Cheyenne, WY................................................. 17.3158
Chicago, IL.................................................. 22.7675
Chico-Paradise, CA........................................... 21.7666
Cincinnati, OH-KY-IN......................................... 19.8701
Clarksville-Hopkinsville, TN-KY.............................. 17.1337
Cleveland-Lorain-Elyria, OH.................................. 20.3885
Colorado Springs, CO......................................... 19.5228
Columbia, MO................................................. 18.8334
Columbia, SC................................................. 19.8182
Columbus, GA-AL.............................................. 17.9587
Columbus, OH................................................. 20.5518
Corpus Christi, TX........................................... 19.5374
Cumberland, MD-WV............................................ 18.6405
Dallas, TX................................................... 19.3512
Danville, VA................................................. 19.1906
Davenport-Moline-Rock Island, IA-IL.......................... 18.4412
Dayton-Springfield, OH....................................... 19.9120
Daytona Beach, FL............................................ 18.9525
Decatur, AL.................................................. 20.9325
Decatur, IL.................................................. 17.6402
Denver, CO................................................... 21.4632
Des Moines, IA............................................... 18.5542
Detroit, MI.................................................. 21.9391
Dothan, AL................................................... 16.5159
Dover, DE.................................................... 19.7645
Dubuque, IA.................................................. 18.0451
Duluth-Superior, MN-WI....................................... 21.5499
Dutchess County, NY.......................................... 22.2045
Eau Claire, WI............................................... 18.9735
El Paso, TX.................................................. 18.8348
Elkhart-Goshen, IN........................................... 19.1690
Elmira, NY................................................... 18.0730
Enid, OK..................................................... 16.8452
Erie, PA..................................................... 19.0352
Eugene-Springfield, OR....................................... 22.0108
Evansville, Henderson, IN-KY................................. 17.5709
Fargo-Moorhead, ND-MN........................................ 18.2572
Fayetteville, NC............................................. 17.9896
Fayetteville-Springdale-Rogers, AR........................... 16.4641
Flagstaff, AZ-UT............................................. 21.9164
Flint, MI.................................................... 23.3401
Florence, AL................................................. 16.7894
Florence, SC................................................. 18.2544
Fort Collins-Loveland, CO.................................... 21.8189
Fort Lauderdale, FL.......................................... 21.5452
Fort Myers-Cape Coral, FL.................................... 18.6973
Fort Pierce-Port St. Lucie, FL............................... 21.1349
Fort Smith, AR-OK............................................ 16.6129
Fort Walton Beach, FL........................................ 18.4550
Fort Wayne, IN............................................... 18.7461
Fort Worth-Arlington, TX..................................... 18.8776
Fresno, CA................................................... 21.7462
Gadsden, AL.................................................. 18.4020
Gainesville, FL.............................................. 21.3475
Galveston-Texas City, TX..................................... 20.0636
Gary, IN..................................................... 19.8645
Glens Falls, NY.............................................. 18.2269
Goldsboro, NC................................................ 17.6500
Grand Forks, ND-MN........................................... 19.2683
Grand Junction, CO........................................... 19.4809
Grand Rapids-Muskegon-Holland, MI............................ 21.3218
Great Falls, MT.............................................. 22.2802
Greeley, CO.................................................. 19.8126
Green Bay, WI................................................ 19.3280
Greensboro-Winston-Salem-High Point, NC...................... 19.1271
Greenville, NC............................................... 20.0665
Greenville-Spartanburg-Anderson, SC.......................... 19.2880
Hagerstown, MD............................................... 18.7266
Hamilton-Middletown, OH...................................... 18.8172
Harrisburg-Lebanon-Carlisle, PA.............................. 20.7504
Hartford, CT................................................. 23.2800
Hattiesburg, MS.............................................. 16.1993
Hickory-Morganton-Lenoir, NC................................. 19.3688
Honolulu, HI................................................. 24.3141
Houma, LA.................................................... 16.5978
Houston, TX.................................................. 19.4711
Huntington-Ashland, WV-KY-OH................................. 20.6552
Huntsville, AL............................................... 18.6863
Indianapolis, IN............................................. 20.7074
Iowa City, IA................................................ 20.3481
Jackson, MI.................................................. 18.7230
Jackson, MS.................................................. 17.7577
Jackson, TN.................................................. 22.9654
Jacksonville, FL............................................. 18.8568
Jacksonville, NC............................................. 16.6300
Jamestown, NY................................................ 16.6418
Janesville-Beloit, WI........................................ 20.3455
Jersey City, NJ.............................................. 24.5703
Johnson City-Kingsport-Bristol,
TN-VA...................................................... 18.6209
Johnstown, PA................................................ 17.5658
Jonesboro, AR................................................ 15.3149
[[Page 24803]]
Joplin, MO................................................... 16.2618
Kalamazoo-Battlecreek, MI.................................... 21.1395
Kankakee, IL................................................. 17.5067
Kansas City, KS-MO........................................... 19.5015
Kenosha, WI.................................................. 18.4010
Killeen-Temple, TX........................................... 21.0317
Knoxville, TN................................................ 19.4838
Kokomo, IN................................................... 18.8885
La Crosse, WI-MN............................................. 18.9205
Lafayette, LA................................................ 16.9163
Lafayette, IN................................................ 18.6572
Lake Charles, LA............................................. 16.5668
Lakeland-Winter Haven, FL.................................... 18.6713
Lancaster, PA................................................ 18.7531
Lansing-East Lansing, MI..................................... 21.1588
Laredo, TX................................................... 17.6272
Las Cruces, NM............................................... 17.9392
Las Vegas, NV-AZ............................................. 23.4456
Lawrence, KS................................................. 17.4151
Lawton, OK................................................... 17.7694
Lewiston-Auburn, ME.......................................... 18.8110
Lexington, KY................................................ 18.1825
Lima, OH..................................................... 18.8613
Lincoln, NE.................................................. 20.4820
Little Rock-North Little Rock, AR............................ 18.2375
Longview-Marshall, TX........................................ 18.5109
Los Angeles-Long Beach, CA................................... 24.8769
Louisville, KY-IN............................................ 19.4923
Lubbock, TX.................................................. 17.6926
Lynchburg, VA................................................ 18.9720
Macon, GA.................................................... 18.0637
Madison, WI.................................................. 21.1696
Mansfield, OH................................................ 17.9415
Mayaguez, PR................................................. 10.1946
McAllen-Edinburg-Mission, TX................................. 17.0929
Medford-Ashland, OR.......................................... 22.2257
Melbourne-Titusville-Palm Bay, FL............................ 19.6889
Memphis, TN-AR-MS............................................ 16.9175
Merced, CA................................................... 21.7673
Miami, FL.................................................... 21.6256
Middlesex-Somerset-Hunterdon, NJ............................. 23.6066
Milwaukee-Waukesha, WI....................................... 20.6321
Minneapolis-St. Paul, MN-WI.................................. 22.2877
Missoula, MT................................................. 19.1769
Mobile, AL................................................... 17.4061
Modesto, CA.................................................. 21.3504
Monmouth-Ocean, NJ........................................... 23.8424
Monroe, LA................................................... 17.4115
Montgomery, AL............................................... 14.6992
Muncie, IN................................................... 22.7904
Myrtle Beach, SC............................................. 18.1305
Naples, FL................................................... 21.4581
Nashville, TN................................................ 19.1647
Nassau-Suffolk, NY........................................... 29.6122
New Haven-Bridgeport-Stamford-
Waterbury-Danbury, CT...................................... 26.1133
New London-Norwich, CT....................................... 22.3392
New Orleans, LA.............................................. 19.0247
New York, NY................................................. 29.8414
Newark, NJ................................................... 25.1990
Newburgh, NY-PA.............................................. 23.1041
Norfolk-Virginia Beach-Newport News, VA-NC................... 17.5474
Oakland, CA.................................................. 31.7590
Ocala, FL.................................................... 20.3639
Odessa-Midland, TX........................................... 16.8070
Oklahoma City, OK............................................ 18.2516
Olympia, WA.................................................. 26.7328
Omaha, NE-IA................................................. 22.4822
Orange County, CA............................................ 24.1961
Orlando, FL.................................................. 20.9377
Owensboro, KY................................................ 16.1873
Panama City, FL.............................................. 19.4291
Parkersburg-Marietta, WV-OH.................................. 17.8217
Pensacola, FL................................................ 17.8744
Peoria-Pekin, IL............................................. 17.6840
Philadelphia, PA-NJ.......................................... 23.1971
Phoenix-Mesa, AZ............................................. 20.0149
Pine Bluff, AR............................................... 16.1227
Pittsburgh, PA............................................... 19.9963
Pittsfield, MA............................................... 22.5755
Pocatello, ID................................................ 19.0128
Ponce, PR.................................................... 10.5379
Portland, ME................................................. 19.9935
Portland-Vancouver, OR-WA.................................... 23.2544
Providence-Warwick, RI....................................... 22.6214
Provo-Orem, UT............................................... 20.5053
Pueblo, CO................................................... 18.7505
Punta Gorda, FL.............................................. 17.9293
Racine, WI................................................... 19.5201
Raleigh-Durham-Chapel Hill, NC............................... 20.1948
Rapid City, SD............................................... 17.7159
Reading, PA.................................................. 19.9741
Redding, CA.................................................. 23.8872
Reno, NV..................................................... 22.5678
Richland-Kennewick-Pasco, WA................................. 23.7721
Richmond-Petersburg, VA...................................... 21.0784
Riverside-San Bernardino, CA................................. 22.6264
Roanoke, VA.................................................. 17.2365
Rochester, MN................................................ 23.1823
Rochester, NY................................................ 19.8100
Rockford, IL................................................. 18.5789
Rocky Mount, NC.............................................. 18.4997
Sacramento, CA............................................... 26.1722
Saginaw-Bay City-Midland, MI................................. 19.6590
St. Cloud, MN................................................ 19.7777
St. Joseph, MO............................................... 18.5272
St. Louis, MO-IL............................................. 19.2606
Salem, OR.................................................... 21.0721
Salinas, CA.................................................. 30.8347
Salt Lake City-Ogden, UT..................................... 20.7240
San Angelo, TX............................................... 16.5012
San Antonio, TX.............................................. 17.3414
San Diego, CA................................................ 24.9816
San Francisco, CA............................................ 29.7441
San Jose, CA................................................. 28.9924
San Juan-Bayamon, PR......................................... 9.9392
San Luis Obispo-Atascadero-
Paso Robles, CA............................................ 22.1746
Santa Barbara-Santa Maria-
Lompoc, CA................................................. 22.9107
Santa Cruz-Watsonville, CA................................... 29.4979
Santa Fe, NM................................................. 19.0044
Santa Rosa, CA............................................... 27.5249
Sarasota-Bradenton, FL....................................... 20.8165
Savannah, GA................................................. 20.7408
Scranton-Wilkes Barre-Hazleton,
PA......................................................... 17.2531
Seattle-Bellevue-Everett, WA................................. 23.8788
Sharon, PA................................................... 17.4261
Sheboygan, WI................................................ 17.3719
Sherman-Denison, TX.......................................... 19.3180
Shreveport-Bossier City, LA.................................. 19.1689
Sioux City, IA-NE............................................ 16.7521
Sioux Falls, SD.............................................. 18.4052
South Bend, IN............................................... 20.7423
Spokane, WA.................................................. 22.8349
Springfield, IL.............................................. 18.3917
Springfield, MO.............................................. 16.7813
Springfield, MA.............................................. 22.2268
State College, PA............................................ 19.3927
Steubenville-Weirton, OH-WV.................................. 18.2449
Stockton-Lodi, CA............................................ 22.2735
Sumter, SC................................................... 17.4486
Syracuse, NY................................................. 19.9107
Tacoma, WA................................................... 24.3185
Tallahassee, FL.............................................. 18.5118
Tampa-St. Petersburg-Clearwater, FL.......................... 19.2631
Terre Haute, IN.............................................. 18.1855
Texarkana, AR-Texarkana, TX.................................. 17.1104
Toledo, OH................................................... 21.0109
Topeka, KS................................................... 19.2788
Trenton, NJ.................................................. 19.2422
Tucson, AZ................................................... 18.5156
Tulsa, OK.................................................... 16.4631
Tuscaloosa, AL............................................... 16.7614
Tyler, TX.................................................... 17.6966
Utica-Rome, NY............................................... 17.5752
Vallejo-Fairfield-Napa, CA................................... 28.2652
Ventura, CA.................................................. 24.0627
Victoria, TX................................................. 16.7918
Vineland-Millville-Bridgeton, NJ............................. 22.2740
Visalia-Tulare-Porterville, CA............................... 21.8242
Waco, TX..................................................... 15.8347
Washington, DC-MD-VA-WV...................................... 23.3111
Waterloo-Cedar Falls, IA..................................... 18.3856
Wausau, WI................................................... 20.0138
West Palm Beach-Boca Raton,
FL......................................................... 21.2057
Wheeling, OH-WV.............................................. 16.1880
Wichita, KS.................................................. 19.1154
Wichita Falls, TX............................................ 16.2079
Williamsport, PA............................................. 18.0547
Wilmington-Newark, DE-MD..................................... 23.8786
Wilmington, NC............................................... 20.8870
Yakima, WA................................................... 21.8824
Yolo, CA..................................................... 20.5840
York, PA..................................................... 19.5997
Youngstown-Warren, OH........................................ 21.1722
Yuba City, CA................................................ 22.5818
Yuma, AZ..................................................... 21.0182
------------------------------------------------------------------------
Table 4E.--Average Hourly Wage for Rural Areas
------------------------------------------------------------------------
Average
Nonurban area hourly
wage
------------------------------------------------------------------------
Alabama...................................................... 15.8142
Alaska....................................................... 25.5400
Arizona...................................................... 18.0528
Arkansas..................................................... 15.2856
California................................................... 21.2880
Colorado..................................................... 18.5603
[[Page 24804]]
Connecticut.................................................. 26.6122
Delaware..................................................... 19.4135
Florida...................................................... 19.0250
Georgia...................................................... 17.1694
Hawaii....................................................... 22.6698
Idaho........................................................ 18.2722
Illinois..................................................... 17.0275
Indiana...................................................... 17.7798
Iowa......................................................... 16.7742
Kansas....................................................... 15.7503
Kentucky..................................................... 17.0443
Louisiana.................................................... 15.5331
Maine........................................................ 18.2533
Maryland..................................................... 19.0722
Massachusetts................................................ 20.7873
Michigan..................................................... 18.6349
Minnesota.................................................... 18.3523
Mississippi.................................................. 15.6269
Missouri..................................................... 16.1473
Montana...................................................... 17.8810
Nebraska..................................................... 16.9308
Nevada....................................................... 20.1989
New Hampshire................................................ 20.9206
New Jersey \1\............................................... .........
New Mexico................................................... 18.0601
New York..................................................... 18.1015
North Carolina............................................... 17.5057
North Dakota................................................. 16.2498
Ohio......................................................... 18.2882
Oklahoma..................................................... 15.4011
Oregon....................................................... 21.1083
Pennsylvania................................................. 17.7969
Puerto Rico.................................................. 9.1814
Rhode Island \1\............................................. .........
South Carolina............................................... 17.9076
South Dakota................................................. 16.0683
Tennessee.................................................... 16.2348
Texas........................................................ 14.6891
Utah......................................................... 17.2326
Vermont...................................................... 19.9290
Virginia..................................................... 16.6151
Washington................................................... 21.9605
West Virginia................................................ 17.2069
Wisconsin.................................................... 18.5387
Wyoming...................................................... 18.6424
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.
Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF)
----------------------------------------------------------------------------------------------------------------
Wage index--
Area Wage index GAF reclassified GAF--reclassified
hospitals hospitals
----------------------------------------------------------------------------------------------------------------
Aguadilla, PR................................ 0.9593 0.9719 .............. .................
Arecibo, PR.................................. 0.9965 0.9976 .............. .................
Caguas, PR................................... 0.9584 0.9713 0.9584 0.9713
Mayaguez, PR................................. 1.0229 1.0156 .............. .................
Ponce, PR.................................... 1.0574 1.0390 .............. .................
San Juan-Bayamon, PR......................... 0.9973 0.9982 .............. .................
Rural Puerto Rico............................ 0.9213 0.9454 .............. .................
----------------------------------------------------------------------------------------------------------------
Table 5.--List of Diagnosis Related Groups (DRGs), Relative Weighting Factors, Geometric and Arithmetic Mean
Length of Stay
----------------------------------------------------------------------------------------------------------------
Relative Geometric Arithmetic
DRG MDC Type of DRG DRG title weights mean LOS mean LOS
----------------------------------------------------------------------------------------------------------------
1.............. 01 SURG CRANIOTOMY AGE >17 EXCEPT 3.0845 6.5 9.3
FOR TRAUMA.
2.............. 01 SURG CRANIOTOMY FOR TRAUMA AGE 3.0989 7.4 9.9
>17.
3.............. 01 SURG *CRANIOTOMY AGE 0-17...... 1.9619 12.7 12.7
4.............. 01 SURG SPINAL PROCEDURES......... 2.3104 4.9 7.5
5.............. 01 SURG EXTRACRANIAL VASCULAR 1.4462 2.5 3.4
PROCEDURES.
6.............. 01 SURG CARPAL TUNNEL RELEASE..... .8119 2.2 3.1
7.............. 01 SURG PERIPH & CRANIAL NERVE & 2.3667 6.6 9.8
OTHER NERV SYST PROC W CC.
8.............. 01 SURG PERIPH & CRANIAL NERVE & 1.3303 2.2 3.1
OTHER NERV SYST PROC W/O
CC.
9.............. 01 MED SPINAL DISORDERS & 1.1785 4.6 6.2
INJURIES.
10............. 01 MED NERVOUS SYSTEM NEOPLASMS W 1.2044 4.9 6.7
CC.
11............. 01 MED NERVOUS SYSTEM NEOPLASMS W/ .8277 3.0 4.1
O CC.
12............. 01 MED DEGENERATIVE NERVOUS .8908 4.6 6.3
SYSTEM DISORDERS.
13............. 01 MED MULTIPLE SCLEROSIS & .7585 4.2 5.2
CEREBELLAR ATAXIA.
14............. 01 MED SPECIFIC CEREBROVASCULAR 1.1924 4.7 6.1
DISORDERS EXCEPT TIA.
15............. 01 MED TRANSIENT ISCHEMIC ATTACK .7405 3.0 3.7
& PRECEREBRAL OCCLUSIONS.
16............. 01 MED NONSPECIFIC 1.0998 4.6 5.9
CEREBROVASCULAR DISORDERS
W CC.
17............. 01 MED NONSPECIFIC .6405 2.6 3.4
CEREBROVASCULAR DISORDERS
W/O CC.
18............. 01 MED CRANIAL & PERIPHERAL NERVE .9365 4.2 5.5
DISORDERS W CC.
19............. 01 MED CRANIAL & PERIPHERAL NERVE .6504 3.0 3.8
DISORDERS W/O CC.
20............. 01 MED NERVOUS SYSTEM INFECTION 2.6065 7.7 10.2
EXCEPT VIRAL MENINGITIS.
21............. 01 MED VIRAL MENINGITIS.......... 1.5010 5.0 6.8
22............. 01 MED HYPERTENSIVE .9637 3.8 4.9
ENCEPHALOPATHY.
23............. 01 MED NONTRAUMATIC STUPOR & COMA .7756 3.1 4.2
24............. 01 MED SEIZURE & HEADACHE AGE >17 .9782 3.7 5.1
W CC.
25............. 01 MED SEIZURE & HEADACHE AGE >17 .5911 2.6 3.4
W/O CC.
26............. 01 MED SEIZURE & HEADACHE AGE 0- .6296 2.8 3.6
17.
[[Page 24805]]
27............. 01 MED TRAUMATIC STUPOR & COMA, 1.3532 3.3 5.3
COMA >1 HR.
28............. 01 MED TRAUMATIC STUPOR & COMA, 1.2680 4.5 6.2
COMA <1 hr="" age="">17 W CC.
29............. 01 MED TRAUMATIC STUPOR & COMA, .6844 2.8 3.6
COMA <1 hr="" age="">17 W/O CC.
30............. 01 MED * TRAUMATIC STUPOR & COMA, .3318 2.0 2.0
COMA <1 hr="" age="" 0-17.="" 31.............="" 01="" med="" concussion="" age="">17 W CC... .8463 3.2 4.3
32............. 01 MED CONCUSSION AGE >17 W/O CC. .5282 2.1 2.7
33............. 01 MED *CONCUSSION AGE 0-17...... .2085 1.6 1.6
34............. 01 MED OTHER DISORDERS OF NERVOUS 1.0267 4.0 5.3
SYSTEM W CC.
35............. 01 MED OTHER DISORDERS OF NERVOUS .5931 2.7 3.5
SYSTEM W/O CC.
36............. 02 SURG RETINAL PROCEDURES........ .6804 1.2 1.4
37............. 02 SURG ORBITAL PROCEDURES........ 1.0261 2.6 3.9
38............. 02 SURG PRIMARY IRIS PROCEDURES... .4871 1.9 2.6
39............. 02 SURG LENS PROCEDURES WITH OR .5682 1.4 1.9
WITHOUT VITRECTOMY.
40............. 02 SURG EXTRAOCULAR PROCEDURES .8131 2.2 3.3
EXCEPT ORBIT AGE >17.
41............. 02 SURG *EXTRAOCULAR PROCEDURES .3378 1.6 1.6
EXCEPT ORBIT AGE 0-17.
42............. 02 SURG INTRAOCULAR PROCEDURES .6222 1.6 2.1
EXCEPT RETINA, IRIS &
LENS.
43............. 02 MED HYPHEMA................... .4416 2.5 4.1
44............. 02 MED ACUTE MAJOR EYE INFECTIONS .6449 4.1 5.0
45............. 02 MED NEUROLOGICAL EYE DISORDERS .6946 2.8 3.4
46............. 02 MED OTHER DISORDERS OF THE EYE .7524 3.5 4.6
AGE >17 W CC.
47............. 02 MED OTHER DISORDERS OF THE EYE .4795 2.5 3.2
AGE >17 W/O CC.
48............. 02 MED *OTHER DISORDERS OF THE .2975 2.9 2.9
EYE AGE 0-17.
49............. 03 SURG MAJOR HEAD & NECK 1.8471 3.7 5.0
PROCEDURES.
50............. 03 SURG SIALOADENECTOMY........... .8390 1.6 2.0
51............. 03 SURG SALIVARY GLAND PROCEDURES .8486 1.9 2.9
EXCEPT SIALOADEN-ECTOMY.
52............. 03 SURG CLEFT LIP & PALATE REPAIR. .7954 1.6 2.0
53............. 03 SURG SINUS & MASTOID PROCEDURES 1.1767 2.3 3.6
AGE >17.
54............. 03 SURG *SINUS & MASTOID .4823 3.2 3.2
PROCEDURES AGE 0-17.
55............. 03 SURG MISCELLANEOUS EAR, NOSE, .8648 1.9 2.8
MOUTH & THROAT PROCEDURES.
56............. 03 SURG RHINOPLASTY............... .8881 2.1 2.8
57............. 03 SURG T&A PROC, EXCEPT 1.1571 3.0 4.8
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY, AGE
>17.
58............. 03 SURG *T&A PROC, EXCEPT .2739 1.5 1.5
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY, AGE 0-
17.
59............. 03 SURG TONSILLECTOMY &/OR .6700 1.9 2.6
ADENOIDECTOMY ONLY, AGE
>17.
60............. 03 SURG *TONSILLECTOMY &/OR .2086 1.5 1.5
ADENOIDECTOMY ONLY, AGE 0-
17.
61............. 03 SURG MYRINGOTOMY W TUBE 1.2529 2.9 4.8
INSERTION AGE >17.
62............. 03 SURG *MYRINGOTOMY W TUBE .2953 1.3 1.3
INSERTION AGE 0-17.
63............. 03 SURG OTHER EAR, NOSE, MOUTH & 1.3078 3.0 4.5
THROAT O.R. PROCEDURES.
64............. 03 MED EAR, NOSE, MOUTH & THROAT 1.2517 4.4 6.7
MALIGNANCY.
65............. 03 MED DYSEQUILIBRIUM............ .5270 2.3 2.9
66............. 03 MED EPISTAXIS................. .5551 2.6 3.2
67............. 03 MED EPIGLOTTITIS.............. .8059 2.9 3.7
68............. 03 MED OTITIS MEDIA & URI AGE >17 .6764 3.4 4.2
W CC.
69............. 03 MED OTITIS MEDIA & URI AGE >17 .5210 2.7 3.3
W/O CC.
70............. 03 MED OTITIS MEDIA & URI AGE 0- .3989 2.3 2.7
17.
71............. 03 MED LARYNGOTRACHEITIS......... .6206 2.8 3.4
72............. 03 MED NASAL TRAUMA & DEFORMITY.. .6464 2.6 3.4
73............. 03 MED OTHER EAR, NOSE, MOUTH & .7671 3.3 4.3
THROAT DIAGNOSES AGE >17.
74............. 03 MED *OTHER EAR, NOSE, MOUTH & .3356 2.1 2.1
THROAT DIAGNOSES AGE 0-17.
75............. 04 SURG MAJOR CHEST PROCEDURES.... 3.1078 7.8 9.9
76............. 04 SURG OTHER RESP SYSTEM O.R. 2.6947 8.3 11.1
PROCEDURES W CC.
77............. 04 SURG OTHER RESP SYSTEM O.R. 1.2105 3.6 5.1
PROCEDURES W/O CC.
78............. 04 MED PULMONARY EMBOLISM........ 1.3898 6.1 7.1
79............. 04 MED RESPIRATORY INFECTIONS & 1.6472 6.6 8.4
INFLAMMATIONS AGE >17 W
CC.
80............. 04 MED RESPIRATORY INFECTIONS & .9030 4.5 5.6
INFLAMMATIONS AGE >17 W/O
CC.
81............. 04 MED *RESPIRATORY INFECTIONS & 1.5196 6.1 6.1
INFLAMMATIONS AGE 0-17.
82............. 04 MED RESPIRATORY NEOPLASMS..... 1.3674 5.2 7.0
83............. 04 MED MAJOR CHEST TRAUMA W CC... .9723 4.3 5.5
84............. 04 MED MAJOR CHEST TRAUMA W/O CC. .5250 2.6 3.2
85............. 04 MED PLEURAL EFFUSION W CC..... 1.2450 5.0 6.5
[[Page 24806]]
86............. 04 MED PLEURAL EFFUSION W/O CC... .6706 2.8 3.8
87............. 04 MED PULMONARY EDEMA & 1.3741 4.8 6.3
RESPIRATORY FAILURE.
88............. 04 MED CHRONIC OBSTRUCTIVE .9431 4.3 5.3
PULMONARY DISEASE.
89............. 04 MED SIMPLE PNEUMONIA & 1.0887 5.1 6.1
PLEURISY AGE >17 W CC.
90............. 04 MED SIMPLE PNEUMONIA & .6753 3.7 4.3
PLEURISY AGE >17 W/O CC.
91............. 04 MED SIMPLE PNEUMONIA & .6245 3.3 4.0
PLEURISY AGE 0-17.
92............. 04 MED INTERSTITIAL LUNG DISEASE 1.1783 5.0 6.2
W CC.
93............. 04 MED INTERSTITIAL LUNG DISEASE .7624 3.5 4.3
W/O CC.
94............. 04 MED PNEUMOTHORAX W CC......... 1.1942 4.8 6.4
95............. 04 MED PNEUMOTHORAX W/O CC....... .5973 3.0 3.6
96............. 04 MED BRONCHITIS & ASTHMA AGE .7963 3.9 4.8
>17 W CC.
97............. 04 MED BRONCHITIS & ASTHMA AGE .5974 3.1 3.7
>17 W/O CC.
98............. 04 MED BRONCHITIS & ASTHMA AGE 0- .6783 3.3 4.5
17.
99............. 04 MED RESPIRATORY SIGNS & .6842 2.4 3.1
SYMPTOMS W CC.
100............ 04 MED RESPIRATORY SIGNS & .5289 1.8 2.2
SYMPTOMS W/O CC.
101............ 04 MED OTHER RESPIRATORY SYSTEM .8502 3.3 4.4
DIAGNOSES W CC.
102............ 04 MED OTHER RESPIRATORY SYSTEM .5426 2.1 2.7
DIAGNOSES W/O CC.
103............ 05 SURG HEART TRANSPLANT.......... 19.0801 35.2 56.0
104............ 05 SURG CARDIAC VALVE & OTHER 7.2220 9.3 11.9
MAJOR CARDIOTHORACIC PROC
W CARDIAC CATH.
105............ 05 SURG CARDIAC VALVE & OTHER 5.6426 7.6 9.4
MAJOR CARDIOTHORACIC PROC
W/O CARDIAC CATH.
106............ 05 SURG CORONARY BYPASS W PTCA.... 7.3332 9.1 10.9
107............ 05 SURG CORONARY BYPASS W CARDIAC 5.4624 9.3 10.5
CATH.
108............ 05 SURG OTHER CARDIOTHORACIC 5.7505 8.3 11.0
PROCEDURES.
109............ 05 SURG CORONARY BYPASS W/O PTCA 4.0337 6.9 7.8
OR CARDIAC CATH.
110............ 05 SURG MAJOR CARDIOVASCULAR 4.1531 7.3 9.6
PROCEDURES W CC.
111............ 05 SURG MAJOR CARDIOVASCULAR 2.2236 4.9 5.7
PROCEDURES W/O CC.
112............ 05 SURG PERCUTANEOUS 1.9200 2.7 3.8
CARDIOVASCULAR PROCEDURES.
113............ 05 SURG AMPUTATION FOR CIRC SYSTEM 2.7188 9.5 12.5
DISORDERS EXCEPT UPPER
LIMB & TOE.
114............ 05 SURG UPPER LIMB & TOE 1.5531 6.0 8.2
AMPUTATION FOR CIRC
SYSTEM DISORDERS.
115............ 05 SURG PRM CARD PACEM IMPL W AMI, 3.4736 6.2 8.4
HRT FAIL OR SHK, OR AICD
LEAD OR GNRTR PR.
116............ 05 SURG OTH PERM CARD PACEMAK IMPL 2.4635 2.8 3.9
OR PTCA W CORONARY ARTERY
STENT IMPLNT.
117............ 05 SURG CARDIAC PACEMAKER REVISION 1.2942 2.7 4.1
EXCEPT DEVICE REPLACEMENT.
118............ 05 SURG CARDIAC PACEMAKER DEVICE 1.5475 2.0 2.9
REPLACEMENT.
119............ 05 SURG VEIN LIGATION & STRIPPING. 1.2288 3.0 4.9
120............ 05 SURG OTHER CIRCULATORY SYSTEM 2.0093 5.0 8.2
O.R. PROCEDURES.
121............ 05 MED CIRCULATORY DISORDERS W 1.6318 5.6 6.8
AMI & MAJOR COMP,
DISCHARGED ALIVE.
122............ 05 MED CIRCULATORY DISORDERS W 1.1091 3.4 4.2
AMI W/O MAJOR COMP,
DISCHARGED ALIVE.
123............ 05 MED CIRCULATORY DISORDERS W 1.5135 2.7 4.4
AMI, EXPIRED.
124............ 05 MED CIRCULATORY DISORDERS 1.4018 3.4 4.5
EXCEPT AMI, W CARD CATH &
COMPLEX DIAG.
125............ 05 MED CIRCULATORY DISORDERS 1.0436 2.2 2.9
EXCEPT AMI, W CARD CATH W/
O COMPLEX DIAG.
126............ 05 MED ACUTE & SUBACUTE 2.5151 9.3 12.1
ENDOCARDITIS.
127............ 05 MED HEART FAILURE & SHOCK..... 1.0156 4.2 5.4
128............ 05 MED DEEP VEIN THROMBOPHLEBITIS .7656 5.1 5.9
129............ 05 MED CARDIAC ARREST, 1.0799 1.8 2.8
UNEXPLAINED.
130............ 05 MED PERIPHERAL VASCULAR .9475 4.7 5.9
DISORDERS W CC.
131............ 05 MED PERIPHERAL VASCULAR .6057 3.7 4.5
DISORDERS W/O CC.
132............ 05 MED ATHEROSCLEROSIS W CC...... .6723 2.5 3.1
133............ 05 MED ATHEROSCLEROSIS W/O CC.... .5656 1.9 2.4
134............ 05 MED HYPERTENSION.............. .5857 2.6 3.3
135............ 05 MED CARDIAC CONGENITAL & .8643 3.3 4.4
VALVULAR DISORDERS AGE
>17 W CC.
136............ 05 MED CARDIAC CONGENITAL & .6011 2.3 2.9
VALVULAR DISORDERS AGE
>17 W/O CC.
137............ 05 MED *CARDIAC CONGENITAL & .8188 3.3 3.3
VALVULAR DISORDERS AGE 0-
17.
138............ 05 MED CARDIAC ARRHYTHMIA & .8164 3.1 4.0
CONDUCTION DISORDERS W CC.
[[Page 24807]]
139............ 05 MED CARDIAC ARRHYTHMIA & .5087 2.1 2.5
CONDUCTION DISORDERS W/O
CC.
140............ 05 MED ANGINA PECTORIS........... .5840 2.3 2.8
141............ 05 MED SYNCOPE & COLLAPSE W CC... .7094 2.9 3.7
142............ 05 MED SYNCOPE & COLLAPSE W/O CC. .5426 2.2 2.7
143............ 05 MED CHEST PAIN................ .5348 1.8 2.2
144............ 05 MED OTHER CIRCULATORY SYSTEM 1.1513 3.8 5.3
DIAGNOSES W CC.
145............ 05 MED OTHER CIRCULATORY SYSTEM .6502 2.2 2.8
DIAGNOSES W/O CC.
146............ 06 SURG RECTAL RESECTION W CC..... 2.7908 9.1 10.3
147............ 06 SURG RECTAL RESECTION W/O CC... 1.6377 6.1 6.7
148............ 06 SURG MAJOR SMALL & LARGE BOWEL 3.4324 10.1 12.1
PROCEDURES W CC.
149............ 06 SURG MAJOR SMALL & LARGE BOWEL 1.5743 6.2 6.7
PROCEDURES W/O CC.
150............ 06 SURG PERITONEAL ADHESIOLYSIS W 2.8115 9.1 11.0
CC.
151............ 06 SURG PERITONEAL ADHESIOLYSIS W/ 1.3464 4.9 6.0
O CC.
152............ 06 SURG MINOR SMALL & LARGE BOWEL 1.9571 6.9 8.3
PROCEDURES W CC.
153............ 06 SURG MINOR SMALL & LARGE BOWEL 1.2162 5.0 5.6
PROCEDURES W/O CC.
154............ 06 SURG STOMACH, ESOPHAGEAL & 4.1380 10.1 13.2
DUODENAL PROCEDURES AGE
>17 W CC.
155............ 06 SURG STOMACH, ESOPHAGEAL & 1.3793 3.5 4.5
DUODENAL PROCEDURES AGE
>17 W/O CC.
156............ 06 SURG *STOMACH, ESOPHAGEAL & .8432 6.0 6.0
DUODENAL PROCEDURES AGE 0-
17.
157............ 06 SURG ANAL & STOMAL PROCEDURES W 1.2385 4.0 5.6
CC.
158............ 06 SURG ANAL & STOMAL PROCEDURES W/ .6580 2.1 2.6
O CC.
159............ 06 SURG HERNIA PROCEDURES EXCEPT 1.3127 3.7 5.0
INGUINAL & FEMORAL AGE
>17 W CC.
160............ 06 SURG HERNIA PROCEDURES EXCEPT .7817 2.2 2.7
INGUINAL & FEMORAL AGE
>17 W/O CC.
161............ 06 SURG INGUINAL & FEMORAL HERNIA 1.1002 2.9 4.2
PROCEDURES AGE >17 W CC.
162............ 06 SURG INGUINAL & FEMORAL HERNIA .6292 1.6 2.0
PROCEDURES AGE >17 W/O CC.
163............ 06 SURG *HERNIA PROCEDURES AGE 0- .8720 2.1 2.1
17.
164............ 06 SURG APPENDECTOMY W COMPLICATED 2.3538 7.3 8.5
PRINCIPAL DIAG W CC.
165............ 06 SURG APPENDECTOMY W COMPLICATED 1.2706 4.4 4.9
PRINCIPAL DIAG W/O CC.
166............ 06 SURG APPENDECTOMY W/O 1.4861 4.1 5.2
COMPLICATED PRINCIPAL
DIAG W CC.
167............ 06 SURG APPENDECTOMY W/O .9038 2.4 2.8
COMPLICATED PRINCIPAL
DIAG W/O CC.
168............ 03 SURG MOUTH PROCEDURES W CC..... 1.2131 3.3 4.7
169............ 03 SURG MOUTH PROCEDURES W/O CC... .7494 1.9 2.5
170............ 06 SURG OTHER DIGESTIVE SYSTEM 2.8361 7.8 11.2
O.R. PROCEDURES W CC.
171............ 06 SURG OTHER DIGESTIVE SYSTEM 1.2561 3.6 4.8
O.R. PROCEDURES W/O CC.
172............ 06 MED DIGESTIVE MALIGNANCY W CC. 1.3135 5.1 6.9
173............ 06 MED DIGESTIVE MALIGNANCY W/O .7110 2.7 3.8
CC.
174............ 06 MED G.I. HEMORRHAGE W CC...... .9997 3.9 4.9
175............ 06 MED G.I. HEMORRHAGE W/O CC.... .5466 2.5 2.9
176............ 06 MED COMPLICATED PEPTIC ULCER.. 1.0992 4.1 5.3
177............ 06 MED UNCOMPLICATED PEPTIC ULCER .8823 3.7 4.5
W CC.
178............ 06 MED UNCOMPLICATED PEPTIC ULCER .6525 2.7 3.2
W/O CC.
179............ 06 MED INFLAMMATORY BOWEL DISEASE 1.0909 4.8 6.2
180............ 06 MED G.I. OBSTRUCTION W CC..... .9229 4.2 5.4
181............ 06 MED G.I. OBSTRUCTION W/O CC... .5285 2.8 3.4
182............ 06 MED ESOPHAGITIS, GASTROENT & .7834 3.4 4.3
MISC DIGEST DISORDERS AGE
>17 W CC.
183............ 06 MED ESOPHAGITIS, GASTROENT & .5726 2.4 3.0
MISC DIGEST DISORDERS AGE
>17 W/O CC.
184............ 06 MED ESOPHAGITIS, GASTROENT & .5266 2.3 3.0
MISC DIGEST DISORDERS AGE
0-17.
185............ 03 MED DENTAL & ORAL DIS EXCEPT .8560 3.3 4.5
EXTRACTIONS &
RESTORATIONS, AGE >17.
186............ 03 MED *DENTAL & ORAL DIS EXCEPT .3214 2.9 2.9
EXTRACTIONS &
RESTORATIONS, AGE 0-17.
187............ 03 MED DENTAL EXTRACTIONS & .7772 2.9 3.9
RESTORATIONS.
188............ 06 MED OTHER DIGESTIVE SYSTEM 1.0941 4.1 5.6
DIAGNOSES AGE >17 W CC.
189............ 06 MED OTHER DIGESTIVE SYSTEM .5841 2.4 3.2
DIAGNOSES AGE >17 W/O CC.
190............ 06 MED OTHER DIGESTIVE SYSTEM .9681 3.8 5.6
DIAGNOSES AGE 0-17.
191............ 07 SURG PANCREAS, LIVER & SHUNT 4.3647 10.6 14.2
PROCEDURES W CC.
192............ 07 SURG PANCREAS, LIVER & SHUNT 1.8479 5.7 7.0
PROCEDURES W/O CC.
[[Page 24808]]
193............ 07 SURG BILIARY TRACT PROC EXCEPT 3.4150 10.3 12.7
ONLY CHOLECYST W OR W/O
C.D.E. W CC.
194............ 07 SURG BILIARY TRACT PROC EXCEPT 1.6394 5.4 6.6
ONLY CHOLECYST W OR W/O
C.D.E. W/O CC.
195............ 07 SURG CHOLECYSTECTOMY W C.D.E. W 2.9468 8.4 10.0
CC.
196............ 07 SURG CHOLECYSTECTOMY W C.D.E. W/ 1.6603 4.9 5.7
O CC.
197............ 07 SURG CHOLECYSTECTOMY EXCEPT BY 2.4209 7.1 8.6
LAPAROSCOPE W/O C.D.E. W
CC.
198............ 07 SURG CHOLECYSTECTOMY EXCEPT BY 1.2360 3.9 4.5
LAPAROSCOPE W/O C.D.E. W/
O CC.
199............ 07 SURG HEPATOBILIARY DIAGNOSTIC 2.3278 7.2 9.7
PROCEDURE FOR MALIGNANCY.
200............ 07 SURG HEPATOBILIARY DIAGNOSTIC 3.0720 7.2 11.1
PROCEDURE FOR NON-
MALIGNANCY.
201............ 07 SURG OTHER HEPATOBILIARY OR 3.5771 10.3 14.2
PANCREAS O.R. PROCEDURES.
202............ 07 MED CIRRHOSIS & ALCOHOLIC 1.3202 5.0 6.6
HEPATITIS.
203............ 07 MED MALIGNANCY OF 1.3042 5.0 6.7
HEPATOBILIARY SYSTEM OR
PANCREAS.
204............ 07 MED DISORDERS OF PANCREAS 1.2186 4.6 6.0
EXCEPT MALIGNANCY.
205............ 07 MED DISORDERS OF LIVER EXCEPT 1.1831 4.7 6.4
MALIG, CIRR, ALC HEPA W
CC.
206............ 07 MED DISORDERS OF LIVER EXCEPT .7257 3.1 4.1
MALIG, CIRR, ALC HEPA W/O
CC.
207............ 07 MED DISORDERS OF THE BILIARY 1.1049 4.0 5.2
TRACT W CC.
208............ 07 MED DISORDERS OF THE BILIARY .6473 2.3 2.9
TRACT W/O CC.
209............ 08 SURG MAJOR JOINT & LIMB 2.1217 4.6 5.2
REATTACHMENT PROCEDURES
OF LOWER EXTREMITY.
210............ 08 SURG HIP & FEMUR PROCEDURES 1.8053 5.9 6.8
EXCEPT MAJOR JOINT AGE
>17 W CC.
211............ 08 SURG HIP & FEMUR PROCEDURES 1.2625 4.5 4.9
EXCEPT MAJOR JOINT AGE
>17 W/O CC.
212............ 08 SURG *HIP & FEMUR PROCEDURES .8468 11.1 11.1
EXCEPT MAJOR JOINT AGE 0-
17.
213............ 08 SURG AMPUTATION FOR 1.7128 6.1 8.3
MUSCULOSKELETAL SYSTEM &
CONN TISSUE DISORDERS.
214............ 08 SURG NO LONGER VALID........... .0000 .0 .0
215............ 08 SURG NO LONGER VALID........... .0000 .0 .0
216............ 08 SURG BIOPSIES OF 2.1374 6.9 9.5
MUSCULOSKELETAL SYSTEM &
CONNECTIVE TISSUE.
217............ 08 SURG WND DEBRID & SKN GRFT 2.7842 8.6 12.6
EXCEPT HAND, FOR
MUSCSKELET & CONN TISS
DIS.
218............ 08 SURG LOWER EXTREM & HUMER PROC 1.4902 4.2 5.3
EXCEPT HIP, FOOT, FEMUR
AGE >17 W CC.
219............ 08 SURG LOWER EXTREM & HUMER PROC 1.0127 2.7 3.2
EXCEPT HIP, FOOT, FEMUR
AGE >17 W/O CC.
220............ 08 SURG *LOWER EXTREM & HUMER PROC .5841 5.3 5.3
EXCEPT HIP, FOOT, FEMUR
AGE 0-17.
221............ 08 SURG NO LONGER VALID........... .0000 .0 .0
222............ 08 SURG NO LONGER VALID........... .0000 .0 .0
223............ 08 SURG MAJOR SHOULDER/ELBOW PROC, .9394 2.0 2.6
OR OTHER UPPER EXTREMITY
PROC W CC.
224............ 08 SURG SHOULDER, ELBOW OR FOREARM .8046 1.7 2.0
PROC, EXC MAJOR JOINT
PROC, W/O CC.
225............ 08 SURG FOOT PROCEDURES........... 1.0528 3.2 4.5
226............ 08 SURG SOFT TISSUE PROCEDURES W 1.4373 4.1 6.0
CC.
227............ 08 SURG SOFT TISSUE PROCEDURES W/O .8175 2.1 2.8
CC.
228............ 08 SURG MAJOR THUMB OR JOINT PROC, 1.0502 2.4 3.6
OR OTH HAND OR WRIST PROC
W CC.
229............ 08 SURG HAND OR WRIST PROC, EXCEPT .7328 1.9 2.4
MAJOR JOINT PROC, W/O CC.
230............ 08 SURG LOCAL EXCISION & REMOVAL 1.1609 3.2 4.7
OF INT FIX DEVICES OF HIP
& FEMUR.
231............ 08 SURG LOCAL EXCISION & REMOVAL 1.3614 3.1 4.6
OF INT FIX DEVICES EXCEPT
HIP & FEMUR.
232............ 08 SURG ARTHROSCOPY............... 1.1675 2.4 4.1
233............ 08 SURG OTHER MUSCULOSKELET SYS & 2.0314 5.3 7.5
CONN TISS O.R. PROC W CC.
234............ 08 SURG OTHER MUSCULOSKELET SYS & 1.2439 2.7 3.4
CONN TISS O.R. PROC W/O
CC.
[[Page 24809]]
235............ 08 MED FRACTURES OF FEMUR........ .7475 3.8 5.1
236............ 08 MED FRACTURES OF HIP & PELVIS. .7167 3.9 5.0
237............ 08 MED SPRAINS, STRAINS, & .5445 2.9 3.6
DISLOCATIONS OF HIP,
PELVIS & THIGH.
238............ 08 MED OSTEOMYELITIS............. 1.2827 6.4 8.4
239............ 08 MED PATHOLOGICAL FRACTURES & .9657 4.9 6.3
MUSCULOSKELETAL & CONN
TISS MALIGNANCY.
240............ 08 MED CONNECTIVE TISSUE 1.2316 5.0 6.7
DISORDERS W CC.
241............ 08 MED CONNECTIVE TISSUE .6066 3.2 4.0
DISORDERS W/O CC.
242............ 08 MED SEPTIC ARTHRITIS.......... 1.0152 5.1 6.6
243............ 08 MED MEDICAL BACK PROBLEMS..... .7170 3.8 4.7
244............ 08 MED BONE DISEASES & SPECIFIC .7014 3.8 4.8
ARTHROPATHIES W CC.
245............ 08 MED BONE DISEASES & SPECIFIC .4801 2.8 3.6
ARTHROPATHIES W/O CC.
246............ 08 MED NON-SPECIFIC ARTHROPATHIES .5573 3.0 3.7
247............ 08 MED SIGNS & SYMPTOMS OF .5564 2.6 3.4
MUSCULOSKELETAL SYSTEM &
CONN TISSUE.
248............ 08 MED TENDONITIS, MYOSITIS & .7566 3.6 4.6
BURSITIS.
249............ 08 MED AFTERCARE, MUSCULOSKELETAL .6508 2.5 3.5
SYSTEM & CONNECTIVE
TISSUE.
250............ 08 MED FX, SPRN, STRN & DISL OF .6705 3.2 4.1
FOREARM, HAND, FOOT AGE
>17 W CC.
251............ 08 MED FX, SPRN, STRN & DISL OF .4615 2.3 2.9
FOREARM, HAND, FOOT AGE
>17 W/O CC.
252............ 08 MED *FX, SPRN, STRN & DISL OF .2537 1.8 1.8
FOREARM, HAND, FOOT AGE 0-
17.
253............ 08 MED FX, SPRN, STRN & DISL OF .7273 3.7 4.8
UPARM, LOWLEG EX FOOT AGE
>17 W CC.
254............ 08 MED FX, SPRN, STRN & DISL OF .4344 2.6 3.2
UPARM, LOWLEG EX FOOT AGE
>17 W/O CC.
255............ 08 MED *FX, SPRN, STRN & DISL OF .2954 2.9 2.9
UPARM, LOWLEG EX FOOT AGE
0-17.
256............ 08 MED OTHER MUSCULOSKELETAL .7645 3.8 5.1
SYSTEM & CONNECTIVE
TISSUE DIAGNOSES.
257............ 09 SURG TOTAL MASTECTOMY FOR .9153 2.3 2.9
MALIGNANCY W CC.
258............ 09 SURG TOTAL MASTECTOMY FOR .7242 1.8 2.1
MALIGNANCY W/O CC.
259............ 09 SURG SUBTOTAL MASTECTOMY FOR .8671 1.9 2.8
MALIGNANCY W CC.
260............ 09 SURG SUBTOTAL MASTECTOMY FOR .6428 1.3 1.5
MALIGNANCY W/O CC.
261............ 09 SURG BREAST PROC FOR NON- .9205 1.7 2.2
MALIGNANCY EXCEPT BIOPSY
& LOCAL EXCISION.
262............ 09 SURG BREAST BIOPSY & LOCAL .8409 2.7 3.9
EXCISION FOR NON-
MALIGNANCY.
263............ 09 SURG SKIN GRAFT &/OR DEBRID FOR 2.0527 8.6 11.8
SKN ULCER OR CELLULITIS W
CC.
264............ 09 SURG SKIN GRAFT &/OR DEBRID FOR 1.1213 5.3 7.1
SKN ULCER OR CELLULITIS W/
O CC.
265............ 09 SURG SKIN GRAFT &/OR DEBRID 1.5630 4.4 7.0
EXCEPT FOR SKIN ULCER OR
CELLULITIS W CC.
266............ 09 SURG SKIN GRAFT &/OR DEBRID .8479 2.4 3.3
EXCEPT FOR SKIN ULCER OR
CELLULITIS W/O CC.
267............ 09 SURG PERIANAL & PILONIDAL .9756 2.9 4.1
PROCEDURES.
268............ 09 SURG SKIN, SUBCUTANEOUS TISSUE 1.1919 2.4 3.8
& BREAST PLASTIC
PROCEDURES.
269............ 09 SURG OTHER SKIN, SUBCUT TISS & 1.6213 5.6 7.9
BREAST PROC W CC.
270............ 09 SURG OTHER SKIN, SUBCUT TISS & .7435 2.2 3.1
BREAST PROC W/O CC.
271............ 09 MED SKIN ULCERS............... .9921 5.6 7.1
272............ 09 MED MAJOR SKIN DISORDERS W CC. .9989 4.8 6.3
273............ 09 MED MAJOR SKIN DISORDERS W/O .6270 3.3 4.4
CC.
274............ 09 MED MALIGNANT BREAST DISORDERS 1.1271 4.7 6.5
W CC.
275............ 09 MED MALIGNANT BREAST DISORDERS .6269 2.5 3.8
W/O CC.
276............ 09 MED NON-MALIGANT BREAST .6538 3.5 4.4
DISORDERS.
277............ 09 MED CELLULITIS AGE >17 W CC... .8323 4.7 5.8
278............ 09 MED CELLULITIS AGE >17 W/O CC. .5628 3.7 4.4
279............ 09 MED CELLULITIS AGE 0-17....... .6722 4.1 5.1
280............ 09 MED TRAUMA TO THE SKIN, SUBCUT .6740 3.3 4.2
TISS & BREAST AGE >17 W
CC.
281............ 09 MED TRAUMA TO THE SKIN, SUBCUT .4577 2.4 3.1
TISS & BREAST AGE >17 W/O
CC.
[[Page 24810]]
282............ 09 MED *TRAUMA TO THE SKIN, .2569 2.2 2.2
SUBCUT TISS & BREAST AGE
0-17.
283............ 09 MED MINOR SKIN DISORDERS W CC. .7141 3.6 4.7
284............ 09 MED MINOR SKIN DISORDERS W/O .4375 2.5 3.2
CC.
285............ 10 SURG AMPUTAT OF LOWER LIMB FOR 2.0096 7.7 10.6
ENDOCRINE, NUTRIT, &
METABOL DISORDERS.
286............ 10 SURG ADRENAL & PITUITARY 2.2196 5.2 6.6
PROCEDURES.
287............ 10 SURG SKIN GRAFTS & WOUND DEBRID 1.8074 7.4 10.4
FOR ENDOC, NUTRIT & METAB
DISORDERS.
288............ 10 SURG O.R. PROCEDURES FOR 2.0819 4.6 5.7
OBESITY.
289............ 10 SURG PARATHYROID PROCEDURES.... .9714 2.0 3.0
290............ 10 SURG THYROID PROCEDURES........ .9187 1.9 2.4
291............ 10 SURG THYROGLOSSAL PROCEDURES... .6730 1.6 2.0
292............ 10 SURG OTHER ENDOCRINE, NUTRIT & 2.4603 7.1 10.4
METAB O.R. PROC W CC.
293............ 10 SURG OTHER ENDOCRINE, NUTRIT & 1.1770 3.5 4.9
METAB O.R. PROC W/O CC.
294............ 10 MED DIABETES AGE >35.......... .7528 3.7 4.8
295............ 10 MED DIABETES AGE 0-35......... .7460 3.0 3.9
296............ 10 MED NUTRITIONAL & MISC .8567 4.0 5.3
METABOLIC DISORDERS AGE
>17 W CC.
297............ 10 MED NUTRITIONAL & MISC .5213 2.8 3.5
METABOLIC DISORDERS AGE
>17 W/O CC.
298............ 10 MED NUTRITIONAL & MISC .4976 2.4 3.5
METABOLIC DISORDERS AGE 0-
17.
299............ 10 MED INBORN ERRORS OF .9448 3.8 5.4
METABOLISM.
300............ 10 MED ENDOCRINE DISORDERS W CC.. 1.0797 4.8 6.2
301............ 10 MED ENDOCRINE DISORDERS W/O CC .5883 2.8 3.6
302............ 11 SURG KIDNEY TRANSPLANT......... 3.5315 8.2 9.7
303............ 11 SURG KIDNEY, URETER & MAJOR 2.5381 7.2 8.7
BLADDER PROCEDURES FOR
NEOPLASM.
304............ 11 SURG KIDNEY, URETER & MAJOR 2.3395 6.5 8.9
BLADDER PROC FOR NON-
NEOPL W CC.
305............ 11 SURG KIDNEY, URETER & MAJOR 1.1790 3.2 3.9
BLADDER PROC FOR NON-
NEOPL W/O CC.
306............ 11 SURG PROSTATECTOMY W CC........ 1.2476 3.7 5.4
307............ 11 SURG PROSTATECTOMY W/O CC...... .6587 2.0 2.4
308............ 11 SURG MINOR BLADDER PROCEDURES W 1.5880 4.1 6.1
CC.
309............ 11 SURG MINOR BLADDER PROCEDURES W/ .9430 2.0 2.5
O CC.
310............ 11 SURG TRANSURETHRAL PROCEDURES W 1.0881 3.0 4.3
CC.
311............ 11 SURG TRANSURETHRAL PROCEDURES W/ .6130 1.6 1.9
O CC.
312............ 11 SURG URETHRAL PROCEDURES, AGE 1.0283 3.1 4.6
>17 W CC.
313............ 11 SURG URETHRAL PROCEDURES, AGE .6653 1.8 2.4
>17 W/O CC.
314............ 11 SURG *URETHRAL PROCEDURES, AGE .4950 2.3 2.3
0-17.
315............ 11 SURG OTHER KIDNEY & URINARY 2.0624 4.5 7.8
TRACT O.R. PROCEDURES.
316............ 11 MED RENAL FAILURE............. 1.3389 4.9 6.7
317............ 11 MED ADMIT FOR RENAL DIALYSIS.. .6906 2.1 3.2
318............ 11 MED KIDNEY & URINARY TRACT 1.1406 4.4 6.0
NEOPLASMS W CC.
319............ 11 MED KIDNEY & URINARY TRACT .6201 2.1 2.9
NEOPLASMS W/O CC.
320............ 11 MED KIDNEY & URINARY TRACT .8664 4.4 5.4
INFECTIONS AGE >17 W CC.
321............ 11 MED KIDNEY & URINARY TRACT .5797 3.3 3.9
INFECTIONS AGE >17 W/O CC.
322............ 11 MED KIDNEY & URINARY TRACT .5653 3.0 3.8
INFECTIONS AGE 0-17.
323............ 11 MED URINARY STONES W CC, &/OR .7851 2.4 3.2
ESW LITHOTRIPSY.
324............ 11 MED URINARY STONES W/O CC..... .4491 1.6 1.9
325............ 11 MED KIDNEY & URINARY TRACT .6292 3.0 3.9
SIGNS & SYMPTOMS AGE >17
W CC.
326............ 11 MED KIDNEY & URINARY TRACT .4193 2.2 2.7
SIGNS & SYMPTOMS AGE >17
W/O CC.
327............ 11 MED *KIDNEY & URINARY TRACT .3541 3.1 3.1
SIGNS & SYMPTOMS AGE 0-17.
328............ 11 MED URETHRAL STRICTURE AGE >17 .7043 2.7 3.7
W CC.
329............ 11 MED URETHRAL STRICTURE AGE >17 .5215 1.7 2.5
W/O CC.
330............ 11 MED *URETHRAL STRICTURE AGE 0- .3189 1.6 1.6
17.
331............ 11 MED OTHER KIDNEY & URINARY 1.0149 4.1 5.5
TRACT DIAGNOSES AGE >17 W
CC.
332............ 11 MED OTHER KIDNEY & URINARY .6079 2.6 3.4
TRACT DIAGNOSES AGE >17 W/
O CC.
333............ 11 MED OTHER KIDNEY & URINARY .7660 3.3 4.4
TRACT DIAGNOSES AGE 0-17.
334............ 12 SURG MAJOR MALE PELVIC 1.5888 4.3 5.0
PROCEDURES W CC.
335............ 12 SURG MAJOR MALE PELVIC 1.1891 3.3 3.5
PROCEDURES W/O CC.
336............ 12 SURG TRANSURETHRAL .8981 2.8 3.6
PROSTATECTOMY W CC.
337............ 12 SURG TRANSURETHRAL .6235 2.0 2.2
PROSTATECTOMY W/O CC.
[[Page 24811]]
338............ 12 SURG TESTES PROCEDURES, FOR 1.1598 3.3 5.1
MALIGNANCY.
339............ 12 SURG TESTES PROCEDURES, NON- 1.0637 2.9 4.5
MALIGNANCY AGE >17.
340............ 12 SURG *TESTES PROCEDURES, NON- .2834 2.4 2.4
MALIGNANCY AGE 0-17.
341............ 12 SURG PENIS PROCEDURES.......... 1.1125 2.1 3.2
342............ 12 SURG CIRCUMCISION AGE >17...... .8606 2.6 3.5
343............ 12 SURG *CIRCUMCISION AGE 0-17.... .1540 1.7 1.7
344............ 12 SURG OTHER MALE REPRODUCTIVE 1.0994 1.6 2.4
SYSTEM O.R. PROCEDURES
FOR MALIGNANCY.
345............ 12 SURG OTHER MALE REPRODUCTIVE .8850 2.5 3.7
SYSTEM O.R. PROC EXCEPT
FOR MALIGNANCY.
346............ 12 MED MALIGNANCY, MALE .9669 4.2 5.7
REPRODUCTIVE SYSTEM, W CC.
347............ 12 MED MALIGNANCY, MALE .5868 2.3 3.1
REPRODUCTIVE SYSTEM, W/O
CC.
348............ 12 MED BENIGN PROSTATIC .6994 3.2 4.2
HYPERTROPHY W CC.
349............ 12 MED BENIGN PROSTATIC .4393 2.0 2.5
HYPERTROPHY W/O CC.
350............ 12 MED INFLAMMATION OF THE MALE .6962 3.6 4.4
REPRODUCTIVE SYSTEM.
351............ 12 MED *STERILIZATION, MALE...... .2363 1.3 1.3
352............ 12 MED OTHER MALE REPRODUCTIVE .6762 2.7 3.9
SYSTEM DIAGNOSES.
353............ 13 SURG PELVIC EVISCERATION, 1.9662 5.4 7.1
RADICAL HYSTERECTOMY &
RADICAL VULVECTOMY.
354............ 13 SURG UTERINE, ADNEXA PROC FOR 1.5142 4.8 5.8
NON-OVARIAN/ADNEXAL MALIG
W CC.
355............ 13 SURG UTERINE, ADNEXA PROC FOR .9471 3.2 3.4
NON-OVARIAN/ADNEXAL MALIG
W/O CC.
356............ 13 SURG FEMALE REPRODUCTIVE SYSTEM .7930 2.2 2.6
RECONSTRUCTIVE PROCEDURES.
357............ 13 SURG UTERINE & ADNEXA PROC FOR 2.3678 7.0 8.7
OVARIAN OR ADNEXAL
MALIGNANCY.
358............ 13 SURG UTERINE & ADNEXA PROC FOR 1.2377 3.7 4.4
NON-MALIGNANCY W CC.
359............ 13 SURG UTERINE & ADNEXA PROC FOR .8724 2.7 2.9
NON-MALIGNANCY W/O CC.
360............ 13 SURG VAGINA, CERVIX & VULVA .8832 2.5 3.0
PROCEDURES.
361............ 13 SURG LAPAROSCOPY & INCISIONAL 1.1850 2.4 3.4
TUBAL INTERRUPTION.
362............ 13 SURG *ENDOSCOPIC TUBAL .3020 1.4 1.4
INTERRUPTION.
363............ 13 SURG D&C, CONIZATION & RADIO- .7775 2.5 3.3
IMPLANT, FOR MALIGNANCY.
364............ 13 SURG D&C, CONIZATION EXCEPT FOR .7605 2.6 3.5
MALIGNANCY.
365............ 13 SURG OTHER FEMALE REPRODUCTIVE 1.8299 4.9 7.1
SYSTEM O.R. PROCEDURES.
366............ 13 MED MALIGNANCY, FEMALE 1.2435 4.7 6.7
REPRODUCTIVE SYSTEM W CC.
367............ 13 MED MALIGNANCY, FEMALE .5558 2.2 3.0
REPRODUCTIVE SYSTEM W/O
CC.
368............ 13 MED INFECTIONS, FEMALE 1.0486 4.8 6.2
REPRODUCTIVE SYSTEM.
369............ 13 MED MENSTRUAL & OTHER FEMALE .5540 2.4 3.2
REPRODUCTIVE SYSTEM
DISORDERS.
370............ 14 SURG CESAREAN SECTION W CC..... 1.1037 4.5 6.0
371............ 14 SURG CESAREAN SECTION W/O CC... .7226 3.3 3.6
372............ 14 MED VAGINAL DELIVERY W .5785 2.6 3.3
COMPLICATING DIAGNOSES.
373............ 14 MED VAGINAL DELIVERY W/O .4018 1.9 2.1
COMPLICATING DIAGNOSES.
374............ 14 SURG VAGINAL DELIVERY W .7118 2.5 3.2
STERILIZATION &/OR D&C.
375............ 14 SURG *VAGINAL DELIVERY W O.R. .6856 4.4 4.4
PROC EXCEPT STERIL &/OR
D&C.
376............ 14 MED POSTPARTUM & POST ABORTION .5246 2.4 3.5
DIAGNOSES W/O O.R.
PROCEDURE.
377............ 14 SURG POSTPARTUM & POST ABORTION 1.3418 3.1 5.4
DIAGNOSES W O.R.
PROCEDURE.
378............ 14 MED ECTOPIC PREGNANCY......... .9321 2.3 2.8
379............ 14 MED THREATENED ABORTION....... .4438 2.1 3.1
380............ 14 MED ABORTION W/O D&C.......... .3447 1.6 1.9
381............ 14 SURG ABORTION W D&C, ASPIRATION .5785 1.7 2.3
CURETTAGE OR HYSTEROTOMY.
382............ 14 MED FALSE LABOR............... .2097 1.2 1.3
383............ 14 MED OTHER ANTEPARTUM DIAGNOSES .5250 2.8 4.0
W MEDICAL COMPLICATIONS.
384............ 14 MED OTHER ANTEPARTUM DIAGNOSES .3457 1.8 2.4
W/O MEDICAL COMPLICATIONS.
385............ 15 ................... *NEONATES, DIED OR 1.3760 1.8 1.8
TRANSFERRED TO ANOTHER
ACUTE CARE FACILITY.
386............ 15 ................... *EXTREME IMMATURITY OR 4.5376 17.9 17.9
RESPIRATORY DISTRESS
SYNDROME, NEONATE.
387............ 15 ................... *PREMATURITY W MAJOR 3.0991 13.3 13.3
PROBLEMS.
388............ 15 ................... *PREMATURITY W/O MAJOR 1.8699 8.6 8.6
PROBLEMS.
[[Page 24812]]
389............ 15 ................... *FULL TERM NEONATE W MAJOR 1.8398 4.7 4.7
PROBLEMS.
390............ 15 ................... *NEONATE W OTHER 1.6011 3.4 3.4
SIGNIFICANT PROBLEMS.
391............ 15 ................... *NORMAL NEWBORN........... .1526 3.1 3.1
392............ 16 SURG SPLENECTOMY AGE >17....... 3.1400 7.2 9.7
393............ 16 SURG *SPLENECTOMY AGE 0-17..... 1.3479 9.1 9.1
394............ 16 SURG OTHER O.R. PROCEDURES OF 1.6743 4.1 6.8
THE BLOOD AND BLOOD
FORMING ORGANS.
395............ 16 MED RED BLOOD CELL DISORDERS .8170 3.3 4.6
AGE >17.
396............ 16 MED RED BLOOD CELL DISORDERS 1.0895 2.1 3.2
AGE 0-17.
397............ 16 MED COAGULATION DISORDERS..... 1.2145 3.9 5.4
398............ 16 MED RETICULOENDOTHELIAL & 1.2525 4.7 6.0
IMMUNITY DISORDERS W CC.
399............ 16 MED RETICULOENDOTHELIAL & .7076 3.0 3.7
IMMUNITY DISORDERS W/O CC.
400............ 17 SURG LYMPHOMA & LEUKEMIA W 2.6450 5.9 9.1
MAJOR O.R. PROCEDURE.
401............ 17 SURG LYMPHOMA & NON-ACUTE 2.6136 7.8 11.0
LEUKEMIA W OTHER O.R.
PROC W CC.
402............ 17 SURG LYMPHOMA & NON-ACUTE 1.0641 2.8 4.2
LEUKEMIA W OTHER O.R.
PROC W/O CC.
403............ 17 MED LYMPHOMA & NON-ACUTE 1.7141 5.7 8.0
LEUKEMIA W CC.
404............ 17 MED LYMPHOMA & NON-ACUTE .8541 3.2 4.3
LEUKEMIA W/O CC.
405............ 17 ................... *ACUTE LEUKEMIA W/O MAJOR 1.9110 4.9 4.9
O.R. PROCEDURE AGE 0-17.
406............ 17 SURG MYELOPROLIF DISORD OR 2.7825 7.5 10.1
POORLY DIFF NEOPL W MAJ
O.R. PROC W CC.
407............ 17 SURG MYELOPROLIF DISORD OR 1.2467 3.4 4.2
POORLY DIFF NEOPL W MAJ
O.R. PROC W/O CC.
408............ 17 SURG MYELOPROLIF DISORD OR 1.9957 4.7 7.8
POORLY DIFF NEOPL W OTHER
O.R. PROC.
409............ 17 MED RADIOTHERAPY.............. 1.0593 4.5 6.1
410............ 17 MED CHEMOTHERAPY W/O ACUTE .8997 2.8 3.6
LEUKEMIA AS SECONDARY
DIAGNOSIS.
411............ 17 MED HISTORY OF MALIGNANCY W/O .4177 1.8 2.3
ENDOSCOPY.
412............ 17 MED HISTORY OF MALIGNANCY W .4028 1.5 2.0
ENDOSCOPY.
413............ 17 MED OTHER MYELOPROLIF DIS OR 1.3970 5.5 7.5
POORLY DIFF NEOPL DIAG W
CC.
414............ 17 MED OTHER MYELOPROLIF DIS OR .7882 3.1 4.2
POORLY DIFF NEOPL DIAG W/
O CC.
415............ 18 SURG O.R. PROCEDURE FOR 3.5467 10.3 14.1
INFECTIOUS & PARASITIC
DISEASES.
416............ 18 MED SEPTICEMIA AGE >17........ 1.5004 5.6 7.3
417............ 18 MED SEPTICEMIA AGE 0-17....... .8818 3.6 4.9
418............ 18 MED POSTOPERATIVE & POST- .9925 4.8 6.1
TRAUMATIC INFECTIONS.
419............ 18 MED FEVER OF UNKNOWN ORIGIN .8892 3.9 4.9
AGE >17 W CC.
420............ 18 MED FEVER OF UNKNOWN ORIGIN .6151 3.0 3.7
AGE >17 W/O CC.
421............ 18 MED VIRAL ILLNESS AGE >17..... .6676 3.1 3.9
422............ 18 MED VIRAL ILLNESS & FEVER OF .4797 2.4 3.0
UNKNOWN ORIGIN AGE 0-17.
423............ 18 MED OTHER INFECTIOUS & 1.6009 5.7 7.7
PARASITIC DISEASES
DIAGNOSES.
424............ 19 SURG O.R. PROCEDURE W PRINCIPAL 2.3807 8.7 14.0
DIAGNOSES OF MENTAL
ILLNESS.
425............ 19 MED ACUTE ADJUSTMENT REACTION .6802 3.0 4.1
& PSYCHOLOGICAL
DYSFUNCTION.
426............ 19 MED DEPRESSIVE NEUROSES....... .5384 3.4 4.7
427............ 19 MED NEUROSES EXCEPT DEPRESSIVE .5750 3.4 5.0
428............ 19 MED DISORDERS OF PERSONALITY & .6910 4.4 6.8
IMPULSE CONTROL.
429............ 19 MED ORGANIC DISTURBANCES & .8447 4.9 6.7
MENTAL RETARDATION.
430............ 19 MED PSYCHOSES................. .7925 6.0 8.4
431............ 19 MED CHILDHOOD MENTAL DISORDERS .7467 4.7 7.0
432............ 19 MED OTHER MENTAL DISORDER .7113 3.3 5.2
DIAGNOSES.
433............ 20 ................... ALCOHOL/DRUG ABUSE OR .2974 2.3 3.1
DEPENDENCE, LEFT AMA.
434............ 20 ................... ALC/DRUG ABUSE OR DEPEND, .7290 3.9 5.2
DETOX OR OTH SYMPT TREAT
W CC.
435............ 20 ................... ALC/DRUG ABUSE OR DEPEND, .4270 3.4 4.4
DETOX OR OTH SYMPT TREAT
W/O CC.
436............ 20 ................... ALC/DRUG DEPENDENCE W .7934 10.7 13.6
REHABILITATION THERAPY.
437............ 20 ................... ALC/DRUG DEPENDENCE, .6899 7.5 9.0
COMBINED REHAB & DETOX
THERAPY.
438............ ....... ................... NO LONGER VALID........... .0000 .0 .0
439............ 21 SURG SKIN GRAFTS FOR INJURIES.. 1.6217 5.0 7.4
440............ 21 SURG WOUND DEBRIDEMENTS FOR 1.9196 5.7 8.9
INJURIES.
[[Page 24813]]
441............ 21 SURG HAND PROCEDURES FOR .9185 2.2 3.1
INJURIES.
442............ 21 SURG OTHER O.R. PROCEDURES FOR 2.2447 5.2 7.9
INJURIES W CC.
443............ 21 SURG OTHER O.R. PROCEDURES FOR .9604 2.5 3.3
INJURIES W/O CC.
444............ 21 MED TRAUMATIC INJURY AGE >17 W .7068 3.3 4.3
CC.
445............ 21 MED TRAUMATIC INJURY AGE >17 W/ .4796 2.4 3.0
O CC.
446............ 21 MED *TRAUMATIC INJURY AGE 0-17 .2962 2.4 2.4
447............ 21 MED ALLERGIC REACTIONS AGE >17 .5218 1.9 2.5
448............ 21 MED *ALLERGIC REACTIONS AGE 0- .0974 2.9 2.9
17.
449............ 21 MED POISONING & TOXIC EFFECTS .8140 2.6 3.7
OF DRUGS AGE >17 W CC.
450............ 21 MED POISONING & TOXIC EFFECTS .4356 1.6 2.0
OF DRUGS AGE >17 W/O CC.
451............ 21 MED *POISONING & TOXIC EFFECTS .2631 2.1 2.1
OF DRUGS AGE 0-17.
452............ 21 MED COMPLICATIONS OF TREATMENT .9922 3.5 4.9
W CC.
453............ 21 MED COMPLICATIONS OF TREATMENT .5065 2.2 2.9
W/O CC.
454............ 21 MED OTHER INJURY, POISONING & .8161 3.2 4.5
TOXIC EFFECT DIAG W CC.
455............ 21 MED OTHER INJURY, POISONING & .4661 1.9 2.6
TOXIC EFFECT DIAG W/O CC.
456............ ....... ................... NO LONGER VALID........... .0000 .0 .0
457............ ....... ................... NO LONGER VALID........... .0000 .0 .0
458............ ....... ................... NO LONGER VALID.......... .0000 .0 .0
459............ ....... ................... NO LONGER VALID........... .0000 .0 .0
460............ ....... ................... NO LONGER VALID........... .0000 .0 .0
461............ 23 SURG O.R. PROC W DIAGNOSES OF 1.1304 2.4 4.5
OTHER CONTACT W HEALTH
SERVICES.
462............ 23 MED REHABILITATION............ 1.3558 9.8 12.4
463............ 23 MED SIGNS & SYMPTOMS W CC..... .6814 3.3 4.3
464............ 23 MED SIGNS & SYMPTOMS W/O CC... .4953 2.5 3.2
465............ 23 MED AFTERCARE W HISTORY OF .6710 2.0 3.6
MALIGNANCY AS SECONDARY
DIAGNOSIS.
466............ 23 MED AFTERCARE W/O HISTORY OF .6995 2.3 3.9
MALIGNANCY AS SECONDARY
DIAGNOSIS.
467............ 23 MED OTHER FACTORS INFLUENCING .5054 2.1 3.3
HEALTH STATUS.
468............ ....... ................... EXTENSIVE O.R. PROCEDURE 3.6495 9.4 13.3
UNRELATED TO PRINCIPAL
DIAGNOSIS.
469............ ....... ................... **PRINCIPAL DIAGNOSIS .0000 .0 .0
INVALID AS DISCHARGE
DIAGNOSIS.
470............ ....... ................... **UNGROUPABLE............. .0000 .0 .0
471............ 08 SURG BILATERAL OR MULTIPLE 3.2312 4.9 5.6
MAJOR JOINT PROCS OF
LOWER EXTREMITY.
472............ ....... ................... NO LONGER VALID........... .0000 .0 .0
473............ 17 ................... ACUTE LEUKEMIA W/O MAJOR 3.7175 7.8 13.4
O.R. PROCEDURE AGE >17.
474............ ....... ................... NO LONGER VALID........... .0000 .0 .0
475............ 04 MED RESPIRATORY SYSTEM 3.7064 8.0 11.2
DIAGNOSIS WITH VENTILATOR
SUPPORT.
476............ ....... SURG PROSTATIC O.R. PROCEDURE 2.2619 8.6 11.7
UNRELATED TO PRINCIPAL
DIAGNOSIS.
477............ ....... SURG NON-EXTENSIVE O.R. 1.7659 5.3 8.0
PROCEDURE UNRELATED TO
PRINCIPAL DIAGNOSIS.
478............ 05 SURG OTHER VASCULAR PROCEDURES 2.3493 5.0 7.3
W CC.
479............ 05 SURG OTHER VASCULAR PROCEDURES 1.4604 2.9 3.8
W/O CC.
480............ ....... SURG LIVER TRANSPLANT.......... 10.7204 17.6 23.1
481............ ....... SURG BONE MARROW TRANSPLANT.... 8.6480 22.2 25.1
482............ ....... SURG TRACHEOSTOMY FOR FACE, 3.6326 9.9 12.9
MOUTH & NECK DIAGNOSES.
483............ ....... SURG TRACHEOSTOMY EXCEPT FOR 15.9802 32.9 40.6
FACE, MOUTH & NECK
DIAGNOSES.
484............ 24 SURG CRANIOTOMY FOR MULTIPLE 5.5399 9.0 13.3
SIGNIFICANT TRAUMA.
485............ 24 SURG LIMB REATTACHMENT, HIP AND 3.0215 7.4 9.1
FEMUR PROC FOR MULTIPLE
SIGNIFICANT TRA.
486............ 24 SURG OTHER O.R. PROCEDURES FOR 4.8710 8.4 12.3
MULTIPLE SIGNIFICANT
TRAUMA.
487............ 24 MED OTHER MULTIPLE SIGNIFICANT 1.9497 5.3 7.4
TRAUMA.
488............ 25 SURG HIV W EXTENSIVE O.R. 4.7592 12.0 18.2
PROCEDURE.
489............ 25 MED HIV W MAJOR RELATED 1.7870 6.1 8.7
CONDITION.
490............ 25 MED HIV W OR W/O OTHER RELATED .9616 3.8 5.3
CONDITION.
491............ 08 SURG MAJOR JOINT & LIMB 1.6696 3.0 3.5
REATTACHMENT PROCEDURES
OF UPPER EXTREMITY.
492............ 17 MED CHEMOTHERAPY W ACUTE 4.4339 11.4 16.8
LEUKEMIA AS SECONDARY
DIAGNOSIS.
493............ 07 SURG LAPAROSCOPIC 1.8341 4.3 5.7
CHOLECYSTECTOMY W/O
C.D.E. W CC.
[[Page 24814]]
494............ 07 SURG LAPAROSCOPIC 1.0276 2.0 2.5
CHOLECYSTECTOMY W/O
C.D.E. W/O CC.
495............ ....... SURG LUNG TRANSPLANT........... 9.1249 13.1 15.9
496............ 08 SURG COMBINED ANTERIOR/ 5.6734 8.4 10.8
POSTERIOR SPINAL FUSION.
497............ 08 SURG SPINAL FUSION W CC........ 2.8425 4.9 6.3
498............ 08 SURG SPINAL FUSION W/O CC...... 1.7943 2.8 3.4
499............ 08 SURG BACK & NECK PROCEDURES 1.4487 3.6 4.8
EXCEPT SPINAL FUSION W CC.
500............ 08 SURG BACK & NECK PROCEDURES .9837 2.3 2.8
EXCEPT SPINAL FUSION W/O
CC.
501............ 08 SURG KNEE PROCEDURES W PDX OF 2.5446 8.0 10.0
INFECTION W CC.
502............ 08 SURG KNEE PROCEDURES W PDX OF 1.5591 5.2 6.3
INFECTION W/O CC.
503............ 08 SURG KNEE PROCEDURES W/O PDX OF 1.2047 3.1 4.0
INFECTION.
504............ 22 SURG EXTENSIVE 3RD DEGREE BURNS 12.8853 23.5 31.1
W SKIN GRAFT.
505............ 22 MED EXTENSIVE 3RD DEGREE BURNS 2.1552 2.6 5.1
W/O SKIN GRAFT.
506............ 22 SURG FULL THICKNESS BURN W SKIN 4.1711 12.5 16.8
GRAFT OR INHAL INJ W CC
OR SIG TRAUMA.
507............ 22 SURG FULL THICKNESS BURN W SKIN 1.8963 6.8 9.5
GRFT OR INHAL INJ W/O CC
OR SIG TRAUMA.
508............ 22 MED FULL THICKNESS BURN W/O 1.5807 5.8 8.6
SKIN GRFT OR INHAL INJ W
CC OR SIG TRAUMA.
509............ 22 MED FULL THICKNESS BURN W/O .8575 3.9 5.4
SKIN GRFT OR INH INJ W/O
CC OR SIG TRAUMA.
510............ 22 MED NON-EXTENSIVE BURNS W CC 1.3433 5.1 7.4
OR SIGNIFICANT TRAUMA.
511............ 22 MED NON-EXTENSIVE BURNS W/O CC .8283 3.5 5.2
OR SIGNIFICANT TRAUMA.
----------------------------------------------------------------------------------------------------------------
* Medicare data have been supplemented by data from 19 states for low volume DRGS.
** DRGS 469 and 470 contain cases which could not be assigned to valid DRGS.
Note: Geometric mean is used only to determine payment for transfer cases.
Note: Arithmetic mean is presented for informational purposes only.
Note: Relative weights are based on medicare patient data and may not be appropriate for other patients.
Table 7A.--Medicare Prospective Payment System, Selected Percentile Lengths of Stay
[FY98 MEDPAR Update 12/98 Grouper V16.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number Arithmetic 10th 25th 50th 75th 90th
DRG discharges mean LOS percentile percentile percentile percentile percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1....................................... 36506 9.2605 2 4 7 12 19
2....................................... 7109 9.8658 3 5 7 12 20
3....................................... 7 10.5714 1 4 12 12 14
4....................................... 6015 7.4519 1 3 5 9 16
5....................................... 98703 3.4164 1 1 2 4 7
6....................................... 377 3.1326 1 1 2 4 7
7....................................... 11683 9.7496 2 4 7 12 19
8....................................... 3373 3.1254 1 1 2 4 7
9....................................... 1698 6.1143 1 3 5 8 12
10...................................... 19098 6.5697 2 3 5 8 13
11...................................... 3155 4.0396 1 2 3 5 8
12...................................... 44239 6.2732 2 3 4 7 12
13...................................... 6486 5.1576 2 3 4 6 9
14...................................... 354618 6.0040 2 3 5 7 11
15...................................... 143996 3.7354 1 2 3 5 7
16...................................... 12049 5.9114 2 3 5 7 11
17...................................... 3303 3.3657 1 2 3 4 6
18...................................... 27014 5.4748 2 3 4 7 10
19...................................... 7911 3.7895 1 2 3 5 7
20...................................... 6115 9.9243 2 5 8 13 19
21...................................... 1409 6.8027 2 3 5 9 13
22...................................... 2567 4.9003 2 2 4 6 9
23...................................... 7637 4.1747 1 2 3 5 8
24...................................... 54321 5.0362 1 2 4 6 10
25...................................... 24173 3.3500 1 2 3 4 6
26...................................... 29 3.5862 1 1 3 4 6
27...................................... 3593 5.2931 1 1 3 7 12
28...................................... 11084 6.0999 1 3 5 8 12
29...................................... 3704 3.6126 1 2 3 5 7
30...................................... 1 13.0000 13 13 13 13 13
31...................................... 3126 4.3349 1 2 3 5 8
[[Page 24815]]
32...................................... 1388 2.6981 1 1 2 3 5
34...................................... 19926 5.3284 1 2 4 6 10
35...................................... 4860 3.4829 1 2 3 4 7
36...................................... 4637 1.4238 1 1 1 1 2
37...................................... 1545 3.8460 1 1 3 5 8
38...................................... 106 2.6415 1 1 2 3 5
39...................................... 1458 1.8759 1 1 1 2 4
40...................................... 1967 3.3421 1 1 2 4 7
42...................................... 3287 2.1150 1 1 1 2 4
43...................................... 84 4.0476 1 2 2 4 7
44...................................... 1346 4.9562 2 3 4 6 9
45...................................... 2489 3.4339 1 2 3 4 6
46...................................... 3035 4.5519 1 2 3 6 9
47...................................... 1196 3.1304 1 1 2 4 6
48...................................... 1 6.0000 6 6 6 6 6
49...................................... 2268 5.0004 1 2 4 6 10
50...................................... 2816 1.9950 1 1 1 2 3
51...................................... 275 2.8873 1 1 1 3 7
52...................................... 242 1.9463 1 1 1 2 3
53...................................... 2676 3.6214 1 1 2 4 8
54...................................... 1 1.0000 1 1 1 1 1
55...................................... 1548 2.8443 1 1 2 3 6
56...................................... 583 2.8405 1 1 2 3 6
57...................................... 496 4.7702 1 1 3 5 12
59...................................... 76 2.5921 1 1 2 3 6
60...................................... 4 1.2500 1 1 1 1 2
61...................................... 236 4.8051 1 1 3 6 10
62...................................... 2 2.5000 2 2 3 3 3
63...................................... 3257 4.4473 1 2 3 5 9
64...................................... 3255 6.6224 1 2 4 8 14
65...................................... 31668 2.9110 1 1 2 4 5
66...................................... 6943 3.2093 1 2 3 4 6
67...................................... 510 3.7118 1 2 3 4 7
68...................................... 13096 4.1846 2 2 3 5 7
69...................................... 4070 3.3174 1 2 3 4 6
70...................................... 38 2.7368 1 2 2 3 5
71...................................... 108 3.4259 1 2 3 4 6
72...................................... 789 3.5349 1 2 3 4 7
73...................................... 6418 4.3408 1 2 3 5 8
74...................................... 1 2.0000 2 2 2 2 2
75...................................... 40117 9.9090 3 5 7 12 19
76...................................... 40189 11.0696 3 5 9 14 21
77...................................... 2189 5.1092 1 2 4 7 10
78...................................... 29868 7.0817 3 5 6 9 12
79...................................... 203034 8.4200 3 4 7 10 16
80...................................... 8367 5.5711 2 3 5 7 10
81...................................... 9 6.1111 1 4 6 7 9
82...................................... 67396 6.9696 2 3 5 9 14
83...................................... 6816 5.4608 2 3 4 7 10
84...................................... 1499 3.2115 1 2 3 4 6
85...................................... 21440 6.5169 2 3 5 8 13
86...................................... 1715 3.7638 1 2 3 5 7
87...................................... 67211 6.2429 1 3 5 8 12
88...................................... 395665 5.2571 2 3 4 7 9
89...................................... 507777 6.1138 2 3 5 8 11
90...................................... 46106 4.3389 2 3 4 5 7
91...................................... 63 3.9683 1 2 3 5 7
92...................................... 14068 6.2258 2 3 5 8 12
93...................................... 1431 4.2851 1 2 4 6 8
94...................................... 12904 6.3868 2 3 5 8 13
95...................................... 1503 3.6334 1 2 3 4 7
96...................................... 63347 4.7647 2 3 4 6 8
97...................................... 28210 3.7386 1 2 3 5 7
98...................................... 18 4.5000 2 2 3 4 5
99...................................... 19288 3.1362 1 1 2 4 6
100..................................... 7679 2.1705 1 1 2 3 4
[[Page 24816]]
101..................................... 19908 4.4001 1 2 3 6 8
102..................................... 4712 2.7177 1 1 2 3 5
103..................................... 526 55.9620 9 15 38 81 125
104..................................... 32469 11.8910 3 6 10 15 22
105..................................... 28435 9.4345 4 6 7 11 17
106..................................... 3874 10.9174 5 7 9 13 18
107..................................... 96633 10.4780 5 7 9 12 17
108..................................... 5213 10.9714 3 6 9 14 21
109..................................... 66066 7.8103 4 5 7 9 13
110..................................... 58950 9.5307 2 5 8 11 18
111..................................... 6548 5.6188 2 4 6 7 8
112..................................... 80275 3.8243 1 1 3 5 8
113..................................... 45999 11.8933 3 5 9 15 23
114..................................... 8660 8.1865 2 4 7 10 16
115..................................... 14332 8.4104 2 4 7 11 16
116..................................... 270327 3.9279 1 1 3 5 8
117..................................... 3493 4.1457 1 1 3 5 9
118..................................... 6394 2.8907 1 1 2 4 6
119..................................... 1547 4.8946 1 1 3 6 11
120..................................... 36472 8.2124 1 2 5 11 18
121..................................... 168411 6.5102 2 4 5 8 12
122..................................... 83057 3.9825 1 2 4 5 7
123..................................... 41857 4.4094 1 1 2 6 10
124..................................... 144199 4.4338 1 2 3 6 8
125..................................... 69258 2.8460 1 1 2 4 6
126..................................... 5245 11.8471 3 6 9 15 23
127..................................... 720949 5.3848 2 3 4 7 10
128..................................... 13882 5.8857 3 4 5 7 9
129..................................... 4476 2.8132 1 1 1 3 7
130..................................... 93152 5.8377 2 3 5 7 10
131..................................... 26175 4.4798 1 3 4 6 7
132..................................... 166567 3.0916 1 2 2 4 6
133..................................... 7046 2.3686 1 1 2 3 4
134..................................... 32604 3.3402 1 2 3 4 6
135..................................... 7501 4.3393 1 2 3 5 8
136..................................... 1134 2.9365 1 1 2 4 6
138..................................... 203034 3.9942 1 2 3 5 8
139..................................... 74491 2.5373 1 1 2 3 5
140..................................... 89482 2.8042 1 1 2 3 5
141..................................... 85001 3.7313 1 2 3 5 7
142..................................... 40519 2.7087 1 1 2 3 5
143..................................... 173003 2.1910 1 1 2 3 4
144..................................... 77203 5.3186 1 2 4 7 11
145..................................... 6725 2.8174 1 1 2 4 5
146..................................... 12161 10.3049 5 7 9 12 17
147..................................... 2295 6.7115 3 5 7 8 10
148..................................... 142496 12.0975 5 7 10 14 21
149..................................... 16260 6.7259 4 5 6 8 10
150..................................... 22047 11.0292 4 6 9 14 19
151..................................... 4378 5.9826 2 3 6 8 11
152..................................... 4733 8.2766 3 5 7 10 14
153..................................... 1785 5.6112 3 4 5 7 8
154..................................... 32146 13.1977 4 7 10 16 25
155..................................... 5559 4.4970 1 2 4 6 8
156..................................... 5 10.6000 2 2 11 13 22
157..................................... 8532 5.5772 1 2 4 7 11
158..................................... 4386 2.6423 1 1 2 3 5
159..................................... 17279 4.9647 1 2 4 6 10
160..................................... 10447 2.7383 1 1 2 4 5
161..................................... 12543 4.1562 1 2 3 5 9
162..................................... 6726 1.9967 1 1 1 2 4
163..................................... 6 3.3333 1 3 3 5 5
164..................................... 5059 8.5274 4 5 7 10 14
165..................................... 1803 4.9434 2 3 5 6 8
166..................................... 3401 5.1541 2 3 4 6 10
167..................................... 2666 2.7817 1 2 2 3 5
[[Page 24817]]
168..................................... 1649 4.6731 1 2 3 6 10
169..................................... 857 2.4982 1 1 2 3 5
170..................................... 12092 11.1993 2 5 8 14 22
171..................................... 1053 4.7673 1 2 4 6 9
172..................................... 31897 6.9143 2 3 5 9 14
173..................................... 2312 3.7855 1 1 3 5 8
174..................................... 249000 4.8426 2 3 4 6 9
175..................................... 25202 2.9397 1 2 3 4 5
176..................................... 17587 5.2799 2 3 4 6 10
177..................................... 10522 4.4893 2 2 4 6 8
178..................................... 3593 3.1795 1 2 3 4 6
179..................................... 12330 6.1658 2 3 5 8 12
180..................................... 90227 5.3446 2 3 4 7 10
181..................................... 24379 3.4107 1 2 3 4 6
182..................................... 234882 4.3349 1 2 3 5 8
183..................................... 76735 2.9911 1 1 2 4 6
184..................................... 89 3.0225 1 1 2 3 7
185..................................... 4222 4.5246 1 2 3 6 9
186..................................... 7 3.2857 1 2 3 4 4
187..................................... 838 3.9224 1 2 3 5 8
188..................................... 75482 5.5481 1 2 4 7 11
189..................................... 9623 3.2219 1 1 2 4 6
190..................................... 66 5.5909 1 2 4 7 9
191..................................... 9649 14.1563 4 7 10 17 28
192..................................... 834 7.0432 2 4 6 9 12
193..................................... 6497 12.6191 5 7 10 15 23
194..................................... 742 6.5660 2 4 6 8 11
195..................................... 5896 9.9910 4 6 8 12 17
196..................................... 1262 5.6830 2 4 5 7 9
197..................................... 22829 8.6119 3 5 7 10 15
198..................................... 6333 4.5173 2 3 4 6 8
199..................................... 1863 9.6334 2 5 7 13 19
200..................................... 1177 11.0110 2 4 8 14 22
201..................................... 1502 14.0752 4 6 11 18 28
202..................................... 27309 6.5861 2 3 5 8 13
203..................................... 29813 6.7010 2 3 5 9 13
204..................................... 54942 5.9723 2 3 5 7 11
205..................................... 23086 6.3271 2 3 5 8 12
206..................................... 1713 4.1004 1 2 3 5 8
207..................................... 32550 5.1222 1 2 4 6 10
208..................................... 9792 2.9086 1 1 2 4 6
209..................................... 353744 5.1342 3 3 4 6 8
210..................................... 133786 6.7558 3 4 6 8 11
211..................................... 29098 4.9011 3 3 4 6 7
212..................................... 8 3.6250 1 2 4 5 5
213..................................... 7866 8.3354 2 4 6 10 17
216..................................... 6023 9.5177 2 4 7 12 19
217..................................... 19595 12.5727 3 5 9 15 26
218..................................... 22521 5.2767 2 3 4 6 9
219..................................... 19288 3.1965 1 2 3 4 5
220..................................... 4 9.2500 1 1 6 12 18
223..................................... 17769 2.5644 1 1 2 3 5
224..................................... 7897 2.0380 1 1 2 3 4
225..................................... 5773 4.4653 1 2 3 6 9
226..................................... 5252 5.9842 1 2 4 8 12
227..................................... 4296 2.7491 1 1 2 3 5
228..................................... 2550 3.5910 1 1 2 4 8
229..................................... 1137 2.4450 1 1 2 3 5
230..................................... 2280 4.7487 1 2 3 6 10
231..................................... 10903 4.6309 1 2 3 6 10
232..................................... 527 4.0892 1 1 2 5 9
233..................................... 4814 7.4909 2 3 5 9 16
234..................................... 2558 3.4461 1 2 3 4 7
235..................................... 5355 5.0045 1 2 4 6 9
236..................................... 39188 4.9057 1 3 4 6 9
237..................................... 1699 3.5621 1 2 3 4 6
[[Page 24818]]
238..................................... 7684 8.2965 3 4 6 10 16
239..................................... 55608 6.2447 2 3 5 8 12
240..................................... 12878 6.6378 2 3 5 8 13
241..................................... 3005 4.0090 1 2 3 5 7
242..................................... 2655 6.5646 2 3 5 8 13
243..................................... 83845 4.7270 1 3 4 6 9
244..................................... 12628 4.8210 1 3 4 6 9
245..................................... 4919 3.5727 1 2 3 4 7
246..................................... 1343 3.7312 1 2 3 5 7
247..................................... 14016 3.4163 1 2 3 4 7
248..................................... 8925 4.6222 1 2 4 6 9
249..................................... 10902 3.5356 1 1 2 4 7
250..................................... 3601 4.1172 1 2 3 5 8
251..................................... 2274 2.9081 1 1 2 4 5
253..................................... 18995 4.7535 1 3 4 6 9
254..................................... 9941 3.2011 1 2 3 4 6
256..................................... 5904 5.0899 1 2 4 6 10
257..................................... 19379 2.9197 1 2 2 3 5
258..................................... 16797 2.0623 1 1 2 2 3
259..................................... 3704 2.7608 1 1 2 3 6
260..................................... 4700 1.4715 1 1 1 2 2
261..................................... 1775 2.1808 1 1 1 3 4
262..................................... 645 3.9271 1 1 3 5 8
263..................................... 25880 11.3104 3 5 8 14 22
264..................................... 3815 7.0029 2 3 5 8 13
265..................................... 4082 6.9581 1 2 4 8 14
266..................................... 2523 3.3436 1 1 2 4 7
267..................................... 240 4.0833 1 1 3 5 9
268..................................... 873 3.7537 1 1 2 4 8
269..................................... 8758 7.8451 2 3 6 10 16
270..................................... 2727 3.0983 1 1 2 4 7
271..................................... 22440 7.0501 3 4 6 8 13
272..................................... 5622 6.2757 2 3 5 7 12
273..................................... 1342 4.3644 1 2 3 5 8
274..................................... 2431 6.4825 1 3 5 8 13
275..................................... 201 3.7612 1 1 2 5 8
276..................................... 989 4.4034 1 2 4 5 8
277..................................... 83986 5.7562 2 3 5 7 10
278..................................... 27530 4.4238 2 3 4 5 8
279..................................... 11 5.0909 1 3 4 5 8
280..................................... 14848 4.2196 1 2 3 5 8
281..................................... 6385 3.0641 1 1 3 4 6
282..................................... 1 3.0000 3 3 3 3 3
283..................................... 5325 4.7213 1 2 4 6 9
284..................................... 1773 3.1985 1 1 3 4 6
285..................................... 5979 10.5514 3 5 8 13 21
286..................................... 2145 6.6112 2 3 5 8 13
287..................................... 5999 10.4182 3 5 7 12 20
288..................................... 1972 5.7221 2 3 4 6 9
289..................................... 4787 3.0171 1 1 2 3 6
290..................................... 8532 2.4319 1 1 2 3 4
291..................................... 76 2.0132 1 1 1 2 3
292..................................... 4798 10.3558 2 4 8 13 21
293..................................... 318 4.9119 1 2 4 6 10
294..................................... 83797 4.7445 1 2 4 6 9
295..................................... 3416 3.8662 1 2 3 5 7
296..................................... 232852 5.2808 2 3 4 6 10
297..................................... 36465 3.5335 1 2 3 4 6
298..................................... 86 3.5116 1 1 2 4 7
299..................................... 1113 5.3998 1 2 4 7 11
300..................................... 16055 6.2361 2 3 5 8 12
301..................................... 2798 3.5647 1 2 3 4 7
302..................................... 7788 9.7017 5 6 7 11 17
303..................................... 19947 8.7442 4 5 7 10 15
304..................................... 12267 8.8996 2 4 7 11 18
305..................................... 2771 3.8964 1 2 3 5 7
[[Page 24819]]
306..................................... 9087 5.4264 1 2 3 7 12
307..................................... 2172 2.3596 1 1 2 3 4
308..................................... 8237 6.1412 1 2 4 8 13
309..................................... 4040 2.5252 1 1 2 3 5
310..................................... 25234 4.3353 1 2 3 5 9
311..................................... 7913 1.9368 1 1 1 2 4
312..................................... 1652 4.5745 1 1 3 6 10
313..................................... 636 2.4009 1 1 2 3 5
314..................................... 1 2.0000 2 2 2 2 2
315..................................... 28095 7.8214 1 2 5 10 17
316..................................... 93946 6.6586 2 3 5 8 13
317..................................... 787 3.1525 1 1 2 3 6
318..................................... 6040 5.9818 1 3 4 8 12
319..................................... 452 2.8496 1 1 2 4 6
320..................................... 182629 5.4053 2 3 4 7 10
321..................................... 26785 3.8728 2 2 3 5 7
322..................................... 66 3.7273 1 2 3 4 6
323..................................... 16620 3.2068 1 1 2 4 6
324..................................... 7588 1.9258 1 1 1 2 4
325..................................... 7746 3.8615 1 2 3 5 7
326..................................... 2359 2.6880 1 1 2 3 5
327..................................... 9 3.4444 1 2 3 6 6
328..................................... 682 3.7097 1 2 3 5 7
329..................................... 107 2.4579 1 1 1 3 5
331..................................... 44791 5.5053 1 3 4 7 11
332..................................... 4640 3.4358 1 1 3 4 7
333..................................... 264 4.4356 1 2 3 5 10
334..................................... 14143 5.0008 3 3 4 6 8
335..................................... 10325 3.5485 2 3 3 4 5
336..................................... 46390 3.6056 1 2 3 4 7
337..................................... 30864 2.2143 1 1 2 3 3
338..................................... 2138 5.1300 1 2 3 7 12
339..................................... 1797 4.5042 1 1 3 6 10
340..................................... 2 1.0000 1 1 1 1 1
341..................................... 4067 3.1913 1 1 2 3 6
342..................................... 874 3.4748 1 2 2 4 7
344..................................... 4100 2.3539 1 1 1 2 5
345..................................... 1230 3.7195 1 1 2 4 8
346..................................... 4931 5.7175 1 3 4 7 11
347..................................... 370 3.1595 1 1 2 4 7
348..................................... 3080 4.1844 1 2 3 5 8
349..................................... 591 2.5296 1 1 2 3 5
350..................................... 6519 4.3806 2 2 4 5 8
352..................................... 692 3.9263 1 1 3 5 7
353..................................... 2693 7.0791 3 4 5 8 13
354..................................... 8980 5.7827 3 3 4 7 10
355..................................... 5919 3.4087 2 3 3 4 5
356..................................... 28210 2.5548 1 2 2 3 4
357..................................... 6046 8.6508 3 5 7 10 16
358..................................... 24803 4.4161 2 3 3 5 7
359..................................... 29406 2.8913 2 2 3 3 4
360..................................... 17303 3.0327 1 2 3 3 5
361..................................... 473 3.3742 1 1 2 4 7
362..................................... 1 1.0000 1 1 1 1 1
363..................................... 3572 3.2900 1 2 2 3 7
364..................................... 1811 3.5400 1 1 2 4 7
365..................................... 2008 7.1116 2 3 5 9 15
366..................................... 4324 6.6751 1 3 5 8 14
367..................................... 466 3.0193 1 1 2 4 6
368..................................... 2756 6.2144 2 3 5 8 12
369..................................... 2740 3.2281 1 1 2 4 6
370..................................... 1120 5.9848 3 3 4 5 9
371..................................... 1192 3.6460 2 3 3 4 5
372..................................... 847 3.2621 1 2 2 3 5
373..................................... 3838 2.1449 1 2 2 2 3
374..................................... 134 3.1716 1 2 2 3 4
[[Page 24820]]
375..................................... 5 4.4000 1 1 5 5 9
376..................................... 199 3.4472 1 1 2 3 7
377..................................... 35 5.4000 1 1 3 5 13
378..................................... 173 2.7746 1 2 2 3 4
379..................................... 350 3.0914 1 1 2 3 6
380..................................... 87 1.8851 1 1 1 2 3
381..................................... 183 2.3005 1 1 1 3 5
382..................................... 54 1.2963 1 1 1 1 2
383..................................... 1486 3.9711 1 2 3 5 8
384..................................... 121 2.4132 1 1 2 3 5
385..................................... 1 2.0000 2 2 2 2 2
389..................................... 6 5.8333 1 5 5 7 7
390..................................... 9 3.3333 1 1 4 4 5
392..................................... 2630 9.6696 3 4 7 12 20
394..................................... 1779 6.8375 1 2 4 8 15
395..................................... 77187 4.5508 1 2 3 6 9
396..................................... 17 3.1765 1 1 2 4 6
397..................................... 19143 5.3427 1 2 4 7 11
398..................................... 18492 5.9583 2 3 5 7 11
399..................................... 1493 3.7173 1 2 3 5 7
400..................................... 7294 9.1058 2 3 6 11 20
401..................................... 6217 11.0227 2 5 8 14 22
402..................................... 1452 4.1887 1 1 3 5 9
403..................................... 36218 8.0041 2 3 6 10 16
404..................................... 4103 4.3359 1 2 3 6 9
406..................................... 2824 10.1331 3 5 8 13 21
407..................................... 667 4.1829 1 2 3 5 7
408..................................... 2404 7.7417 1 2 5 10 18
409..................................... 3746 6.1030 2 3 4 6 12
410..................................... 49872 3.5697 1 2 3 4 6
411..................................... 21 2.2857 1 1 2 3 4
412..................................... 28 2.0000 1 1 1 2 4
413..................................... 7391 7.4619 2 3 6 10 15
414..................................... 687 4.1499 1 2 3 5 9
415..................................... 42535 14.0456 4 6 11 17 28
416..................................... 213568 7.3051 2 4 6 9 14
417..................................... 41 4.7805 1 2 4 6 10
418..................................... 22297 6.0470 2 3 5 7 11
419..................................... 15835 4.9039 2 2 4 6 9
420..................................... 3029 3.6524 1 2 3 5 7
421..................................... 13089 3.9185 1 2 3 5 7
422..................................... 91 2.9890 1 1 2 4 6
423..................................... 9072 7.7017 2 3 6 9 16
424..................................... 1385 14.0072 2 5 10 17 27
425..................................... 15534 4.0610 1 2 3 5 8
426..................................... 4568 4.6421 1 2 3 6 9
427..................................... 1659 4.9458 1 2 3 6 11
428..................................... 855 6.7766 1 2 4 8 14
429..................................... 29447 6.5176 2 3 5 8 13
430..................................... 58875 8.3608 2 3 6 11 17
431..................................... 306 6.9869 1 3 5 8 13
432..................................... 438 5.2283 1 2 3 5 10
433..................................... 6312 3.1039 1 1 2 4 6
434..................................... 21675 5.1476 1 2 4 6 10
435..................................... 14502 4.3431 1 2 4 5 8
436..................................... 3279 13.5166 4 7 12 21 27
437..................................... 11570 8.9775 3 5 8 11 15
439..................................... 1183 7.4480 1 3 5 9 15
440..................................... 5298 8.9332 2 3 6 11 19
441..................................... 562 3.0498 1 1 2 4 7
442..................................... 15691 7.9084 1 3 6 10 16
443..................................... 3343 3.2767 1 1 2 4 7
444..................................... 5016 4.2845 1 2 3 5 8
445..................................... 2198 3.0100 1 1 2 4 6
447..................................... 4686 2.5378 1 1 2 3 5
448..................................... 2 1.5000 1 1 2 2 2
[[Page 24821]]
449..................................... 25965 3.6989 1 1 3 4 7
450..................................... 6281 2.0492 1 1 1 2 4
451..................................... 4 3.7500 1 1 2 4 8
452..................................... 22264 4.9182 1 2 3 6 10
453..................................... 4242 2.8868 1 1 2 4 5
454..................................... 5953 4.4749 1 2 3 5 9
455..................................... 974 2.6078 1 1 2 3 5
461..................................... 3446 4.5133 1 1 2 5 11
462..................................... 10911 12.2067 4 6 10 16 23
463..................................... 16562 4.2876 1 2 3 5 8
464..................................... 4467 3.1842 1 2 3 4 6
465..................................... 202 3.5693 1 1 1 4 7
466..................................... 1753 3.9395 1 1 2 4 8
467..................................... 1206 3.2629 1 1 2 4 6
468..................................... 59861 13.2552 3 6 10 17 26
471..................................... 11866 5.6302 3 3 5 6 9
473..................................... 7998 13.1317 2 3 7 19 33
475..................................... 109305 11.0583 2 5 9 15 22
476..................................... 5166 11.6465 2 6 10 15 21
477..................................... 26937 8.0048 1 3 6 10 17
478..................................... 118559 7.2875 1 3 5 9 15
479..................................... 21234 3.7671 1 2 3 5 7
480..................................... 446 23.0807 7 11 16 28 47
481..................................... 269 25.0632 11 19 23 30 40
482..................................... 6415 12.8803 4 7 10 15 23
483..................................... 42782 38.7045 14 21 32 48 70
484..................................... 392 13.2219 1 6 10 18 27
485..................................... 3148 9.0886 4 5 7 11 17
486..................................... 2027 12.1722 1 5 10 16 24
487..................................... 3604 7.3047 1 3 6 9 15
488..................................... 784 18.0982 3 7 13 23 37
489..................................... 14037 8.7084 2 3 6 11 18
490..................................... 4768 5.2685 1 2 4 7 10
491..................................... 11583 3.5480 2 2 3 4 6
492..................................... 2575 16.8287 4 5 12 27 35
493..................................... 55018 5.7173 1 3 5 7 11
494..................................... 26030 2.5108 1 1 2 3 5
495..................................... 130 15.9154 6 8 13 22 29
496..................................... 1095 10.7826 4 5 8 13 21
497..................................... 23026 6.2674 2 3 5 7 11
498..................................... 16601 3.4126 1 2 3 4 6
499..................................... 33369 4.8049 1 2 4 6 9
500..................................... 40659 2.7628 1 1 2 3 5
501..................................... 1974 10.0172 4 5 8 12 19
502..................................... 544 6.2702 3 4 5 7 11
503..................................... 5860 3.9602 1 2 3 5 7
504..................................... 121 31.1488 9 15 26 40 62
505..................................... 157 5.0446 1 1 2 6 11
506..................................... 1107 16.4625 4 7 13 22 33
507..................................... 410 9.4780 2 4 8 13 20
508..................................... 1102 7.4093 2 3 5 9 14
509..................................... 493 4.9270 1 2 3 6 11
510..................................... 1017 6.9646 2 3 5 8 15
511..................................... 301 4.7176 1 2 3 6 9
----------------
11177104
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 7B.--Medicare Prospective Payment System, Selected Percentile Lengths of Stay
[FY98 MEDPAR Update 12/98 Grouper V17.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number Arithmetic 10th 25th 50th 75th 90th
DRG discharges mean LOS percentile percentile percentile percentile percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1....................................... 36506 9.2605 2 4 7 12 19
2....................................... 7109 9.8658 3 5 7 12 20
[[Page 24822]]
3....................................... 7 10.5714 1 4 12 12 14
4....................................... 6015 7.4519 1 3 5 9 16
5....................................... 98703 3.4164 1 1 2 4 7
6....................................... 377 3.1326 1 1 2 4 7
7....................................... 11683 9.7496 2 4 7 12 19
8....................................... 3373 3.1254 1 1 2 4 7
9....................................... 1698 6.1143 1 3 5 8 12
10...................................... 19098 6.5697 2 3 5 8 13
11...................................... 3155 4.0396 1 2 3 5 8
12...................................... 44239 6.2732 2 3 4 7 12
13...................................... 6486 5.1576 2 3 4 6 9
14...................................... 354510 6.0035 2 3 5 7 11
15...................................... 143996 3.7354 1 2 3 5 7
16...................................... 12049 5.9114 2 3 5 7 11
17...................................... 3303 3.3657 1 2 3 4 6
18...................................... 27014 5.4748 2 3 4 7 10
19...................................... 7911 3.7895 1 2 3 5 7
20...................................... 6115 9.9243 2 5 8 13 19
21...................................... 1409 6.8027 2 3 5 9 13
22...................................... 2567 4.9003 2 2 4 6 9
23...................................... 7637 4.1747 1 2 3 5 8
24...................................... 54321 5.0362 1 2 4 6 10
25...................................... 24173 3.3500 1 2 3 4 6
26...................................... 29 3.5862 1 1 3 4 6
27...................................... 3593 5.2931 1 1 3 7 12
28...................................... 11084 6.0999 1 3 5 8 12
29...................................... 3704 3.6126 1 2 3 5 7
30...................................... 1 13.0000 13 13 13 13 13
31...................................... 3126 4.3349 1 2 3 5 8
32...................................... 1388 2.6981 1 1 2 3 5
34...................................... 19926 5.3284 1 2 4 6 10
35...................................... 4860 3.4829 1 2 3 4 7
36...................................... 4637 1.4238 1 1 1 1 2
37...................................... 1545 3.8460 1 1 3 5 8
38...................................... 106 2.6415 1 1 2 3 5
39...................................... 1458 1.8759 1 1 1 2 4
40...................................... 1967 3.3421 1 1 2 4 7
42...................................... 3287 2.1150 1 1 1 2 4
43...................................... 84 4.0476 1 2 2 4 7
44...................................... 1346 4.9562 2 3 4 6 9
45...................................... 2489 3.4339 1 2 3 4 6
46...................................... 3035 4.5519 1 2 3 6 9
47...................................... 1196 3.1304 1 1 2 4 6
48...................................... 1 6.0000 6 6 6 6 6
49...................................... 2268 5.0004 1 2 4 6 10
50...................................... 2816 1.9950 1 1 1 2 3
51...................................... 275 2.8873 1 1 1 3 7
52...................................... 242 1.9463 1 1 1 2 3
53...................................... 2676 3.6214 1 1 2 4 8
54...................................... 1 1.0000 1 1 1 1 1
55...................................... 1548 2.8443 1 1 2 3 6
56...................................... 583 2.8405 1 1 2 3 6
57...................................... 496 4.7702 1 1 3 5 12
59...................................... 76 2.5921 1 1 2 3 6
60...................................... 4 1.2500 1 1 1 1 2
61...................................... 236 4.8051 1 1 3 6 10
62...................................... 2 2.5000 2 2 3 3 3
63...................................... 3257 4.4473 1 2 3 5 9
64...................................... 3255 6.6224 1 2 4 8 14
65...................................... 31668 2.9110 1 1 2 4 5
66...................................... 6943 3.2093 1 2 3 4 6
67...................................... 510 3.7118 1 2 3 4 7
68...................................... 13096 4.1846 2 2 3 5 7
69...................................... 4070 3.3174 1 2 3 4 6
70...................................... 38 2.7368 1 2 2 3 5
71...................................... 108 3.4259 1 2 3 4 6
[[Page 24823]]
72...................................... 789 3.5349 1 2 3 4 7
73...................................... 6418 4.3408 1 2 3 5 8
74...................................... 1 2.0000 2 2 2 2 2
75...................................... 40117 9.9090 3 5 7 12 19
76...................................... 40189 11.0696 3 5 9 14 21
77...................................... 2189 5.1092 1 2 4 7 10
78...................................... 29868 7.0817 3 5 6 9 12
79...................................... 203034 8.4200 3 4 7 10 16
80...................................... 8367 5.5711 2 3 5 7 10
81...................................... 9 6.1111 1 4 6 7 9
82...................................... 67396 6.9696 2 3 5 9 14
83...................................... 6816 5.4608 2 3 4 7 10
84...................................... 1499 3.2115 1 2 3 4 6
85...................................... 21440 6.5169 2 3 5 8 13
86...................................... 1715 3.7638 1 2 3 5 7
87...................................... 67211 6.2429 1 3 5 8 12
88...................................... 395665 5.2571 2 3 4 7 9
89...................................... 507777 6.1138 2 3 5 8 11
90...................................... 46106 4.3389 2 3 4 5 7
91...................................... 63 3.9683 1 2 3 5 7
92...................................... 14068 6.2258 2 3 5 8 12
93...................................... 1431 4.2851 1 2 4 6 8
94...................................... 12904 6.3868 2 3 5 8 13
95...................................... 1503 3.6334 1 2 3 4 7
96...................................... 63347 4.7647 2 3 4 6 8
97...................................... 28210 3.7386 1 2 3 5 7
98...................................... 18 4.5000 2 2 3 4 5
99...................................... 19288 3.1362 1 1 2 4 6
100..................................... 7679 2.1705 1 1 2 3 4
101..................................... 19908 4.4001 1 2 3 6 8
102..................................... 4712 2.7177 1 1 2 3 5
103..................................... 526 55.9620 9 15 38 81 125
104..................................... 32469 11.8910 3 6 10 15 22
105..................................... 28435 9.4345 4 6 7 11 17
106..................................... 3874 10.9174 5 7 9 13 18
107..................................... 96633 10.4780 5 7 9 12 17
108..................................... 5213 10.9714 3 6 9 14 21
109..................................... 66066 7.8103 4 5 7 9 13
110..................................... 58950 9.5307 2 5 8 11 18
111..................................... 6548 5.6188 2 4 6 7 8
112..................................... 80275 3.8243 1 1 3 5 8
113..................................... 45978 11.8914 3 5 9 15 23
114..................................... 8660 8.1865 2 4 7 10 16
115..................................... 14332 8.4104 2 4 7 11 16
116..................................... 270327 3.9279 1 1 3 5 8
117..................................... 3493 4.1457 1 1 3 5 9
118..................................... 6394 2.8907 1 1 2 4 6
119..................................... 1547 4.8946 1 1 3 6 11
120..................................... 36569 8.2082 1 2 5 11 18
121..................................... 168411 6.5102 2 4 5 8 12
122..................................... 83057 3.9825 1 2 4 5 7
123..................................... 41857 4.4094 1 1 2 6 10
124..................................... 144199 4.4338 1 2 3 6 8
125..................................... 69258 2.8460 1 1 2 4 6
126..................................... 5245 11.8471 3 6 9 15 23
127..................................... 720949 5.3848 2 3 4 7 10
128..................................... 13882 5.8857 3 4 5 7 9
129..................................... 4476 2.8132 1 1 1 3 7
130..................................... 93152 5.8377 2 3 5 7 10
131..................................... 26175 4.4798 1 3 4 6 7
132..................................... 166567 3.0916 1 2 2 4 6
133..................................... 7046 2.3686 1 1 2 3 4
134..................................... 32604 3.3402 1 2 3 4 6
135..................................... 7501 4.3393 1 2 3 5 8
136..................................... 1134 2.9365 1 1 2 4 6
138..................................... 203034 3.9942 1 2 3 5 8
[[Page 24824]]
139..................................... 74491 2.5373 1 1 2 3 5
140..................................... 89482 2.8042 1 1 2 3 5
141..................................... 85001 3.7313 1 2 3 5 7
142..................................... 40519 2.7087 1 1 2 3 5
143..................................... 173003 2.1910 1 1 2 3 4
144..................................... 77203 5.3186 1 2 4 7 11
145..................................... 6725 2.8174 1 1 2 4 5
146..................................... 12161 10.3049 5 7 9 12 17
147..................................... 2295 6.7115 3 5 7 8 10
148..................................... 142496 12.0975 5 7 10 14 21
149..................................... 16260 6.7259 4 5 6 8 10
150..................................... 22047 11.0292 4 6 9 14 19
151..................................... 4378 5.9826 2 3 6 8 11
152..................................... 4733 8.2766 3 5 7 10 14
153..................................... 1785 5.6112 3 4 5 7 8
154..................................... 32146 13.1977 4 7 10 16 25
155..................................... 5559 4.4970 1 2 4 6 8
156..................................... 5 10.6000 2 2 11 13 22
157..................................... 8532 5.5772 1 2 4 7 11
158..................................... 4386 2.6423 1 1 2 3 5
159..................................... 17279 4.9647 1 2 4 6 10
160..................................... 10447 2.7383 1 1 2 4 5
161..................................... 12543 4.1562 1 2 3 5 9
162..................................... 6726 1.9967 1 1 1 2 4
163..................................... 6 3.3333 1 3 3 5 5
164..................................... 5059 8.5274 4 5 7 10 14
165..................................... 1803 4.9434 2 3 5 6 8
166..................................... 3401 5.1541 2 3 4 6 10
167..................................... 2666 2.7817 1 2 2 3 5
168..................................... 1649 4.6731 1 2 3 6 10
169..................................... 857 2.4982 1 1 2 3 5
170..................................... 12092 11.1993 2 5 8 14 22
171..................................... 1053 4.7673 1 2 4 6 9
172..................................... 31897 6.9143 2 3 5 9 14
173..................................... 2312 3.7855 1 1 3 5 8
174..................................... 249000 4.8426 2 3 4 6 9
175..................................... 25202 2.9397 1 2 3 4 5
176..................................... 17587 5.2799 2 3 4 6 10
177..................................... 10522 4.4893 2 2 4 6 8
178..................................... 3593 3.1795 1 2 3 4 6
179..................................... 12330 6.1658 2 3 5 8 12
180..................................... 90227 5.3446 2 3 4 7 10
181..................................... 24379 3.4107 1 2 3 4 6
182..................................... 234882 4.3349 1 2 3 5 8
183..................................... 76735 2.9911 1 1 2 4 6
184..................................... 89 3.0225 1 1 2 3 7
185..................................... 4222 4.5246 1 2 3 6 9
186..................................... 7 3.2857 1 2 3 4 4
187..................................... 838 3.9224 1 2 3 5 8
188..................................... 75482 5.5481 1 2 4 7 11
189..................................... 9623 3.2219 1 1 2 4 6
190..................................... 66 5.5909 1 2 4 7 9
191..................................... 9649 14.1563 4 7 10 17 28
192..................................... 834 7.0432 2 4 6 9 12
193..................................... 6497 12.6191 5 7 10 15 23
194..................................... 742 6.5660 2 4 6 8 11
195..................................... 5896 9.9910 4 6 8 12 17
196..................................... 1262 5.6830 2 4 5 7 9
197..................................... 22829 8.6119 3 5 7 10 15
198..................................... 6333 4.5173 2 3 4 6 8
199..................................... 1863 9.6334 2 5 7 13 19
200..................................... 1177 11.0110 2 4 8 14 22
201..................................... 1502 14.0752 4 6 11 18 28
202..................................... 27309 6.5861 2 3 5 8 13
203..................................... 29813 6.7010 2 3 5 9 13
204..................................... 54942 5.9723 2 3 5 7 11
[[Page 24825]]
205..................................... 23086 6.3271 2 3 5 8 12
206..................................... 1713 4.1004 1 2 3 5 8
207..................................... 32550 5.1222 1 2 4 6 10
208..................................... 9792 2.9086 1 1 2 4 6
209..................................... 353674 5.1341 3 3 4 6 8
210..................................... 133764 6.7556 3 4 6 8 11
211..................................... 29096 4.9012 3 3 4 6 7
212..................................... 8 3.6250 1 2 4 5 5
213..................................... 7866 8.3354 2 4 6 10 17
216..................................... 6023 9.5177 2 4 7 12 19
217..................................... 19595 12.5727 3 5 9 15 26
218..................................... 22521 5.2767 2 3 4 6 9
219..................................... 19288 3.1965 1 2 3 4 5
220..................................... 4 9.2500 1 1 6 12 18
223..................................... 17769 2.5644 1 1 2 3 5
224..................................... 7897 2.0380 1 1 2 3 4
225..................................... 5773 4.4653 1 2 3 6 9
226..................................... 5252 5.9842 1 2 4 8 12
227..................................... 4296 2.7491 1 1 2 3 5
228..................................... 2550 3.5910 1 1 2 4 8
229..................................... 1137 2.4450 1 1 2 3 5
230..................................... 2280 4.7487 1 2 3 6 10
231..................................... 10903 4.6309 1 2 3 6 10
232..................................... 527 4.0892 1 1 2 5 9
233..................................... 4814 7.4909 2 3 5 9 16
234..................................... 2558 3.4461 1 2 3 4 7
235..................................... 5355 5.0045 1 2 4 6 9
236..................................... 39179 4.9058 1 3 4 6 9
237..................................... 1699 3.5621 1 2 3 4 6
238..................................... 7684 8.2965 3 4 6 10 16
239..................................... 55608 6.2447 2 3 5 8 12
240..................................... 12878 6.6378 2 3 5 8 13
241..................................... 3005 4.0090 1 2 3 5 7
242..................................... 2655 6.5646 2 3 5 8 13
243..................................... 83845 4.7270 1 3 4 6 9
244..................................... 12628 4.8210 1 3 4 6 9
245..................................... 4919 3.5727 1 2 3 4 7
246..................................... 1343 3.7312 1 2 3 5 7
247..................................... 14016 3.4163 1 2 3 4 7
248..................................... 8925 4.6222 1 2 4 6 9
249..................................... 10902 3.5356 1 1 2 4 7
250..................................... 3601 4.1172 1 2 3 5 8
251..................................... 2274 2.9081 1 1 2 4 5
253..................................... 18995 4.7535 1 3 4 6 9
254..................................... 9941 3.2011 1 2 3 4 6
256..................................... 5904 5.0899 1 2 4 6 10
257..................................... 19379 2.9197 1 2 2 3 5
258..................................... 16797 2.0623 1 1 2 2 3
259..................................... 3704 2.7608 1 1 2 3 6
260..................................... 4700 1.4715 1 1 1 2 2
261..................................... 1775 2.1808 1 1 1 3 4
262..................................... 645 3.9271 1 1 3 5 8
263..................................... 25866 11.3105 3 5 8 14 22
264..................................... 3810 7.0034 2 3 5 8 13
265..................................... 4082 6.9581 1 2 4 8 14
266..................................... 2523 3.3436 1 1 2 4 7
267..................................... 240 4.0833 1 1 3 5 9
268..................................... 873 3.7537 1 1 2 4 8
269..................................... 8758 7.8451 2 3 6 10 16
270..................................... 2727 3.0983 1 1 2 4 7
271..................................... 22440 7.0501 3 4 6 8 13
272..................................... 5622 6.2757 2 3 5 7 12
273..................................... 1342 4.3644 1 2 3 5 8
274..................................... 2431 6.4825 1 3 5 8 13
275..................................... 201 3.7612 1 1 2 5 8
276..................................... 989 4.4034 1 2 4 5 8
[[Page 24826]]
277..................................... 83986 5.7562 2 3 5 7 10
278..................................... 27530 4.4238 2 3 4 5 8
279..................................... 11 5.0909 1 3 4 5 8
280..................................... 14848 4.2196 1 2 3 5 8
281..................................... 6385 3.0641 1 1 3 4 6
282..................................... 1 3.0000 3 3 3 3 3
283..................................... 5325 4.7213 1 2 4 6 9
284..................................... 1773 3.1985 1 1 3 4 6
285..................................... 5979 10.5514 3 5 8 13 21
286..................................... 2145 6.6112 2 3 5 8 13
287..................................... 5999 10.4182 3 5 7 12 20
288..................................... 1972 5.7221 2 3 4 6 9
289..................................... 4787 3.0171 1 1 2 3 6
290..................................... 8532 2.4319 1 1 2 3 4
291..................................... 76 2.0132 1 1 1 2 3
292..................................... 4798 10.3558 2 4 8 13 21
293..................................... 318 4.9119 1 2 4 6 10
294..................................... 83797 4.7445 1 2 4 6 9
295..................................... 3416 3.8662 1 2 3 5 7
296..................................... 232852 5.2808 2 3 4 6 10
297..................................... 36465 3.5335 1 2 3 4 6
298..................................... 86 3.5116 1 1 2 4 7
299..................................... 1113 5.3998 1 2 4 7 11
300..................................... 16055 6.2361 2 3 5 8 12
301..................................... 2798 3.5647 1 2 3 4 7
302..................................... 7788 9.7017 5 6 7 11 17
303..................................... 19947 8.7442 4 5 7 10 15
304..................................... 12267 8.8996 2 4 7 11 18
305..................................... 2771 3.8964 1 2 3 5 7
306..................................... 9087 5.4264 1 2 3 7 12
307..................................... 2172 2.3596 1 1 2 3 4
308..................................... 8237 6.1412 1 2 4 8 13
309..................................... 4040 2.5252 1 1 2 3 5
310..................................... 25234 4.3353 1 2 3 5 9
311..................................... 7913 1.9368 1 1 1 2 4
312..................................... 1652 4.5745 1 1 3 6 10
313..................................... 636 2.4009 1 1 2 3 5
314..................................... 1 2.0000 2 2 2 2 2
315..................................... 28095 7.8214 1 2 5 10 17
316..................................... 93946 6.6586 2 3 5 8 13
317..................................... 787 3.1525 1 1 2 3 6
318..................................... 6040 5.9818 1 3 4 8 12
319..................................... 452 2.8496 1 1 2 4 6
320..................................... 182629 5.4053 2 3 4 7 10
321..................................... 26785 3.8728 2 2 3 5 7
322..................................... 66 3.7273 1 2 3 4 6
323..................................... 16620 3.2068 1 1 2 4 6
324..................................... 7588 1.9258 1 1 1 2 4
325..................................... 7746 3.8615 1 2 3 5 7
326..................................... 2359 2.6880 1 1 2 3 5
327..................................... 9 3.4444 1 2 3 6 6
328..................................... 682 3.7097 1 2 3 5 7
329..................................... 107 2.4579 1 1 1 3 5
331..................................... 44791 5.5053 1 3 4 7 11
332..................................... 4640 3.4358 1 1 3 4 7
333..................................... 264 4.4356 1 2 3 5 10
334..................................... 14143 5.0008 3 3 4 6 8
335..................................... 10325 3.5485 2 3 3 4 5
336..................................... 46390 3.6056 1 2 3 4 7
337..................................... 30864 2.2143 1 1 2 3 3
338..................................... 2138 5.1300 1 2 3 7 12
339..................................... 1797 4.5042 1 1 3 6 10
340..................................... 2 1.0000 1 1 1 1 1
341..................................... 4067 3.1913 1 1 2 3 6
342..................................... 874 3.4748 1 2 2 4 7
344..................................... 4100 2.3539 1 1 1 2 5
[[Page 24827]]
345..................................... 1230 3.7195 1 1 2 4 8
346..................................... 4931 5.7175 1 3 4 7 11
347..................................... 370 3.1595 1 1 2 4 7
348..................................... 3080 4.1844 1 2 3 5 8
349..................................... 591 2.5296 1 1 2 3 5
350..................................... 6519 4.3806 2 2 4 5 8
352..................................... 692 3.9263 1 1 3 5 7
353..................................... 2693 7.0791 3 4 5 8 13
354..................................... 8980 5.7827 3 3 4 7 10
355..................................... 5919 3.4087 2 3 3 4 5
356..................................... 28210 2.5548 1 2 2 3 4
357..................................... 6046 8.6508 3 5 7 10 16
358..................................... 24803 4.4161 2 3 3 5 7
359..................................... 29406 2.8913 2 2 3 3 4
360..................................... 17303 3.0327 1 2 3 3 5
361..................................... 473 3.3742 1 1 2 4 7
362..................................... 1 1.0000 1 1 1 1 1
363..................................... 3572 3.2900 1 2 2 3 7
364..................................... 1811 3.5400 1 1 2 4 7
365..................................... 2008 7.1116 2 3 5 9 15
366..................................... 4324 6.6751 1 3 5 8 14
367..................................... 466 3.0193 1 1 2 4 6
368..................................... 2756 6.2144 2 3 5 8 12
369..................................... 2740 3.2281 1 1 2 4 6
370..................................... 1120 5.9848 3 3 4 5 9
371..................................... 1192 3.6460 2 3 3 4 5
372..................................... 847 3.2621 1 2 2 3 5
373..................................... 3838 2.1449 1 2 2 2 3
374..................................... 134 3.1716 1 2 2 3 4
375..................................... 5 4.4000 1 1 5 5 9
376..................................... 199 3.4472 1 1 2 3 7
377..................................... 35 5.4000 1 1 3 5 13
378..................................... 173 2.7746 1 2 2 3 4
379..................................... 350 3.0914 1 1 2 3 6
380..................................... 87 1.8851 1 1 1 2 3
381..................................... 183 2.3005 1 1 1 3 5
382..................................... 54 1.2963 1 1 1 1 2
383..................................... 1486 3.9711 1 2 3 5 8
384..................................... 121 2.4132 1 1 2 3 5
385..................................... 1 2.0000 2 2 2 2 2
389..................................... 6 5.8333 1 5 5 7 7
390..................................... 9 3.3333 1 1 4 4 5
392..................................... 2630 9.6696 3 4 7 12 20
394..................................... 1779 6.8375 1 2 4 8 15
395..................................... 77187 4.5508 1 2 3 6 9
396..................................... 17 3.1765 1 1 2 4 6
397..................................... 19143 5.3427 1 2 4 7 11
398..................................... 18492 5.9583 2 3 5 7 11
399..................................... 1493 3.7173 1 2 3 5 7
400..................................... 7294 9.1058 2 3 6 11 20
401..................................... 6217 11.0227 2 5 8 14 22
402..................................... 1452 4.1887 1 1 3 5 9
403..................................... 36218 8.0041 2 3 6 10 16
404..................................... 4103 4.3359 1 2 3 6 9
406..................................... 2824 10.1331 3 5 8 13 21
407..................................... 667 4.1829 1 2 3 5 7
408..................................... 2404 7.7417 1 2 5 10 18
409..................................... 3746 6.1030 2 3 4 6 12
410..................................... 49872 3.5697 1 2 3 4 6
411..................................... 21 2.2857 1 1 2 3 4
412..................................... 28 2.0000 1 1 1 2 4
413..................................... 7391 7.4619 2 3 6 10 15
414..................................... 687 4.1499 1 2 3 5 9
415..................................... 42535 14.0456 4 6 11 17 28
416..................................... 213568 7.3051 2 4 6 9 14
417..................................... 41 4.7805 1 2 4 6 10
[[Page 24828]]
418..................................... 22297 6.0470 2 3 5 7 11
419..................................... 15835 4.9039 2 2 4 6 9
420..................................... 3029 3.6524 1 2 3 5 7
421..................................... 13089 3.9185 1 2 3 5 7
422..................................... 91 2.9890 1 1 2 4 6
423..................................... 9072 7.7017 2 3 6 9 16
424..................................... 1385 14.0072 2 5 10 17 27
425..................................... 15534 4.0610 1 2 3 5 8
426..................................... 4568 4.6421 1 2 3 6 9
427..................................... 1659 4.9458 1 2 3 6 11
428..................................... 855 6.7766 1 2 4 8 14
429..................................... 29435 6.5167 2 3 5 8 13
430..................................... 58875 8.3608 2 3 6 11 17
431..................................... 306 6.9869 1 3 5 8 13
432..................................... 438 5.2283 1 2 3 5 10
433..................................... 6312 3.1039 1 1 2 4 6
434..................................... 21675 5.1476 1 2 4 6 10
435..................................... 14502 4.3431 1 2 4 5 8
436..................................... 3279 13.5166 4 7 12 21 27
437..................................... 11570 8.9775 3 5 8 11 15
439..................................... 1183 7.4480 1 3 5 9 15
440..................................... 5298 8.9332 2 3 6 11 19
441..................................... 562 3.0498 1 1 2 4 7
442..................................... 15691 7.9084 1 3 6 10 16
443..................................... 3343 3.2767 1 1 2 4 7
444..................................... 5016 4.2845 1 2 3 5 8
445..................................... 2198 3.0100 1 1 2 4 6
447..................................... 4686 2.5378 1 1 2 3 5
448..................................... 2 1.5000 1 1 2 2 2
449..................................... 25965 3.6989 1 1 3 4 7
450..................................... 6281 2.0492 1 1 1 2 4
451..................................... 4 3.7500 1 1 2 4 8
452..................................... 22264 4.9182 1 2 3 6 10
453..................................... 4242 2.8868 1 1 2 4 5
454..................................... 5953 4.4749 1 2 3 5 9
455..................................... 974 2.6078 1 1 2 3 5
461..................................... 3446 4.5133 1 1 2 5 11
462..................................... 10911 12.2067 4 6 10 16 23
463..................................... 16562 4.2876 1 2 3 5 8
464..................................... 4467 3.1842 1 2 3 4 6
465..................................... 202 3.5693 1 1 1 4 7
466..................................... 1753 3.9395 1 1 2 4 8
467..................................... 1206 3.2629 1 1 2 4 6
468..................................... 59764 13.2659 3 6 10 17 26
471..................................... 11866 5.6302 3 3 5 6 9
473..................................... 7998 13.1317 2 3 7 19 33
475..................................... 109305 11.0583 2 5 9 15 22
476..................................... 5166 11.6465 2 6 10 15 21
477..................................... 26937 8.0048 1 3 6 10 17
478..................................... 118559 7.2875 1 3 5 9 15
479..................................... 21234 3.7671 1 2 3 5 7
480..................................... 446 23.0807 7 11 16 28 47
481..................................... 269 25.0632 11 19 23 30 40
482..................................... 6415 12.8803 4 7 10 15 23
483..................................... 42777 38.7018 14 21 32 48 70
484..................................... 392 13.2219 1 6 10 18 27
485..................................... 3148 9.0886 4 5 7 11 17
486..................................... 2027 12.1722 1 5 10 16 24
487..................................... 3604 7.3047 1 3 6 9 15
488..................................... 784 18.0982 3 7 13 23 37
489..................................... 14037 8.7084 2 3 6 11 18
490..................................... 4768 5.2685 1 2 4 7 10
491..................................... 11583 3.5480 2 2 3 4 6
492..................................... 2575 16.8287 4 5 12 27 35
493..................................... 55018 5.7173 1 3 5 7 11
494..................................... 26030 2.5108 1 1 2 3 5
[[Page 24829]]
495..................................... 130 15.9154 6 8 13 22 29
496..................................... 1095 10.7826 4 5 8 13 21
497..................................... 23026 6.2674 2 3 5 7 11
498..................................... 16601 3.4126 1 2 3 4 6
499..................................... 33369 4.8049 1 2 4 6 9
500..................................... 40659 2.7628 1 1 2 3 5
501..................................... 1974 10.0172 4 5 8 12 19
502..................................... 544 6.2702 3 4 5 7 11
503..................................... 5860 3.9602 1 2 3 5 7
504..................................... 121 31.1488 9 15 26 40 62
505..................................... 157 5.0446 1 1 2 6 11
506..................................... 966 16.7598 4 8 13 22 33
507..................................... 349 9.4413 2 4 8 13 19
508..................................... 599 8.5192 2 3 6 9 17
509..................................... 210 5.3000 1 2 4 7 10
510..................................... 1661 7.3323 2 3 5 9 16
511..................................... 645 5.1581 1 2 3 6 11
----------------
11176836
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 8A.--Statewide Average Operating Cost-to-Charge Ratios for Urban
and Rural Hospitals (Case Weighted) March 1999
------------------------------------------------------------------------
State Urban Rural
------------------------------------------------------------------------
ALABAMA............................................. 0.373 0.377
ALASKA.............................................. 0.507 0.732
ARIZONA............................................. 0.368 0.536
ARKANSAS............................................ 0.478 0.452
CALFORNIA........................................... 0.369 0.472
COLORADO............................................ 0.449 0.559
CONNECTICUT......................................... 0.500 0.505
DELAWARE............................................ 0.495 0.453
DISTRICT OF COLUMBIA................................ 0.519 ........
FLORIDA............................................. 0.378 0.387
GEORGIA............................................. 0.486 0.487
HAWAII.............................................. 0.492 0.556
IDAHO............................................... 0.548 0.576
ILLINOIS............................................ 0.443 0.543
INDIANA............................................. 0.559 0.596
IOWA................................................ 0.506 0.629
KANSAS.............................................. 0.420 0.627
KENTUCKY............................................ 0.491 0.515
LOUISIANA........................................... 0.430 0.495
MAINE............................................... 0.615 0.570
MARYLAND............................................ 0.764 0.821
MASSACHUSETTS....................................... 0.528 0.559
MICHIGAN............................................ 0.469 0.580
MINNESOTA........................................... 0.518 0.591
MISSISSIPPI......................................... 0.472 0.488
MISSOURI............................................ 0.423 0.506
MONTANA............................................. 0.501 0.559
NEBRASKA............................................ 0.488 0.626
NEVADA.............................................. 0.296 0.474
NEW HAMPSHIRE....................................... 0.575 0.595
NEW JERSEY.......................................... 0.412 ........
NEW MEXICO.......................................... 0.477 0.510
NEW YORK............................................ 0.545 0.620
NORTH CAROLINA...................................... 0.536 0.506
NORTH DAKOTA........................................ 0.616 0.662
OHIO................................................ 0.521 0.565
OKLAHOMA............................................ 0.438 0.531
OREGON.............................................. 0.545 0.593
PENNSYLVANIA........................................ 0.407 0.531
PUERTO RICO......................................... 0.488 0.589
RHODE ISLAND........................................ 0.590 ........
SOUTH CAROLINA...................................... 0.453 0.455
SOUTH DAKOTA........................................ 0.536 0.617
TENNESSEE........................................... 0.465 0.495
TEXAS............................................... 0.415 0.517
UTAH................................................ 0.529 0.654
VERMONT............................................. 0.644 0.603
VIRGINA............................................. 0.473 0.494
WASHINGTON.......................................... 0.590 0.660
WEST VIRGINIA....................................... 0.592 0.574
WISCONSIN........................................... 0.562 0.634
WYOMING............................................. 0.475 0.677
------------------------------------------------------------------------
Table 8B.--Statewide Average Capital Cost-to-Charge Ratios (Case
Weighted) March 1999
------------------------------------------------------------------------
State Ratio
------------------------------------------------------------------------
ALABAMA....................................................... 0.047
ALASKA........................................................ 0.066
ARIZONA....................................................... 0.042
ARKANSAS...................................................... 0.051
CALIFORNIA.................................................... 0.039
COLORADO...................................................... 0.050
CONNECTICUT................................................... 0.039
DELAWARE...................................................... 0.054
DISTRICT OF COLUMBIA.......................................... 0.039
FLORIDA....................................................... 0.046
GEORGIA....................................................... 0.056
HAWAII........................................................ 0.046
IDAHO......................................................... 0.060
ILLINOIS...................................................... 0.043
INDIANA....................................................... 0.059
IOWA.......................................................... 0.054
KANSAS........................................................ 0.049
KENTUCKY...................................................... 0.051
LOUISIANA..................................................... 0.053
MAINE......................................................... 0.040
MARYLAND...................................................... 0.013
MASSACHUSETTS................................................. 0.056
MICHIGAN...................................................... 0.045
MINNESOTA..................................................... 0.049
MISSISSIPPI................................................... 0.048
MISSOURI...................................................... 0.048
MONTANA....................................................... 0.051
NEBRASKA...................................................... 0.057
NEVADA........................................................ 0.031
NEW HAMPSHIRE................................................. 0.066
NEW JERSEY.................................................... 0.037
NEW MEXICO.................................................... 0.045
NEW YORK...................................................... 0.052
NORTH CAROLINA................................................ 0.050
NORTH DAKOTA.................................................. 0.075
OHIO.......................................................... 0.052
OKLAHOMA...................................................... 0.052
OREGON........................................................ 0.050
PENNSYLVANIA.................................................. 0.042
PUERTO RICO................................................... 0.049
RHODE ISLAND.................................................. 0.035
SOUTH CAROLINA................................................ 0.047
SOUTH DAKOTA.................................................. 0.060
TENNESSEE..................................................... 0.055
TEXAS......................................................... 0.051
UTAH.......................................................... 0.054
VERMONT....................................................... 0.051
VIRGINIA...................................................... 0.060
WASHINGTON.................................................... 0.066
WEST VIRGINIA................................................. 0.056
WISCONSIN..................................................... 0.056
[[Page 24830]]
WYOMING....................................................... 0.054
------------------------------------------------------------------------
Appendix A: Regulatory Impact Analysis
I. Introduction
We generally prepare a regulatory flexibility analysis that is
consistent with the Regulatory Flexibility Act (RFA) (5 U.S.C. 601
through 612), unless we certify that a 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 Act requires us 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 (Pub. L. 98-21) designated hospitals in certain
New England counties as belonging to the adjacent NECMA. Thus, for
purposes of the hospital inpatient prospective payment system, we
classify these hospitals as urban hospitals.
It is clear that the changes being 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.
In accordance with the provisions of Executive Order 12866, this
proposed rule was reviewed by the Office of Management and Budget.
II. Objectives
The primary objective of the hospital inpatient 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 preserving the Medicare Trust Fund.
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 reasonable and
equitable while avoiding or minimizing unintended adverse
consequences.
III. Limitations of Our Analysis
As has been the case in our previously published regulatory
impact analyses, the following quantitative analysis presents the
projected effects of our proposed policy changes, as well as
statutory changes effective for FY 2000, on various hospital groups.
We estimate the effects of individual policy changes by estimating
payments per case while holding all other payment policies constant.
We use the best data available, but we do not attempt to predict
behavioral responses to our policy changes, and we do not make
adjustments for future changes in such variables as admissions,
lengths of stay, or case mix. 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 45 Indian Health Service hospitals in our database, which we
excluded from the analysis due to the special characteristics of the
prospective payment method for these hospitals. Among other short-
term, acute care hospitals, only the 50 such hospitals in Maryland
remain excluded from the prospective payment system under the waiver
at section 1814(b)(3) of the Act. Thus, as of February 1999, we have
included 4,874 hospitals in our analysis. This represents about 82
percent of all Medicare-participating hospitals. The majority of
this impact analysis focuses on this set of hospitals.
The remaining 18 percent are specialty hospitals that are
excluded from the prospective payment system and continue to be paid
on the basis of their reasonable costs (subject to a rate-of-
increase ceiling on their inpatient operating costs per discharge).
These hospitals include psychiatric, rehabilitation, long-term care,
children's, and cancer hospitals. The impacts of our final policy
changes on these hospitals are discussed below.
V. Impact on Excluded Hospitals and Units
As of February 1999, there were 1,085 specialty hospitals
excluded from the prospective payment system and instead paid on a
reasonable cost basis subject to the rate-of-increase ceiling under
Sec. 413.40. Broken down by speciality, there were 587 psychiatric,
191 rehabilitation, 208 long-term care, 70 childrens', 19 Christian
Science Sanatoria, and 10 cancer hospitals. In addition, there were
1,494 psychiatric and 901 rehabilitation units in hospitals
otherwise subject to the prospective payment system. These excluded
units are also paid in accordance with Sec. 413.40. Under
Sec. 413.40(a)(2)(i)(A), the target rate-of-increase ceiling is not
applicable to the 36 specialty hospitals and units in Maryland that
are paid in accordance with the waiver at section 1814(b)(3) of the
Act.
As required by section 1886(b)(3)(B) of the Act, the update
factor applicable to the rate-of-increase limit for excluded
hospitals and units for FY 2000 would be between 0 and 2.6 percent,
depending on the hospital's or unit's costs in relation to its limit
for the most recent cost reporting period for which information is
available.
The impact on excluded hospitals and units of the update in the
rate-of-increase limit depends on the cumulative cost increases
experienced by each excluded hospital or unit since its applicable
base period. For excluded hospitals and units that have maintained
their cost increases at a level below the percentage increases in
the rate-of-increase limits since their base period, the major
effect will be on the level of incentive payments these hospitals
and units receive. Conversely, for excluded hospitals and units with
per-case cost increases above the cumulative update in their rate-
of-increase limits, the major effect will be the amount of excess
costs that would not be reimbursed.
We note that, under Sec. 413.40(d)(3), an excluded hospital or
unit whose costs exceed 110 percent of its rate-of-increase limit
receives its rate-of-increase limit plus 50 percent of the
difference between its reasonable costs and 110 percent of the
limit, not to exceed 110 percent of its limit. In addition, under
the various provisions set forth in Sec. 413.40, certain excluded
hospitals and units can obtain payment adjustments for justifiable
increases in operating costs that exceed the limit. At the same
time, however, by generally limiting payment increases, we continue
to provide an incentive for excluded hospitals and units to restrain
the growth in their spending for patient services.
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 estimate the total impact of
these changes for FY 2000 payments compared to FY 1999 payments to
be approximately a $250 million reduction. We have prepared separate
impact analyses of the proposed changes to each system. This section
deals with changes to the operating prospective payment system.
The data used in developing the quantitative analyses presented
below are taken from the FY 1998 MedPAR file and the most current
provider-specific file that is used for payment purposes. Although
the analyses of the changes to the operating prospective payment
system do not
[[Page 24831]]
incorporate cost data, the most recently available hospital cost
report data were used to categorize hospitals. Our analysis has
several qualifications. First, we do not make adjustments for
behavioral changes that hospitals may adopt in response to these
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 1998 MedPAR file, we simulated payments
under the operating prospective payment system given various
combinations of payment parameters. Any short-term, acute care
hospitals not paid under the general prospective payment systems
(Indian Health Service hospitals and hospitals in Maryland) are
excluded from the simulations. Payments under the capital
prospective payment system, or payments for costs other than
inpatient operating costs, are not analyzed here. Estimated payment
impacts of proposed FY 2000 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 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 1996 data).
The effects of fully removing from the wage index the
costs and hours associated with teaching physicians Part A,
residents, and CRNAs; and the effects of our proposal to implement
the first year of a 5-year phase-out of these costs, by calculating
a wage index based on 20 percent of hospitals' average hourly wages
after removing the costs and hours associated with teaching
physicians, residents, and CRNAs, and 80 percent of hospitals'
average hourly wages with these costs included.
The effects of geographic reclassifications by the
MGCRB that will be effective in FY 2000.
The total change in payments based on FY 2000 policies
relative to payments based on FY 1999 policies.
To illustrate the impacts of the FY 2000 proposed changes, our
analysis begins with a FY 2000 baseline simulation model using: the
FY 1999 GROUPER (version 16.0); the FY 1999 wage index; and no MGCRB
reclassifications. Outlier payments are set at 5.1 percent of total
DRG plus outlier payments.
Each proposed and statutory policy change is then added
incrementally to this baseline model, finally arriving at an FY 2000
model incorporating all of the changes. This allows us to isolate
the effects of each change.
Our final comparison illustrates the percent change in payments
per case from FY 1999 to FY 2000. Four factors have significant
impacts here. The first is the update to the standardized amounts.
In accordance with section 1886(d)(3)(A)(iv) of the Act, we are
proposing to update the large urban and the other areas average
standardized amounts for FY 2000 using the most recently forecasted
hospital market basket increase for FY 2000 of 2.7 percent minus 1.8
percentage points. Similarly, section 1886(b)(3)(C)(ii) of the Act
provides that the update factor applicable to the hospital-specific
rates for sole community hospitals (SCHs), essential access
community hospitals (EACHs) (which are treated as SCHs for payment
purposes), and Medicare-dependent, small rural hospitals (MDHs) is
equal to the market basket increase of 2.7 percent minus 1.8
percentage points (for an update of 0.9 percent).
A second significant factor that impacts changes in hospitals'
payments per case from FY 1999 to FY 2000 is a change in MGCRB
reclassification status from one year to the next. That is,
hospitals reclassified in FY 1999 that are no longer reclassified in
FY 2000 may have a negative payment impact going from FY 1999 to FY
2000; conversely, hospitals not reclassified in FY 1999 that are
reclassified in FY 2000 may have a positive impact. In some cases,
these impacts can be quite substantial, so if a relatively small
number of hospitals in a particular category lose their
reclassification status, the percentage increase in payments for the
category may be below the national mean.
A third significant factor is that we currently estimate that
actual outlier payments during FY 1999 will be 6.2 percent of actual
total DRG payments. When the FY 1999 final rule was published, we
projected FY 1999 outlier payments would be 5.1 percent of total DRG
plus outlier payments, and the standardized amounts were reduced
correspondingly. The effects of the higher than expected outlier
payments during FY 1999 (as discussed in the Addendum to this
proposed rule) are reflected in the analyses below comparing our
current estimates of FY 1999 payments per case to estimated FY 2000
payments per case.
Fourth, payments per case in FY 1999 are reduced from FY 1999
for hospitals that receive the IME or the DSH adjustments. Section
1886(d)(5)(B)(ii) of the Act provides that the IME adjustment is
reduced from approximately a 6.5 percent increase for every 10
percent increase in a hospital's resident-to-bed ratio in FY 1999,
to a 6.0 percent increase in FY 2000. Similarly, in accordance with
section 1886(d)(5)(F)(ix) of the Act, the DSH adjustment for FY 2000
is reduced by 3 percent from what would otherwise have been paid,
compared to a 2 percent reduction for FY 1999.
Table I demonstrates the results of our analysis. The table
categorizes hospitals by various geographic and special payment
consideration groups to illustrate the varying impacts on different
types of hospitals. The top row of the table shows the overall
impact on the 4,874 hospitals included in the analysis. This is 100
fewer hospitals than were included in the impact analysis in the FY
1999 final rule with comment period (63 FR 41106).
The next four rows of Table I contain hospitals categorized
according to their geographic location (all urban, which is further
divided into large urban and other urban, or rural). There are 2,712
hospitals located in urban areas (MSAs or NECMAs) included in our
analysis. Among these, there are 1,553 hospitals located in large
urban areas (populations over 1 million), and 1,160 hospitals in
other urban areas (populations of 1 million or fewer). In addition,
there are 2,162 hospitals in rural areas. The next two groupings are
by bed-size categories, shown separately for urban and rural
hospitals. The final groupings by geographic location are by census
divisions, also shown separately for urban and rural hospitals.
The second part of Table I shows hospital groups based on
hospitals' FY 2000 payment classifications, including any
reclassifications under section 1886(d)(10) of the Act. For example,
the rows labeled urban, large urban, other urban, and rural show
that the number of hospitals paid based on these categorizations
(after consideration of geographic reclassifications) are 2,790,
1,628, 1,161, and 2,085, 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 IME adjustment) or
receive DSH payments, or some combination of these two adjustments.
There are 3,772 nonteaching hospitals in our analysis, 868 teaching
hospitals with fewer than 100 residents, and 234 teaching hospitals
with 100 or more residents.
In the DSH categories, hospitals are grouped according to their
DSH payment status, and whether they are considered urban or rural
after MGCRB reclassifications. Hospitals in the rural DSH
categories, therefore, represent hospitals that were not
reclassified for purposes of the standardized amount or for purposes
of the DSH adjustment. (They may, however, have been reclassified
for purposes of the wage index.) The next category groups hospitals
considered urban after geographic reclassification, in terms of
whether they receive the IME adjustment, the DSH adjustment, both,
or neither.
The next five rows examine the impacts of the proposed changes
on rural hospitals by special payment groups (SCHs, rural referral
centers (RRCs), and MDHs), as well as rural hospitals not receiving
a special payment designation. The RRCs (151), SCHs (639), MDHs
(353), and SCH and RRCs (58) shown here were not reclassified for
purposes of the standardized amount. There are three SCHs that will
be reclassified for the standardized amount in FY 2000 that,
therefore, are not included in these rows.
[[Page 24832]]
The next two groupings are based on type of ownership and the
hospital's Medicare utilization expressed as a percent of total
patient days. These data are taken primarily from the FY 1997
Medicare cost report files, if available (otherwise FY 1996 data are
used). Data needed to determine ownership status or Medicare
utilization percentages were unavailable for 37 hospitals. For the
most part, these are new hospitals.
The next series of groupings concern the geographic
reclassification status of hospitals. The first three groupings
display hospitals that were reclassified by the MGCRB for both FY
1999 and FY 2000, or for either of those 2 years, by urban and rural
status. The next rows illustrate the overall number of FY 2000
reclassifications, as well as the numbers of reclassified hospitals
grouped by urban and rural location. The final row in Table I
contains hospitals located in rural counties but deemed to be urban
under section 1886(d)(8)(B) of the Act.
Table I.--Impact Analysis of Changes for FY 2000 Operating Prospective Payment System
[Percent Changes in Payments Per Case]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Remove Blended
Number of Drg New wage GME and wage DRG & WI MGCRB All FY
hosps. recalib. date \3\ CRNA index changes reclassification 2000
\1\ \2\ costs \4\ costs \5\ \6\ \7\ changes
(0) (1) (2) (3) (4) (5) (6) (7)
--------------------------------------------------------------------------------------------------------------------------------------------------------
(BY GEOGRAPHIC LOCATION):
ALL HOSPITALS................................. 4,875 0.0 0.2 0.2 0.0 0.0 0.0 -0.6
URBAN HOSPITALS............................... 2,712 -0.1 0.1 0.2 0.0 -0.2 -0.4 -0.8
LARGE URBAN............................... 1,552 -0.1 -0.1 0.1 0.0 -0.4 -0.5 -1.0
OTHER URBAN............................... 1,160 -0.1 0.4 0.4 0.1 0.1 -0.3 -0.3
RURAL HOSPITALS............................... 2,162 0.2 0.8 0.4 0.1 0.9 2.5 0.9
BED SIZE (URBAN):
0- 99 BEDS.................................... 679 0.2 -0.1 0.3 0.1 -0.1 -0.5 -0.3
100-199 BEDS.................................. 918 0.1 0.1 0.3 0.1 0.0 -0.5 -0.3
200-299 BEDS.................................. 553 0.0 0.2 0.3 0.1 0.0 -0.4 -0.6
300-499 BEDS.................................. 423 -0.1 0.1 0.3 0.1 -0.2 -0.3 -0.8
500 OR MORE BEDS.............................. 139 -0.2 -0.1 -0.1 0.0 -0.5 -0.4 -2.0
BED SIZE (RURAL):
0-49 BEDS..................................... 1,194 0.5 0.6 0.4 0.1 0.9 0.2 1.5
50-99 BEDS.................................... 581 0.3 0.7 0.4 0.1 0.8 0.9 1.1
100-149 BEDS.................................. 232 0.2 0.8 0.5 0.1 0.8 3.8 0.8
150-199 BEDS.................................. 85 0.1 1.0 0.4 0.1 1.0 4.3 1.1
200 OR MORE BEDS.............................. 70 0.0 0.9 0.4 0.1 0.8 4.2 0.0
URBAN BY CENSUS DIVISION:
NEW ENGLAND................................... 149 0.0 0.5 0.1 0.0 0.3 -0.3 -0.6
MIDDLE ATLANTIC............................... 416 0.0 -0.5 -0.3 -0.1 -0.8 -0.4 -2.0
SOUTH ATLANTIC................................ 401 -0.1 0.8 0.5 0.1 0.6 -0.4 0.2
EAST NORTH CENTRAL............................ 446 -0.1 0.7 0.0 0.0 0.4 -0.4 -0.3
EAST SOUTH CENTRAL............................ 157 -0.1 0.8 0.4 0.1 0.6 -0.4 0.1
WEST NORTH CENTRAL............................ 183 -0.1 -0.2 0.1 0.0 -0.5 -0.4 -1.0
WEST SOUTH CENTRAL............................ 343 0.0 -1.2 0.5 0.1 -1.4 -0.4 -2.0
MOUNTAIN...................................... 126 -0.1 0.3 0.2 0.0 0.0 -0.4 -0.3
PACIFIC....................................... 444 -0.1 -0.3 0.7 0.1 -0.4 -0.4 -0.9
PUERTO RICO................................... 47 0.2 0.9 0.3 0.1 0.9 -0.5 0.5
RURAL BY CENSUS DIVISION:
NEW ENGLAND................................... 52 0.1 0.0 0.0 0.0 -0.2 2.3 0.2
MIDDLE ATLANTIC............................... 81 0.2 -0.5 0.2 0.0 -0.5 2.2 0.0
SOUTH ATLANTIC................................ 285 0.2 1.7 0.6 0.1 1.8 2.7 0.8
EAST NORTH CENTRAL............................ 301 0.2 0.8 0.5 0.1 0.8 2.0 0.8
EAST SOUTH CENTRAL............................ 270 0.3 1.6 0.6 0.1 1.8 2.5 1.8
WEST NORTH CENTRAL............................ 490 0.2 1.2 0.2 0.0 1.2 2.3 1.6
WEST SOUTH CENTRAL............................ 338 0.3 -1.1 0.5 0.1 -0.9 3.5 -0.2
MOUNTAIN...................................... 201 0.3 0.5 0.3 0.1 0.5 2.0 1.4
PACIFIC....................................... 139 0.2 0.4 0.5 0.1 0.4 1.9 0.4
PUERTO RICO................................... 5 0.2 3.2 0.4 0.1 3.2 0.7 2.5
(BY PAYMENT CATEGORIES):
URBAN HOSPITALS............................... 2,790 -0.1 0.1 0.2 0.0 -0.1 -0.3 -0.8
LARGE URBAN............................... 1,628 -0.1 -0.1 0.1 0.0 -0.3 -0.4 -1.0
OTHER URBAN............................... 1,161 -0.1 0.4 0.3 0.1 0.2 -0.3 -0.2
RURAL HOSPITALS............................... 2,085 0.2 0.8 0.4 0.1 0.8 2.2 0.9
TEACHING STATUS:
NON-TEACHING.................................. 3,772 0.1 0.3 0.4 0.1 0.2 0.3 0.1
LESS THAN 100 RESIDENTS....................... 868 -0.1 0.2 0.2 0.0 -0.1 -0.3 -0.6
100+ RESIDENTS................................ 234 -0.1 -0.1 -0.1 0.0 -0.4 -0.2 -2.0
DISPROPORTIONATE SHARE HOSPITALS (DSH):
NON-DSH....................................... 3,048 0.0 0.3 0.3 0.1 0.1 0.2 -0.3
URBAN DSH
100 BEDS OR MORE.......................... 1,365 -0.1 0.0 0.2 0.0 -0.2 -0.3 -0.9
FEWER THAN 100 BEDS....................... 86 0.2 -0.3 0.5 0.1 -0.2 -0.5 -0.3
RURAL DSH
SOLE COMMUNITY (SCH)...................... 153 0.4 0.8 0.4 0.1 1.0 -0.1 1.5
REFERRAL CENTERS (RRC).................... 55 0.2 1.4 0.6 0.1 1.4 4.7 1.0
OTHER RURAL DSH HOSPITALS
100 BEDS OR MORE.......................... 57 0.3 1.4 0.6 0.1 1.6 1.1 -0.1
FEWER THAN 100 BEDS....................... 110 0.5 1.7 0.6 0.1 2.0 0.2 2.7
URBAN TEACHING AND DSH:
BOTH TEACHING AND DSH......................... 703 -0.1 0.0 0.1 0.0 -0.3 -0.4 -1.0
[[Page 24833]]
TEACHING AND NO DSH........................... 337 -0.1 0.2 0.1 0.0 -0.1 -0.3 -1.0
NO TEACHING AND DSH........................... 748 0.0 0.1 0.5 0.1 0.0 -0.2 -0.1
NO TEACHING AND NO DSH........................ 1,002 0.0 0.2 0.3 0.1 0.1 -0.5 -0.3
RURAL HOSPITAL TYPES:
NONSPECIAL STATUS HOSPITALS................... 884 0.3 1.1 0.6 0.1 1.3 1.1 0.9
RRC........................................... 151 0.1 0.9 0.5 0.1 0.9 5.6 0.3
SCH........................................... 639 0.3 0.3 0.2 0.0 0.4 0.3 1.2
MDH........................................... 353 0.4 0.6 0.4 0.1 0.9 0.3 1.3
SCH AND RRC................................... 58 0.1 0.3 0.2 0.0 0.2 2.2 1.4
TYPE OF OWNERSHIP:
VOLUNTARY..................................... 2,838 0.0 0.1 0.2 0.0 -0.1 -0.1 -0.7
PROPRIETARY................................... 743 0.0 0.1 0.4 0.1 0.0 0.0 -0.3
GOVERNMENT.................................... 1,256 0.1 0.6 0.4 0.1 0.5 0.2 -0.2
UNKNOWN....................................... 37 -0.1 -0.3 -0.4 -0.1 -0.6 -0.2 -2.0
MEDICARE UTILIZATION AS A PERCENT OF INPATIENT
DAYS:
0-25.......................................... 372 0.0 -0.4 0.6 0.1 -0.5 -0.1 -2.0
25-50......................................... 1,745 -0.1 0.0 0.2 0.0 -0.3 -0.2 -1.0
50-65......................................... 1,893 0.0 0.3 0.2 0.0 0.2 0.1 -0.2
OVER 65....................................... 822 0.1 0.7 0.3 0.1 0.6 0.3 0.2
UNKNOWN....................................... 42 -0.1 -0.3 -0.4 -0.1 -0.6 -0.2 -2.0
HOSPITALS RECLASSIFIED BY THE MEDICARE GEOGRAPHIC
REVIEW BOARD:
RECLASSIFICATION STATUS DURING FY 1999 AND FY
2000:
RECLASSIFIED DURING BOTH FY 1999 AND FY 2000.. 373 0.1 0.6 0.4 0.1 0.5 5.6 -0.3
URBAN..................................... 55 0.0 0.1 0.5 0.1 0.0 4.1 -2.0
RURAL..................................... 318 0.1 0.8 0.4 0.1 0.7 6.3 0.5
RECLASSIFIED DURING FY 2000 ONLY.............. 131 0.0 1.2 0.3 0.1 1.0 3.3 4.5
URBAN..................................... 30 -0.2 1.2 0.2 0.0 0.8 2.2 2.9
RURAL..................................... 101 0.2 1.1 0.4 0.1 1.2 5.4 7.3
RECLASSIFIED DURING FY 1999 ONLY.............. 136 0.1 0.4 0.4 0.1 0.4 -0.7 -6.0
URBAN..................................... 32 -0.1 -0.1 0.4 0.1 -0.3 -0.9 -6.0
RURAL..................................... 104 0.3 1.0 0.5 0.1 1.1 -0.4 -5.0
FY 2000 RECLASSIFICATIONS:
ALL RECLASSIFIED HOSPITALS.................... 504 0.0 0.7 0.4 0.1 0.6 5.1 0.8
STANDARDIZED AMOUNT ONLY.................. 65 0.2 0.6 0.5 0.1 0.7 2.7 -0.7
WAGE INDEX ONLY........................... 393 0.0 0.8 0.4 0.1 0.6 5.5 1.0
BOTH...................................... 46 0.1 0.4 0.4 0.1 0.3 3.8 0.2
NONRECLASSIFIED........................... 4,344 0.0 0.1 0.2 0.0 -0.1 -0.5 -0.7
ALL URBAN RECLASSIFIED........................ 85 -0.1 0.5 0.3 0.1 0.3 3.4 -0.1
STANDARDIZED AMOUNT ONLY.................. 13 0.1 -0.4 0.5 0.1 -0.3 0.9 -4.0
WAGE INDEX ONLY........................... 49 -0.2 0.8 0.3 0.1 0.5 4.3 0.5
BOTH...................................... 23 0.1 -0.2 0.4 0.1 -0.2 0.4 -0.9
NONRECLASSIFIED........................... 2,627 -0.1 0.1 0.2 0.0 -0.2 -0.6 -0.9
ALL RURAL RECLASSIFIED........................ 419 0.1 0.8 0.4 0.1 0.8 6.1 1.4
STANDARDIZED AMOUNT ONLY.................. 52 0.2 1.3 0.6 0.1 1.4 4.0 1.9
WAGE INDEX ONLY........................... 344 0.1 0.7 0.4 0.1 0.7 6.0 1.3
BOTH...................................... 23 0.1 1.4 0.4 0.1 1.3 9.3 1.8
NONRECLASSIFIED........................... 1,717 0.3 0.8 0.4 0.1 0.9 -0.4 0.9
OTHER RECLASSIFIED HOSPITALS (SECTION 26 0.2 0.7 0.6 0.1 0.8 -0.5 -9.0
1886(d)(8)(B))...................................
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Because data necessary to classify some hospitals by category were missing, the total number of hospitals in each category may not equal the
national total. Discharge data are from FY 1998, and hospital cost report data are from reporting periods beginning in FY 1996 and FY 1997.
\2\ This column displays the payment impact of the recalibration of the DRG weights based on FY 1998 MedPAR data and the DRG reclassification changes,
in accordance with section 1886(d)(4)(C) of the Act.
\3\ This column shows the payment effects of updating the data used to calculate the wage index with data from the FY 1996 cost reports.
\4\ This column displays the impact of completely removing the costs and hours associated with teaching physicians Part A, residents, and CRNAs from the
wage index calculation.
\5\ This column illustrates the payment impact of phasing out the costs and hours associated with teaching physicians Part A, residents, and CRNAs, by
calculating the wage index by blending 20 percent of an average hourly wage after removing these costs with 80 percent of an average hourly wage
without removing these costs.
\6\ This column displays the combined impact of the reclassification and recalibration of the DRGs, the updated and revised wage data used to calculate
the wage index, and the budget neutrality adjustment factor for these two changes, in accordance with sections 1886(d)(4)(C)(iii) and 1886(d)(3)(E) of
the Act. Thus, it represents the combined impacts shown in columns 1, 2, 3, and 4, and the FY 2000 budget neutrality factor of 0.997393.
\7\ Shown here are the effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB). The effects demonstrate
the FY 2000 payment impact of going from no reclassifications to the reclassifications scheduled to be in effect for FY 2000. Reclassification for
prior years has no bearing on the payment impacts shown here.
\8\ This column shows changes in payments from FY 1999 to FY 2000. It incorporates all of the changes displayed in columns 5 and 6 (the changes
displayed in columns 1, 2, and 4 are included in column 5). It also displays the impact of the FY 2000 update, changes in hospitals' reclassification
status in FY 2000 compared to FY 1999, the difference in outlier payments from FY 1999 to FY 2000, and the reductions to payments through the IME and
DSH adjustments taking effect during FY 2000. The sum of these columns may be different from the percentage changes shown here due to rounding and
interactive effects.
[[Page 24834]]
B. Impact of the Proposed Changes to the DRG Reclassifications and
Recalibration of Relative Weights (Column 1)
In column 1 of Table I, we present the combined effects of the
DRG reclassifications and recalibration, as discussed in section II
of the preamble to this proposed rule. Section 1886(d)(4)(C)(i) of
the Act requires us to annually make appropriate classification
changes and to recalibrate the DRG weights in order to reflect
changes in treatment patterns, technology, and any other factors
that may change the relative use of hospital resources.
We compared aggregate payments using the FY 1999 DRG relative
weights (GROUPER version 16) to aggregate payments using the
proposed FY 2000 DRG relative weights (GROUPER version 17). Overall
payments are unaffected by the DRG reclassification and
recalibration. Consistent with the minor changes we are proposing
for the FY 2000 GROUPER, the redistributional impacts of DRG
reclassifications and recalibration across hospital groups are very
small (a 0.1 percent decrease for large and other urban hospitals; a
0.2 percent increase for rural hospitals). Within hospital
categories, the net effects for urban hospitals are small positive
changes for small hospitals (a 0.2 percent increase for hospitals
with fewer than 100 beds), and small decreases for larger hospitals
(a 0.2 percent decrease for hospitals with more than 500 beds).
Among rural hospitals, small hospital categories experience the
largest increases, a 0.5 percent increase for hospitals with fewer
than 50 beds.
The breakdown by urban census division shows that the decrease
among urban hospitals is spread across most census categories.
Payments to urban hospitals in New England, the Middle Atlantic, and
the West South Central census divisions are unchanged, while
payments to urban hospitals in Puerto Rico rise by 0.2 percent. All
rural hospital census divisions experience payment increases ranging
from 0.1 percent for hospitals in New England, to 0.3 percent for
hospitals in the East South Central, West South Central, and
Mountain census divisions. All other divisions experience a 0.2
percent increase.
This pattern of payment increases for small hospitals and
decreases for larger hospitals persists among other categories.
Declines in the relative weights of several specific DRGs likely
contribute to this trend. Among these DRGs, the relative weight for
DRG 108 (Other Cardiothoracic Procedures), declined from 5.9764 in
FY 1999 to 5.7505 in this proposed rule for FY 2000. Also, the
relative weight for DRG 112 (Percutaneous Cardiovascular Procedures)
declined from 1.9893 in FY 1999 to 1.9200 in this proposed rule for
FY 2000. Although these cardiovascular procedures are not
necessarily limited to very large hospitals, we would expect they
are more likely to occur in larger hospitals. As the relative
weights of DRGs predominantly occurring in large hospitals decline,
the relative weights of other DRGs rise, leading to the small
payment increases in hospitals less likely to be affected by the
declines in the DRGs noted above.
C. Impact of 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 2000 is based on data submitted for hospital cost
reporting periods beginning on or after October 1, 1995 and before
October 1, 1996. As with the previous column, the impact of the new
data on hospital payments is isolated by holding the other payment
parameters constant in the two simulations. That is, column 2 shows
the percentage changes in payments when going from a model using the
FY 1999 wage index (effective for discharges on or after March 1,
1999 (64 FR 9378)) based on FY 1995 wage data before geographic
reclassifications to a model using the FY 2000 prereclassification
wage index based on FY 1996 wage data.
The wage data collected on the FY 1996 cost reports is similar
to the data used in the calculation of the FY 1999 wage index. For
example, the wage index values used here include all physician Part
A costs (direct and contracted), resident costs, and CRNA costs.
Also, as in the calculation for the FY 1999 wage index, contract
labor costs and hours for top management positions are included, and
the overhead costs allocated to patient care areas excluded from the
calculation of the wage index are excluded as well.
The results indicate that the new wage data have an overall
impact of a 0.2 percent increase in hospital payments (prior to
applying the budget neutrality factor, see column 5). Rural
hospitals especially appear to benefit from the update. Their
payments increase by 0.8 percent. These increases are attributable
to relatively large increases in the wage index values for the rural
areas of particular States; Arizona, Puerto Rico, and South Carolina
all had increases greater than 6 percent in their
prereclassification wage index values. At the same time, several
States experience large declines due to moving to the FY 1996 wage
data; Massachusetts, Texas, and Utah all had decreases greater than
6 percent.
Urban hospitals as a group are not significantly affected by the
updated wage data. The gains of hospitals in other urban areas (0.4
percent increase) are offset by decreases among hospitals in large
urban areas (0.1 percent decrease). Urban West South Central
hospitals experience a 1.0 percent decrease, largely due to a number
of MSAs in Texas with prereclassified FY 2000 wage indexes that fall
by 6 percent or more. We note that the wage data used for the
proposed wage index are based upon the data available as of February
22, 1999, and therefore, do not reflect revision requests received
by the fiscal intermediaries after February 22, 1999. To the extent
these requests are granted by hospitals' fiscal intermediaries,
these revisions are likely to affect the impacts shown in the final
rule. In addition, we continue to verify the accuracy of the data
for hospitals with extraordinary changes in their data from the
prior year.
The largest increases are seen in the rural census divisions.
Rural Puerto Rico experiences the greatest positive impact, 3.2
percent. Hospitals in three other census divisions receive positive
impacts over 1.0 percent; South Atlantic at 1.7 percent, East South
Central at 1.6 percent, and West North Central at 1.2 percent.
D. Impact of Removing Teaching Physicians' Part A, Residents', and
CRNAs' Costs (Column 3)
As discussed in section III.C of the preamble, we are proposing
to revise the calculation of the wage index by phasing out the costs
and hours associated with teaching physicians Part A, residents, and
CRNAs. Although the proposed FY 2000 wage index is based upon a
blend of 20 percent of hospitals' average hourly wages after
removing these costs and 80 percent of average hourly wages
calculated without removing these costs, this column displays the
impacts on payments per case of completely removing these costs from
the wage index calculation.
As described above in section III.C.1 of the preamble, we
determined teaching physician costs by first subtracting the costs
and hours attributable to teaching physicians based upon the special
survey data we collected for this purpose. If these data were not
available from the survey for a particular teaching hospital, 80
percent of the total physician Part A costs and hours for that
hospital were removed, consistent with the recommendation of
hospital (see discussion in section III.C.1 of the preamble). If a
teaching hospital did not separately report its physician Part A
costs on the cost report, the amount reported on Line 23, Column 1,
of the Worksheet A was removed from the total wage data (as was an
associated amount for hours). Resident and CRNA costs and hours were
removed in their entirety, based upon the data separately attributed
to these employees on the Worksheet S-3.
Column 3 shows the payment impacts of completely removing these
costs, relative to wage index values calculated based on the FY 1996
wage data without removing these costs. The overall payment impact
of completely removing these costs and hours from the wage index
calculation would be a 0.2 percent increase in total payments (prior
to applying budget neutrality). The FY 2000 proposed wage index is,
however, based on a blended average hourly wage. The impacts of this
blended approach are shown in column 4.
The impact of removing these costs from the wage index
calculation are generally positive across the majority of hospital
categories. However, examining the impacts across urban and rural
census divisions indicate that urban Middle Atlantic hospitals
experience a 0.3 percent decrease. This effect is attributable to
the concentration of teaching hospitals in this census division. The
largest positive impact occurs in the
[[Page 24835]]
urban Pacific census division, a 0.7 percent payment increase.
As noted above, the data used to prepare the proposed FY 2000
wage index are subject to revision. In particular, in early February
1999, we instructed the fiscal intermediaries to review the survey
data on collected teaching physician costs. We have also extended
the deadline for teaching hospitals to request revisions to their
teaching physician survey data until June 7, 1999. The extent of
these requests and the number of changes that are approved by the
fiscal intermediaries may change the impacts in the final rule.
E. Impact of 5-Year Phase-Out of Teaching Physicians', Residents',
and CRNA Costs (Column 4)
As described above in section III.E of this preamble, the
proposed FY 2000 wage index is calculated by blending 80 percent of
hospitals' average hourly wages calculated without removing teaching
physician Part A, residents, or CRNA costs (and hours); and 20
percent of average hourly wages calculated after removing these
costs (and hours). This constitutes the first year of a 5-year
phase-out of these costs, where the proportion of the calculation
based upon average hourly wages after removing these costs increases
by 20 percentage points per year.
This column shows the impact of the blended wage index relative
to a wage index using FY 1996 wage data without removing costs or
hours of teaching physicians Part A, residents, or CRNAs. The
impacts in column 4 are minimal (an increase or decrease of 0.1
percent). As expected, the hospital categories experiencing negative
payment impacts in column 3 experience either negative 0.1 percent
changes or no change here. The overall impact is 0.0 percent.
The combined wage index changes in Table I are determined by
summing the individual impacts in columns 2 and 4. For example, the
urban West South Central census division loses 1.2 percent from the
new wage data, and gains 0.1 percent from the blended wage index.
Therefore, the combined impact of the proposed FY 2000 wage index
for these hospitals is a 1.1 percent decrease.
The following chart compares the shifts in wage index values for
labor market areas for FY 2000 relative to FY 1999. This chart
demonstrates the impact of the proposed changes for the FY 2000 wage
index relative to the FY 1999 wage index. The majority of labor
market areas (299) experience less than a 5 percent change. A total
of 47 labor market areas experience an increase of more than 5
percent with 14 having an increase greater than 10 percent. A total
of 28 areas experience decreases of more than 5 percent. Of those, 7
decline by 10 percent or more.
------------------------------------------------------------------------
Number of labor market areas
Percentage change in area wage index -------------------------------
values FY 1999 FY 2000
------------------------------------------------------------------------
Increase more than 10 percent........... 9 14
Increase more than 5 percent and less 29 33
than 10 percent........................
Increase or decrease less than 5 percent 305 299
Decrease more than 5 percent and less 28 21
than 10 percent........................
Decrease more than 10 percent........... 0 7
------------------------------------------------------------------------
Among urban hospitals, 169 would experience an increase of
between 5 and 10 percent and 40 more than 10 percent. A total of 139
rural hospitals have increases greater than 5 percent, but none
greater than 10 percent. On the negative side, 130 urban hospitals
and 187 rural hospitals have decreases in their wage index values of
at least 5 percent but less than 10 percent. There are no rural
hospitals with decreases greater than 10 percent, and 21 urban
hospitals in this category. The following chart shows the projected
impact for urban and rural hospitals.
------------------------------------------------------------------------
Number of hospitals
Percentage change in area wage index -------------------------------
values Urban Rural
------------------------------------------------------------------------
Increase more than 10 percent........... 40 0
Increase more than 5 percent and less 169 139
than 10 percent........................
Increase or decrease less than 5 percent 2352 1836
Decrease more than 5 percent and less 130 187
than 10 percent........................
Decrease more than 10 percent........... 21 0
------------------------------------------------------------------------
F. Combined Impact of DRG and Wage Index Changes--Including Budget
Neutrality Adjustment (Column 5)
The impact of DRG reclassifications and recalibration on
aggregate payments is required by section 1886(d)(4)(C)(iii) of the
Act to be budget neutral. In addition, section 1886(d)(3)(E) of the
Act specifies that any updates or adjustments to the wage index are
to be budget neutral. As noted in the Addendum to this proposed
rule, we compared simulated aggregate payments using the FY 1999 DRG
relative weights and wage index to simulated aggregate payments
using the proposed FY 2000 DRG relative weights and blended wage
index. Based on this comparison, we computed a wage and
recalibration budget neutrality factor of 0.997393. In Table I, the
combined overall impacts of the effects of both the DRG
reclassifications and recalibration and the updated wage index are
shown in column 5. The 0.0 percent impact for All Hospitals
demonstrates that these changes, in combination with the budget
neutrality factor, are budget neutral.
For the most part, the changes in this column are the sum of the
changes in columns 1, 2, and 4, minus approximately 0.3 percent
attributable to the budget neutrality factor. There may be some
variation of plus or minus 0.1 percent due to rounding.
G. Impact of MGCRB Reclassifications (Column 6)
Our impact analysis to this point has assumed hospitals are paid
on the basis of their actual geographic location (with the exception
of ongoing policies that provide that certain hospitals receive
payments on bases other than where they are geographically located,
such as hospitals in rural counties that are deemed urban under
section 1886(d)(8)(B) of the Act). The changes in column 6 reflect
the per case payment impact of moving from this baseline to a
simulation incorporating the MGCRB decisions for FY 2000. As noted
below, these decisions affect hospitals' standardized amount and
wage index area assignments. In addition, rural hospitals
reclassified for purposes of the standardized amount qualify to be
treated as urban for purposes of the DSH adjustment.
Beginning in 1998, by February 28 of each year, the MGCRB makes
reclassification determinations that will be effective for the next
fiscal year, which begins on October 1. (In previous years, these
determinations were made by March 30.) The MGCRB may approve a
hospital's reclassification request for the purpose of using the
other area's standardized amount, wage index value, or both or for
FYs 1999-2001 for purposes of
[[Page 24836]]
qualifying for a DSH adjustment or to receive a higher DSH payment.
The proposed FY 2000 wage index values incorporate all of the
MGCRB's reclassification decisions for FY 2000. The wage index
values also reflect any decisions made by the HCFA Administrator
through the appeals and review process for MGCRB decisions as of
February 27, 1999. 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 2000.
The overall effect of geographic reclassification is required by
section 1886(d)(8)(D) of the Act to be budget neutral. Therefore, we
applied an adjustment of 0.994453 to ensure that the effects of
reclassification are budget neutral. (See section II.A.4.b. of the
Addendum to this proposed rule.)
As a group, rural hospitals benefit from geographic
reclassification. Their payments rise 2.5 percent, while payments to
urban hospitals decline 0.4 percent. Hospitals in other urban areas
see a decrease in payments of 0.3 percent, while large urban
hospitals lose 0.5 percent. Among urban hospital groups (that is,
bed size, census division, and special payment status), payments
generally decline.
A positive impact is evident among all rural hospital groups.
The smallest increases among the rural census divisions is 0.7
percent for Puerto Rico and 1.9 percent for Pacific. The largest
increase is in rural West South Central, with an increase of 3.5
percent.
Among rural hospitals designated as RRCs, 127 hospitals are
reclassified for purposes of the wage index only, leading to the 5.6
percent increase in payments among RRCs overall. This positive
impact on RRCs is also reflected in the category of rural hospitals
with 200 or more beds, which has a 4.2 percent increase in payments.
Rural hospitals reclassified for FY 1999 and FY 2000 experience
a 6.3 percent increase in payments. This may be due to the fact that
these hospitals have the most to gain from reclassification and have
been reclassified for a period of years. Rural hospitals
reclassified for FY 2000 only experience a 5.4 percent increase in
payments, while rural hospitals reclassified for FY 1999 only
experience a 0.4 percent decrease in payments. Urban hospitals
reclassified for FY 1999 but not FY 2000 experience a 0.9 percent
decline in payments overall. Urban hospitals reclassified for FY
2000 but not for FY 1999 experience a 3.3 percent increase in
payments.
The FY 2000 Reclassification rows of Table I show the changes in
payments per case for all FY 2000 reclassified and nonreclassified
hospitals in urban and rural locations for each of the three
reclassification categories (standardized amount only, wage index
only, or both). The table illustrates that the largest impact for
reclassified rural hospitals is for those hospitals reclassified for
both the standardized amount and the wage index. These hospitals
receive a 9.3 percent increase in payments. In addition, rural
hospitals reclassified just for the wage index receive a 6.0 percent
payment increase. The overall impact on reclassified hospitals is to
increase their payments per case by an average of 5.1 percent for FY
2000.
The reclassification of hospitals primarily affects payment to
nonreclassified hospitals through changes in the wage index and the
geographic reclassification budget neutrality adjustment required by
section 1886(d)(8)(D) of the Act. Among hospitals that are not
reclassified, the overall impact of hospital reclassifications is an
average decrease in payments per case of about 0.5 percent. Rural
nonreclassified hospitals decrease by 0.4 percent, and urban
nonreclassified hospitals lose 0.6 percent (the amount of the budget
neutrality offset).
The foregoing analysis was based on MGCRB and HCFA Administrator
decisions made by February 27, 1999. 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.
H. All Changes (Column 7)
Column 7 compares our estimate of payments per case,
incorporating all changes reflected in this proposed rule for FY
2000 (including statutory changes), to our estimate of payments per
case in FY 1999. It includes the effects of the 0.9 percent update
to the standardized amounts and the hospital-specific rates for SCHs
and MDHs. It also reflects the 1.1 percentage point difference
between the projected outlier payments in FY 2000 (5.1 percent of
total DRG payments) and the current estimate of the percentage of
actual outlier payments in FY 1999 (6.2 percent), as described in
the introduction to this Appendix and the Addendum to this proposed
rule.
Additional changes affecting the difference between FY 1999 and
FY 2000 payments are the reductions to the IME and DSH adjustments
enacted by the Balanced Budget Act of 1997. These changes initially
went into effect during FY 1998 and include additional decreases in
payment for each of several succeeding years. As noted in the
introduction to this impact analysis, for FY 2000, IME is reduced to
approximately a 6.0 percent rate of increase, and DSH is reduced by
3 percent from what hospitals otherwise would receive. We estimate
the overall effect of these statutory changes to be a 0.5 percent
reduction in FY 2000 payments. For hospitals receiving both IME and
DSH, the impact is estimated to be a 0.8 percent reduction in
payments per case.
We also note that column 8 includes the impacts of FY 2000 MGCRB
reclassifications compared to the payment impacts of FY 1999
reclassifications. Therefore, when comparing FY 2000 payments to FY
1999, the percent changes due to FY 2000 reclassifications shown in
column 6 need to be offset by the effects of reclassification on
hospitals' FY 1999 payments (column 7 of Table 1, July 31, 1998
final rule (63 FR 41106)). For example, the impact of MGCRB
reclassifications on rural hospitals' FY 1999 payments was
approximately a 2.7 percent increase, more than offsetting the 2.5
percent increase in column 6 for FY 2000. Therefore, the net change
in FY 2000 payments due to reclassification for rural hospitals is
actually a decrease of 0.2 percent relative to FY 1999. However,
last year's analysis contained a somewhat different set of
hospitals, so this might affect the numbers slightly.
There might also be interactive effects among the various
factors comprising the payment system that we are not able to
isolate. For these reasons, the values in column 7 may not equal the
sum of the changes in columns 5 and 6, plus the other impacts that
we are able to identify.
The overall payment change from FY 1999 to FY 2000 for all
hospitals is a 0.6 percent decrease. This reflects the 0.9 percent
update for FY 2000, the 1.1 percent lower outlier payments in FY
1999 compared to FY 1999 (5.1 percent compared to 6.2 percent); and
the 0.5 percent reduction due to lower IME and DSH payments.
Hospitals in urban areas experience a 0.8 percent drop in
payments per case compared to FY 1999. The 0.4 percent negative
impact due to reclassification is offset by an identical negative
impact for FY 1999. The impact of reducing IME and DSH is a 0.6
percent reduction in FY 2000 payments per case. Payment to hospitals
in large urban areas are expected to fall 1.0 percent per case
compared to 0.3 percent per case for hospitals in other urban areas.
Hospitals in rural areas, meanwhile, experience a 0.9 percent
payment increase. As discussed previously, this is primarily due to
the positive effect due to the wage index and DRG changes (0.9
percent increase).
Among census divisions, urban Middle Atlantic and the West South
Central display the largest negative impacts, 2.0 percent decrease
in payments per case for hospitals in these two divisions. These
negative impacts are primarily related to the relatively large
decreases attributable to the proposed wage index. Hospitals in the
South Atlantic and East South Central census divisions, along with
Puerto Rico, are the only urban categories grouped by census
division exhibiting increases in payments per case for FY 2000.
Again, this appears to be related to the proposed FY 2000 wage
index.
The only rural census division to experience a negative payment
impact is West South Central (0.2 percent fall), and as is generally
the case, this appears to be related to a negative payment impact
related to their FY 1996 wage data. The largest increases by rural
hospitals are in Puerto Rico at 2.5 percent. Among rural census
divisions, the largest increases are in the East South Central and
West North Central, with 1.8 percent and 1.6 percent increases in
their FY 2000 payments per case, respectively. As with the other
impacts discussed above, this is generally due to updating the wage
data. One rural census division that did not experience an increase
in payments as large
[[Page 24837]]
as suggested by the positive impact of updating the wage data was
the South Atlantic. This census division experienced a 3.8 percent
payment increase due to geographic reclassification in FY 1999, but
the effect of geographic reclassification in FY 2000 was only 2.7
percent.
Among special categories of rural hospitals, those hospitals
receiving payment under the hospital-specific methodology (SCHs,
MDHs, and SCH/RRCs) experience payment increases of 1.2 percent, 1.3
percent, and 1.4 percent, respectively. This outcome is primarily
related to the fact that, for hospitals receiving payments under the
hospital-specific methodology, there are no outlier payments.
Therefore, these hospitals do not experience negative payment
impacts from the decline in outlier payments from FY 1999 to FY 2000
(from 6.2 of total DRG plus outlier payments to 5.1 percent) as do
hospitals paid based on the national standardized amounts.
The largest negative payment impacts from FY 1999 to FY 2000 are
among hospitals that were reclassified for FY 1999 and are not
reclassified for FY 2000. Overall, these hospitals lose 6.0 percent.
The urban hospitals in this category lose 6.0 percent, while the
rural hospitals lose 5.0 percent. On the other hand, hospitals
reclassified for FY 2000 that were not reclassified for FY 1999
would experience the greatest payment increases: 4.5 percent
overall; 7.3 percent for 101 rural hospitals in this category and
2.9 percent for 32 urban hospitals.
Table II--Impact Analysis of Changes for FY 2000 Operating Prospective Payment System
[Payments Per Case]
----------------------------------------------------------------------------------------------------------------
Average FY1999 Average FY
Number of payment per 2000 payment All changes
hospitals case per case
(1) (2) 1 (3) 1 (4)
----------------------------------------------------------------------------------------------------------------
(BY GEOGRAPHIC LOCATION):
ALL HOSPITALS............................... 4,875 6,770 6,730 -0.6
URBAN HOSPITALS......................... 2,712 7,346 7,285 -0.8
LARGE URBAN AREAS....................... 1,552 7,879 7,787 -1.2
OTHER URBAN AREAS........................... 1,160 6,623 6,604 -0.3
RURAL HOSPITALS............................. 2,162 4,505 4,546 0.9
BED SIZE (URBAN):
0-99 BEDS................................... 679 4,973 4,957 -0.3
100-199 BEDS................................ 918 6,165 6,147 -0.3
200-299 BEDS................................ 553 6,998 6,958 -0.6
300-499 BEDS................................ 423 7,803 7,741 -0.8
500 OR MORE BEDS............................ 139 9,912 9,733 -1.8
BED SIZE (RURAL):
0-49 BEDS................................... 1,194 3,725 3,779 1.5
50-99 BEDS.................................. 581 4,226 4,274 1.1
100-149 BEDS................................ 232 4,605 4,643 0.8
150-199 BEDS................................ 85 4,930 4,983 1.1
200 OR MORE BEDS............................ 70 5,734 5,733 0.0
URBAN BY CENSUS DIVISION:
NEW ENGLAND................................. 149 7,723 7,677 -0.6
MIDDLE ATLANTIC............................. 416 8,278 8,110 -2.0
SOUTH ATLANTIC.............................. 401 6,990 7,001 0.2
EAST NORTH CENTRAL.......................... 446 6,994 6,973 -0.3
EAST SOUTH CENTRAL.......................... 157 6,579 6,586 0.1
WEST NORTH CENTRAL.......................... 183 7,053 6,981 -1.0
WEST SOUTH CENTRAL.......................... 343 6,785 6,660 -1.8
MOUNTAIN.................................... 126 7,016 6,996 -0.3
PACIFIC..................................... 444 8,460 8,388 -0.9
PUERTO RICO................................. 47 3,108 3,124 0.5
RURAL BY CENSUS DIVISION:
NEW ENGLAND................................. 52 5,356 5,369 0.2
MIDDLE ATLANTIC............................. 81 4,862 4,860 0.0
SOUTH ATLANTIC.............................. 285 4,681 4,721 0.8
EAST NORTH CENTRAL.......................... 301 4,559 4,596 0.8
EAST SOUTH CENTRAL.......................... 270 4,162 4,239 1.8
WEST NORTH CENTRAL.......................... 490 4,279 4,349 1.6
WEST SOUTH CENTRAL.......................... 338 4,002 3,993 -0.2
MOUNTAIN.................................... 201 4,751 4,817 1.4
PACIFIC..................................... 139 5,600 5,625 0.4
PUERTO RICO................................. 5 2,334 2,392 2.5
(BY PAYMENT CATEGORIES):
URBAN HOSPITALS............................. 2,790 7,310 7,251 -0.8
LARGE URBAN............................. 1,628 7,806 7,715 -1.2
OTHER URBAN............................. 1,161 6,610 6,596 -0.2
RURAL HOSPITALS............................. 2,085 4,480 4,519 0.9
TEACHING STATUS:
NON-TEACHING................................ 3,772 5,473 5,477 0.1
FEWER THAN 100 RESIDENTS.................... 868 7,184 7,138 -0.6
100 OR MORE RESIDENTS....................... 234 10,858 10,658 -1.8
DISPROPORTIONATE SHARE HOSPITALS (DSH):
[[Page 24838]]
NON-DSH..................................... 3,048 5,792 5,775 -0.3
URBAN DSH:
100 BEDS OR MORE............................ 1,365 7,972 7,900 -0.9
FEWER THAN 100 BEDS......................... 86 5,193 5,180 -0.3
RURAL DSH:
SOLE COMMUNITY (SCH):....................... 153 4,205 4,266 1.5
REFERRAL CENTERS (RRC)...................... 55 5,357 5,408 1.0
OTHER RURAL DSH HOSPITALS:
100 BEDS OR MORE............................ 57 4,186 4,183 -0.1
FEWER THAN 100 BEDS......................... 110 3,597 3,692 2.7
URBAN TEACHING AND DSH:
BOTH TEACHING AND DSH....................... 703 8,936 8,826 -1.2
TEACHING AND NO DSH......................... 337 7,281 7,211 -1.0
NO TEACHING AND DSH......................... 748 6,371 6,362 -0.1
NO TEACHING AND NO DSH...................... 1,002 5,646 5,630 -0.3
RURAL HOSPITAL TYPES:
NONSPECIAL STATUS HOSPITALS................. 884 3,964 3,997 0.9
RRC......................................... 151 5,225 5,243 0.3
SCH......................................... 639 4,470 4,524 1.2
MDH......................................... 353 3,757 3,805 1.3
SCH AND RRC................................. 58 5,368 5,442 1.4
TYPE OF OWNERSHIP:
VOLUNTARY................................... 2,838 6,943 6,895 -0.7
PROPRIETARY................................. 743 6,202 6,181 -0.3
GOVERNMENT.................................. 1,256 6,286 6,273 -0.2
UNKNOWN..................................... 37 9,806 9,626 -1.8
MEDICARE UTILIZATION AS A PERCENT OF INPATIENT
DAYS:
0-25........................................ 372 8,826 8,692 -1.5
25-50....................................... 1,745 7,924 7,844 -1.0
50-65....................................... 1,893 5,997 5,986 -0.2
OVER 65..................................... 822 5,272 5,285 0.2
UNKNOWN..................................... 42 9,716 9,539 -1.8
HOSPITALS RECLASSIFIED BY THE MEDICARE
GEOGRAPHIC REVIEW BOARD:
RECLASSIFICATION STATUS DURING FY 1999 AND FY
2000:
RECLASSIFIED DURING BOTH FY 1999 AND FY 2000 373 5,819 5,803 -0.3
URBAN................................... 55 8,004 7,849 -1.9
RURAL................................... 318 5,202 5,226 0.5
RECLASSIFIED DURING FY 2000 ONLY............ 131 6,183 6,459 4.5
URBAN....................................... 30 8,096 8,327 2.9
RURAL................................... 101 4,362 4,682 7.3
RECLASSIFIED DURING FY 1999 ONLY............ 136 5,577 5,267 -5.6
URBAN................................... 32 6,976 6,568 -5.8
RURAL................................... 104 4,611 4,369 -5.3
FY 2000 RECLASSIFICATIONS:
ALL RECLASSIFIED HOSPITALS.................. 504 5,896 5,943 0.8
STANDARDIZED AMOUNT ONLY................ 65 4,764 4,732 -0.7
WAGE INDEX ONLY......................... 393 5,981 6,041 1.0
BOTH.................................... 46 6,156 6,168 0.2
NONRECLASSIFIED......................... 4,344 6,889 6,839 -0.7
ALL URBAN RECLASSIFIED...................... 85 8,039 8,028 -0.1
STANDARDIZED AMOUNT ONLY................ 13 5,253 5,032 -4.2
WAGE INDEX ONLY......................... 49 8,867 8,908 0.5
BOTH.................................... 23 6,894 6,834 -0.9
NONRECLASSIFIED......................... 2,627 7,318 7,255 -0.9
ALL RURAL RECLASSIFIED...................... 419 5,075 5,144 1.4
STANDARDIZED AMOUNT ONLY................ 52 4,468 4,551 1.9
WAGE INDEX ONLY......................... 344 5,110 5,175 1.3
BOTH.................................... 23 5,281 5,379 1.8
NONRECLASSIFIED......................... 1,717 4,108 4,143 0.9
OTHER RECLASSIFIED HOSPITALS (SECTION 26 4,781 4,361 -8.8
1886(d)(8)(B)).................................
----------------------------------------------------------------------------------------------------------------
\1\ These payment amounts per case do not reflect any estimates of annual case-mix increase.
[[Page 24839]]
Table II presents the projected impact of the proposed changes
for FY 2000 for urban and rural hospitals and for the different
categories of hospitals shown in Table I. It compares the projected
payments per case for FY 2000 with the average estimated per case
payments for FY 1999, as calculated under our models. Thus, this
table presents, in terms of the average dollar amounts paid per
discharge, the combined effects of the changes presented in Table I.
The percentage changes shown in the last column of Table II equal
the percentage changes in average payments from column 7 of Table I.
VII. Impact of Proposed Changes in the Capital Prospective Payment
System
A. General Considerations
We now have cost report data for the 5th and 6th years of the
capital prospective payment system (cost reports beginning in FY
1996 and in FY 1997) available through the December 1998 update of
the HCRIS. We also have updated information on the projected
aggregate amount of obligated capital approved by the fiscal
intermediaries. However, our impact analysis of payment changes for
capital-related costs is still limited by the lack of hospital-
specific data on several items. These are the hospital's projected
new capital costs for each year, its projected old capital costs for
each year, and the actual amounts of obligated capital that will be
put in use for patient care and recognized as Medicare old capital
costs in each year. The lack of this information affects our impact
analysis in the following ways:
Major investment in hospital capital assets (for
example, in building and major fixed equipment) occurs at irregular
intervals. As a result, there can be significant variation in the
growth rates of Medicare capital-related costs per case among
hospitals. We do not have the necessary hospital-specific budget
data to project the hospital capital growth rate for individual
hospitals.
Our policy of recognizing certain obligated capital as
old capital makes it difficult to project future capital-related
costs for individual hospitals. Under Sec. 412.302(c), a hospital is
required to notify its intermediary that it has obligated capital by
the later of October 1, 1992, or 90 days after the beginning of the
hospital's first cost reporting period under the capital prospective
payment system. The intermediary must then notify the hospital of
its determination whether the criteria for recognition of obligated
capital have been met by the later of the end of the hospital's
first cost reporting period subject to the capital prospective
payment system or 9 months after the receipt of the hospital's
notification. The amount that is recognized as old capital is
limited to the lesser of the actual allowable costs when the asset
is put in use for patient care or the estimated costs of the capital
expenditure at the time it was obligated. We have substantial
information regarding 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 2000 capital cost projections. In
Appendix B of this proposed rule, we discuss the assumptions and
computations that we employ to generate the amount of obligated
capital commitments for use in the FY 2000 capital cost projections.
In Table III of this section, we present the redistributive
effects that are expected to occur between ``hold-harmless''
hospitals and ``fully prospective'' hospitals in FY 2000. In
addition, we have integrated sufficient hospital-specific
information into our actuarial model to project the impact of the
proposed FY 2000 capital payment policies by the standard
prospective payment system hospital groupings. While we now have
actual information on the effects of the transition payment
methodology and interim payments under the capital prospective
payment system and cost report data for most hospitals, we still
need to randomly generate numbers for the change in old capital
costs, new capital costs for each year, and obligated amounts that
will be put in use for patient care services and recognized as old
capital each year. We continue to be unable to predict accurately FY
2000 capital costs for individual hospitals, but with the most
recent data hospitals' experience under the capital prospective
payment system, there is adequate information to estimate the
aggregate impact on most hospital groupings.
B. Projected Impact Based on the Proposed FY 2000 Actuarial Model
1. Assumptions
In this impact analysis, we model dynamically the impact of the
capital prospective payment system from FY 1999 to FY 2000 using a
capital cost model. The FY 2000 model, as described in Appendix B of
this 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 1997 as
reported on the December 1998 update of HCRIS, interim payment data
for hospitals already receiving capital prospective payments through
PRICER, and data reported by the intermediaries that include the
hospital-specific rate determinations that have been made through
January 1, 1999 in the provider-specific file. We used these data to
determine the proposed FY 2000 capital rates. However, we do not
have individual hospital data on old capital changes, new capital
formation, and actual obligated capital costs. We have data on costs
for capital in use in FY 1997, and we age that capital by a formula
described in Appendix B. Therefore, we need to randomly generate
only new capital acquisitions for any year after FY 1997. All
Federal rate payment parameters are assigned to the applicable
hospital.
For purposes of this impact analysis, the proposed FY 2000
actuarial model includes the following assumptions:
Medicare inpatient capital costs per discharge will
change at the following rates during these periods:
Average Percentage Change in Capital Costs per Discharge
------------------------------------------------------------------------
Percentage
Fiscal year change
------------------------------------------------------------------------
1998........................................................ -0.71
1999........................................................ -0.15
2000........................................................ 0.75
------------------------------------------------------------------------
The Medicare case-mix index will increase by 1.0
percent in FY 1999 and 0.5 percent in FY 2000.
The Federal capital rate and hospital-specific rate
were updated in FY 1996 by an analytical framework that considers
changes in the prices associated with capital-related costs, and
adjustments to account for forecast error, changes in the case-mix
index, allowable changes in intensity, and other factors. The
proposed FY 2000 update is -0.6 percent (see section IV of the
Addendum to this proposed rule).
2. Results
We have used the actuarial model to estimate the change in
payment for capital-related costs from FY 1999 to FY 2000. Table III
shows the effect of the capital prospective payment system on low
capital cost hospitals and high capital cost hospitals. We consider
a hospital to be a low capital cost hospital if, based on a
comparison of its initial hospital-specific rate and the applicable
Federal rate, it will be paid under the fully prospective payment
methodology. A high capital cost hospital is a hospital that, based
on its initial hospital-specific rate and the applicable Federal
rate, will be paid under the hold-harmless payment methodology.
Based on our actuarial model, the breakdown of hospitals is as
follows:
[[Page 24840]]
Capital Transition Payment Methodology for FY 2000
----------------------------------------------------------------------------------------------------------------
Percent of
Type of Hospital Percent of Percent of Percent of capital
hospitals discharges capital costs payments
----------------------------------------------------------------------------------------------------------------
Low Cost Hospital............................... 66 61 54 59
High Cost Hospital.............................. 34 39 46 41
----------------------------------------------------------------------------------------------------------------
A low capital cost hospital may request to have its hospital-
specific rate redetermined based on old capital costs in the current
year, through the later of the hospital's cost reporting period
beginning in FY 1994 or the first cost reporting period beginning
after obligated capital comes into use (within the limits
established in Sec. 412.302(e) for putting obligated capital into
use for patient care). If the redetermined hospital-specific rate is
greater than the adjusted Federal rate, these hospitals will be paid
under the hold-harmless payment methodology. Regardless of whether
the hospital became a hold-harmless payment hospital as a result of
a redetermination, we continue to show these hospitals as low
capital cost hospitals in Table III.
Assuming no behavioral changes in capital expenditures, Table
III displays the percentage change in payments from FY 1999 to FY
2000 using the above described actuarial model. With the proposed
Federal rate, we estimate aggregate Medicare capital payments will
increase by 2.66 percent in FY 2000.
Table III.--Impact of Proposed Changes for FY 2000 on Payments per Discharge
--------------------------------------------------------------------------------------------------------------------------------------------------------
Percent
Number of Adjusted Average Hospital Hold Exceptions Total change
hospitals Discharges Federal Federal specific harmless payment payment over FY
payment percent payment payment 1999
--------------------------------------------------------------------------------------------------------------------------------------------------------
FY 1999 Payments per Discharge:
Low Cost Hospitals......................... 3,200 6,737,171 $521.48 81.42 $58.83 $3.46 $8.72 $592.49
Fully Prospective...................... 2,977 6,138,720 511.78 80.00 64.57 ......... 8.44 584.79 .........
100% Federal Rate...................... 193 538,418 642.90 100.00 ......... ......... 4.44 647.34 .........
Hold Harmless.......................... 30 60,033 423.55 60.65 ......... 388.55 75.12 887.21 .........
High Cost Hospitals........................ 1,634 4,248,111 658.19 97.70 ......... 22.81 14.66 695.65 .........
100% Federal Rate...................... 1,424 3,876,299 677.27 100.00 ......... ......... 7.26 684.53 .........
Hold Harmless.......................... 210 371,812 459.27 72.18 ......... 260.63 91.71 811.60 .........
--------------------------------------------------------------------------------------------------------
Total Hospitals.................... 4,834 10,985,282 574.34 87.91 36.08 10.94 11.01 632.38 .........
FY 2000 Payments per Discharge:
Low Cost Hospitals......................... 3,200 6,785,508 573.45 90.60 29.15 2.91 10.29 615.79 3.93
Fully Prospective...................... 2,977 6,182,772 569.26 90.00 31.99 ......... 9.24 610.48 4.39
100% Federal Rate...................... 194 543,519 632.85 100.00 ......... ......... 4.51 637.36 -1.54
Hold Harmless.......................... 29 59,217 465.60 68.51 ......... 333.70 173.36 972.66 9.63
High Cost Hospitals........................ 1,634 4,278,443 649.22 98.47 ......... 16.61 24.44 690.27 -0.77
100% Federal Rate...................... 1,442 3,951,867 663.34 100.00 ......... ......... 11.28 674.62 -1.45
Hold Harmless.......................... 192 326,576 478.35 78.33 ......... 217.65 183.66 879.66 8.38
--------------------------------------------------------------------------------------------------------
Total Hospitals.................... 4,834 11,063,951 602.75 93.72 17.87 8.21 15.76 644.59 1.93
--------------------------------------------------------------------------------------------------------------------------------------------------------
We project that low capital cost hospitals paid under the fully
prospective payment methodology will experience an average increase
in payments per case of 4.39 percent, and high capital cost
hospitals will experience an average decrease of 0.77 percent. These
results are due to the change in the blended percentages to the
payment system to 90 percent adjusted Federal rate and 10 percent
hospital-specific rate.
For hospitals paid under the fully prospective payment
methodology, the Federal rate payment percentage will increase from
80 percent to 90 percent and the hospital-specific rate payment
percentage will decrease from 20 to 10 percent in FY 2000. The
Federal rate payment percentage for hospitals paid under the hold-
harmless payment methodology is based on the hospital's ratio of new
capital costs to total capital costs. The average Federal rate
payment percentage for high cost hospitals receiving a hold-harmless
payment for old capital will increase from 72.18 percent to 78.83
percent. We estimate the percentage of hold-harmless hospitals paid
based on 100 percent of the Federal rate will increase from 87.1
percent to 88.2 percent. We estimate that the few remaining high
cost hold-harmless hospitals (192) will experience an increase in
payments of 8.38 percent from FY 1999 to FY 2000. The increase
occurs because we estimate that exception payments per discharge
will increase 50.1 percent from FY 1999 to FY 2000 for high cost
hold-harmless hospitals. While we estimate that this group's regular
hold-harmless payments for old capital will decline by 16.5 percent
due to the retirement of old capital, we estimate that its high
overall capital costs will cause an increase in these hospitals'
exceptions payments from $91.71 per discharge in FY 1999 to $183.66
per discharge in FY 2000. This is primarily due to the estimated
decrease in outlier payments, which will cause an estimated increase
in exceptions payments to cover unmet capital costs.
We expect that the average hospital-specific rate payment per
discharge will decrease from $64.57 in FY 1999 to $31.99 in FY 2000.
This is mostly due to the decrease in the hospital-specific rate
payment percentage from 20 percent in FY 1999 to 10 percent in FY
2000.
We are proposing no changes in our exceptions policies for FY
2000. As a result, the minimum payment levels would be--
[[Page 24841]]
90 percent for sole community hospitals;
80 percent for urban hospitals with 100 or more beds
and a disproportionate share patient percentage of 20.2 percent or
more; or
70 percent for all other hospitals.
We estimate that exceptions payments will increase from 1.74
percent of total capital payments in FY 1999 to 2.45 percent of
payments in FY 2000. The projected distribution of the exception
payments is shown in the chart below:
Estimated FY 2000 Exceptions Payments
------------------------------------------------------------------------
Percent of
Type of hospital Number of exceptions
hospitals payments
------------------------------------------------------------------------
Low Capital Cost.............................. 180 40
High Capital Cost............................. 208 60
-------------------------
Total..................................... 388 100
------------------------------------------------------------------------
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
number of Percentage Percentage paid fully
hospitals paid hold- paid fully prospective
harmless (A) federal (B) rate
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
All hospitals............................... 4,834 4.6 33.8 61.6
Large urban areas (populations over 1 1,531 4.8 41.7 53.4
million)...................................
Other urban areas (populations of 1 million 1,146 5.7 42.0 52.4
of fewer)..................................
Rural areas................................. 2,157 3.8 23.9 72.3
Urban hospitals............................. 2,677 5.2 41.8 53.0
0-99 beds............................... 650 6.5 34.3 59.2
100-199 beds............................ 912 7.2 48.5 44.3
200-299 beds............................ 553 4.2 42.3 53.5
300-499 beds............................ 423 1.4 39.2 59.3
500 or more beds........................ 139 1.4 39.6 59.0
Rural hospitals............................. 2,157 3.8 23.9 72.3
0-49 beds............................... 1,190 3.4 16.8 79.7
50-99 beds.............................. 580 4.5 29.5 66.0
100-149 beds............................ 232 4.7 36.6 58.6
150-199 beds............................ 85 3.5 30.6 65.9
200 or more beds........................ 70 1.4 48.6 50.0
By Region:
Urban by Region............................. 2,677 5.2 41.8 53.0
New England............................. 148 0.7 28.4 70.9
Middle Atlantic......................... 412 2.7 36.4 60.9
South Atlantic.......................... 399 5.3 52.9 41.9
East North Central...................... 444 6.1 31.8 62.2
East South Central...................... 154 10.4 46.8 42.9
West North Central...................... 179 3.4 40.2 56.4
West South Central...................... 331 10.3 59.2 30.5
Mountain................................ 123 5.7 50.4 43.9
Pacific................................. 440 3.4 36.6 60.0
Puerto Rico............................. 47 2.1 27.7 70.2
Rural by Region............................. 2,157 3.8 23.9 72.3
New England............................. 52 1.9 23.1 75.0
Middle Atlantic......................... 80 6.3 20.0 73.8
South Atlantic.......................... 285 1.4 34.7 63.9
East North Central...................... 300 3.3 18.3 78.3
East South Central...................... 270 2.6 34.1 63.3
West North Central...................... 490 3.7 15.9 80.4
West South Central...................... 337 3.9 27.9 68.2
Mountain................................ 200 8.5 18.0 73.5
Pacific................................. 138 5.1 23.9 71.0
By Payment Classification:
Large urban areas (populations over 1 1,607 4.7 41.8 53.6
million)...................................
Other urban areas (populations of 1 million 1,147 5.8 41.3 52.9
of fewer)..................................
Rural areas................................. 2,080 3.8 23.6 72.5
Teaching Status:
Non-teaching............................ 3,732 5.0 33.1 61.9
Fewer than 100 Residents................ 868 3.8 37.0 59.2
100 or more Residents................... 234 1.3 33.3 65.4
[[Page 24842]]
Disproportionate share hospitals (DSH):.
Non-DSH................................. 3,014 4.6 29.9 65.5
Urban DSH:
100 or more beds.................... 1,362 4.4 44.6 51.0
Less than 100 beds.................. 84 8.3 23.8 67.9
Rural DSH:
Sole Community (SCH)................ 153 5.9 20.9 73.2
Referral Center (RRC)............... 55 3.6 43.6 52.7
Other Rural:........................
100 or more beds.................... 57 1.8 43.9 54.4
Less than 100 beds.................. 109 2.8 25.7 71.6
Urban teaching and DSH:
Both teaching and DSH....................... 703 2.7 37.7 59.6
Teaching and no DSH......................... 337 4.5 33.8 61.7
No teaching and DSH......................... 743 6.5 48.7 44.8
No teaching and no DSH...................... 971 6.1 41.6 52.3
Rural Hospital Types:
Non special status hospitals................ 881 1.7 25.0 73.3
RRC/EACH.................................... 151 0.7 43.0 56.3
SCH/EACH.................................... 638 7.7 21.0 71.3
Medicare-dependent hospitals (MDH).......... 352 2.3 16.2 81.5
SCH, RRC and EACH........................... 58 12.1 25.9 62.1
Type of Ownership:
Voluntary................................... 2,826 4.0 33.4 62.6
Proprietary................................. 721 7.6 59.1 33.3
Government.................................. 1,255 3.8 20.8 75.4
Medicare Utilization as a Percent of Inpatient
Days:
0-25........................................ 360 4.4 27.8 67.8
25-50....................................... 1,739 4.8 36.6 58.7
50-65....................................... 1,885 4.2 33.3 62.5
Over 65..................................... 817 4.7 32.9 62.4
----------------------------------------------------------------------------------------------------------------
As we explain in Appendix B of this proposed rule, we were not
able to determine a hospital-specific rate for 40 of the 4,874
hospitals in our database. Consequently, the payment methodology
distribution is based on 4,834 hospitals. These data should be fully
representative of the payment methodologies that will be applicable
to hospitals.
The cross-sectional distribution of hospital by payment
methodology is presented by: (1) Geographic location; (2) region;
and (3) payment classification. This provides an indication of the
percentage of hospitals within a particular hospital grouping that
will be paid under the fully prospective payment methodology and the
hold-harmless payment methodology.
The percentage of hospitals paid fully Federal (100 percent of
the Federal rate) as hold-harmless hospitals is expected to increase
to 33.8 percent in FY 2000.
Table IV indicates that 61.6 percent of hospitals will be paid
under the fully prospective payment methodology. (This figure,
unlike the figure of 66 percent for low cost capital hospitals in
the chart on ``Capital Transition Payment Methodology for FY 2000,''
in section VII.B.2. of this preamble takes into account the effects
of redeterminations. In other words, this figure does not include
low cost hospitals that, following a hospital-specific rate
redetermination, are now paid under the hold-harmless methodology.)
As expected, a relatively higher percentage of rural and
governmental hospitals (72.5 percent and 75.4 percent, respectively
by payment classification) are being paid under the fully
prospective payment methodology. This is a reflection of their lower
than average capital costs per case. In contrast, only 33.3 percent
of proprietary hospitals are being paid under the fully prospective
methodology. This is a reflection of their higher than average
capital costs per case. (We found at the time of the August 30, 1991
final rule (56 FR 43430) that 62.7 percent of proprietary hospitals
had a capital cost per case above the national average cost per
case.)
D. Cross-Sectional Analysis of Changes in Aggregate Payments
We used our FY 2000 actuarial model to estimate the potential
impact of our proposed changes for FY 2000 on total capital payments
per case, using a universe of 4,834 hospitals. The individual
hospital payment parameters are taken from the best available data,
including: the January 1, 1999 update to the provider-specific file,
cost report data, and audit information supplied by intermediaries.
In Table V we present the results of the cross-sectional analysis
using the results of our actuarial model and the aggregate impact of
the proposed FY 2000 payment policies. Columns 3 and 4 show
estimates of payments per case under our model for FY 1999 and FY
2000. Column 5 shows the total percentage change in payments from FY
1999 to FY 2000. Column 6 presents the percentage change in payments
that can be attributed to Federal rate changes alone.
Federal rate changes represented in Column 6 include the 1.0
percent decrease in the Federal rate, a 0.5 percent increase in case
mix, changes in the adjustments to the Federal rate (for example,
the effect of the new hospital wage index on the geographic
adjustment factor), and reclassifications by the MGCRB. Column 5
includes the effects of the Federal rate changes represented in
Column 6. Column 5 also reflects the effects
[[Page 24843]]
of all other changes, including the change from 80 percent to 90
percent in the portion of the Federal rate for fully prospective
hospitals, the hospital-specific rate update, changes in the
proportion of new to total capital for hold-harmless hospitals,
changes in old capital (for example, obligated capital put in use),
hospital-specific rate redeterminations, and exceptions. The
comparisons are provided by: (1) Geographic location, (2) region,
and (3) payment classification.
The simulation results show that, on average, capital payments
per case can be expected to increase 1.9 percent in FY 2000, despite
the effect of the 1.4 percent decrease attributable to the reduction
in the Federal rate and other factors (which include changes in the
adjustment to the Federal rate, the increase in case mix, and the
other components of column 6 of table V).
Our comparison by geographic location shows that urban and rural
hospitals will experience slightly different rates of increase in
capital payments per case (1.8 percent and 2.8 percent,
respectively). This difference is due to the higher rate of decrease
for urban hospitals relative to rural hospitals (1.6 percent and 0.4
percent, respectively) from the Federal rate changes alone. Urban
hospitals will gain approximately the same as rural hospitals (3.4
percent versus 3.2 percent) from the effects of all other changes.
Most regions are estimated to receive increases in total capital
payments per case, partly due to the increased share of payments
that are based on the Federal rate (from 80 to 90 percent). Changes
by region vary from a low of 1.1 percent decrease (West South
Central urban region) to a high of 5.9 percent increase (West North
Central rural region).
By type of ownership, government hospitals are projected to have
the largest rate of increase of total payment changes (3.1 percent,
a 3.9 percent increase from the effects of all other changes and a
0.8 percent decrease due to Federal rate changes). Payments to
voluntary hospitals will increase 1.9 percent (a 3.3 percent
increase from the effects of all other changes and a 1.4 percent
decrease due to Federal rate changes), and payments to proprietary
hospitals will increase 1.1 percent (a 3.1 percent increase from the
effects of all other changes and a 2.0 percent decrease due to
Federal rate changes).
Section 1886(d)(10) of the Act established the MGCRB. Hospitals
may apply for reclassification for purposes of the standardized
amount, wage index, or both and for purposes of DSH, for FY 1999-
2001. Although the Federal capital rate is not affected, a
hospital's geographic classification for purposes of the operating
standardized amount does affect a hospital's capital payments as a
result of the large urban adjustment factor and the disproportionate
share adjustment for urban hospitals with 100 or more beds.
Reclassification for wage index purposes affects the geographic
adjustment factor, since that factor is constructed from the
hospital wage index.
To present the effects of the hospitals being reclassified for
FY 2000 compared to the effects of reclassification for FY 1999, we
show the average payment percentage increase for hospitals
reclassified in each fiscal year and in total. For FY 2000
reclassifications, we indicate those hospitals reclassified for
standardized amount purposes only, for wage index purposes only, and
for both purposes. The reclassified groups are compared to all other
nonreclassified hospitals. These categories are further identified
by urban and rural designation.
Hospitals reclassified for FY 2000 as a whole are projected to
experience a 2.8 percent increase in payments (a 3.1 percent
increase attributable to the effects of all other changes and a 0.3
percent decrease attributable to Federal rate changes). Payments to
nonreclassified hospitals will increase slightly less (1.9 percent)
than reclassified hospitals (2.8 percent) overall. Payments to
nonreclassified hospitals will decrease more than reclassified
hospitals from the Federal rate changes (1.5 percent compared to 0.3
percent), but they will gain about the same from the effects of all
other changes (3.4 percent compared to 3.1 percent).
Table V.--Comparison of Total Payments Per Case
[FY 1999 Compared to FY 2000]
----------------------------------------------------------------------------------------------------------------
Portion
Number of Average FY Average FY attributable
hospitals 1999 payments/ 2000 payments/ All changes to Federal
case case rate change
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
All hospitals............... 4,834 632 645 1.9 -1.4
Large urban areas 1,531 731 742 1.5 -1.8
(populations over 1
million)...................
Other urban areas 1,146 622 636 2.3 -1.3
(populations of 1 million
or fewer)..................
Rural areas................. 2,157 426 438 2.8 -0.4
Urban hospitals............. 2,677 684 697 1.8 -1.6
0-99 beds............... 650 501 507 1.1 -1.6
100-199 beds............ 912 602 609 1.2 -1.5
200-299 beds............ 553 660 673 2.0 -1.6
300-499 beds............ 423 704 720 2.3 -1.5
500 or more beds........ 139 892 906 1.5 -1.9
Rural hospitals............. 2,157 426 438 2.8 -0.4
0-49 beds............... 1,190 346 359 3.9 0.2
50-99 beds.............. 580 400 413 3.4 -0.1
100-149 beds............ 232 439 451 2.7 -0.4
150-199 beds............ 85 459 479 4.3 -0.4
200 or more beds........ 70 549 550 0.1 -1.1
By Region:
Urban by Region............. 2,677 684 697 1.8 -1.6
New England............. 148 693 715 3.1 -1.0
Middle Atlantic......... 412 751 759 1.1 -2.2
South Atlantic.......... 399 671 692 3.1 -1.0
East North Central...... 444 645 663 2.7 -0.9
East South Central...... 154 642 662 3.1 -1.3
West North Central...... 179 664 672 1.3 -1.8
West South Central...... 331 664 657 -1.1 -2.9
Mountain................ 123 657 667 1.6 -1.2
Pacific................. 440 762 773 1.5 -1.9
Puerto Rico............. 47 298 295 -1.0 -1.4
[[Page 24844]]
Rural by Region............. 2,157 426 438 2.8 -0.4
New England............. 52 507 515 1.6 -0.6
Middle Atlantic......... 80 446 458 2.7 -1.3
South Atlantic.......... 285 439 451 2.6 -0.4
East North Central...... 300 441 449 1.8 -0.4
East South Central...... 270 391 403 3.2 0.4
West North Central...... 490 417 442 5.9 0.6
West South Central...... 337 380 381 0.3 -1.7
Mountain................ 200 447 466 4.3 0.5
Pacific................. 138 498 512 2.8 -0.7
By Payment Classification:
All hospitals............... 4,834 632 645 1.9 -1.4
Large urban areas 1,607 724 735 1.5 -1.8
(populations over 1
million)...................
Other urban areas 1,147 620 635 2.3 -1.3
(populations of 1 million
or fewer)..................
Rural areas................. 2,080 423 435 2.9 -0.4
Teaching Status:
Non-teaching............ 3,732 532 541 1.7 -1.2
Fewer than 100 Residents 868 664 679 2.1 -1.6
100 or more Residents... 234 946 967 2.2 -1.8
Urban DSH:
100 or more beds.... 1,362 724 737 1.8 -1.6
Less than 100 beds.. 84 505 500 -0.9 -1.2
Rural DSH:
Sole Community (SCH/ 153 390 418 7.3 0.1
EACH)..............
Referral Center (RRC/ 55 484 492 1.8 -0.5
EACH)..............
Other Rural:
100 or more beds 57 392 396 1.1 -0.6
Less than 100 109 331 348 5.3 1.4
beds...........
Urban teaching and DSH:
Both teaching and DSH... 703 794 811 2.1 -1.7
Teaching and no DSH..... 337 681 696 2.2 -1.6
No teaching and DSH..... 743 607 614 1.3 -1.5
No teaching and no DSH.. 971 573 580 1.3 -1.5
Rural Hospital Types:
Non special status 881 378 387 2.6 -0.4
hospitals..............
RRC/EACH................ 151 490 500 1.9 -0.9
SCH/EACH................ 638 428 446 4.4 0.0
Medicare-dependent 352 345 357 3.5 0.0
hospitals (MDH)........
SCH, RRC and EACH....... 58 498 511 2.4 0.2
Hospitals Reclassified by
the Medicare Geographic
Classification Review
Board:
Reclassification Status
During FY1999 and
FY2000:
Reclassified During 373 553 561 1.3 -1.3
Both FY1999 and
FY2000.............
Reclassified During 131 594 642 8.1 3.1
FY2000 Only............
Reclassified During 136 531 513 -3.4 -6.3
FY1999 Only............
FY2000 Reclassifications:
All Reclassified 504 562 578 2.8 -0.3
Hospitals..............
All Nonreclassified 4,304 642 654 1.9 -1.5
Hospitals..............
All Urban Reclassified 85 751 775 3.2 -1.1
Hospitals..............
Urban Nonreclassified 2,592 682 694 1.7 -1.6
Hospitals..............
All Reclassified Rural 419 489 502 2.6 0.1
Hospitals..............
Rural Nonreclassified 1,712 381 394 3.4 -0.4
Hospitals..............
Other Reclassified Hospitals 26 463 429 -7.3 -8.8
(Section 1886(D)(8)(B))....
Type of Ownership:
Voluntary............... 2,826 646 658 1.9 -1.4
Proprietary............. 721 634 641 1.1 -2.0
Government.............. 1,255 555 572 3.1 -0.8
Medicare Utilization as a
Percent of Inpatient Days:
0-25.................... 360 768 789 2.8 -2.1
25-50................... 1,739 726 737 1.5 -1.7
50-65................... 1,885 575 588 2.2 -1.2
----------------------------------------------------------------------------------------------------------------
[[Page 24845]]
Appendix B: Technical Appendix on the Capital Cost Model and Required
Adjustments
Under section 1886(g)(1)(A) of the Act, we set capital
prospective payment rates for FY 1992 through FY 1995 so that
aggregate prospective payments for capital costs were projected to
be 10 percent lower than the amount that would have been payable on
a reasonable cost basis for capital-related costs in that year. To
implement this requirement, we developed the capital acquisition
model to determine the budget neutrality adjustment factor. Even
though the budget neutrality requirement expired effective with FY
1996, we must continue to determine the recalibration and geographic
reclassification budget neutrality adjustment factor and the
reduction in the Federal and hospital-specific rates for exceptions
payments. To determine these factors, we must continue to project
capital costs and payments.
We used the capital acquisition model from the start of
prospective payments for capital costs through FY 1997. We now have
6 years of cost reports under the capital prospective payment
system. For FY 1998, we developed a new capital cost model to
replace the capital acquisition model. This revised model makes use
of the data from these cost reports.
The following cost reports are used in the capital cost model
for this proposed rule: the December 31, 1998 update of the cost
reports for PPS-IX (cost reporting periods beginning in FY 1992),
PPS-X (cost reporting periods beginning in FY 1993), PPS-XI (cost
reporting periods beginning in FY 1994), PPS-XII (cost reporting
periods beginning in FY 1995), PPS-XIII (cost reporting periods
beginning in FY 1996), and PPS-XIV (cost reporting periods beginning
in FY 1997). In addition, to model payments, we use the January 1,
1999 update of the provider-specific file, and the March 1994 update
of the intermediary audit file.
Since hospitals under alternative payment system waivers (that
is, hospitals in Maryland) are currently not paid under the capital
prospective payment system, we excluded these hospitals from our
model.
We developed FY 1992 through FY 1999 hospital-specific rates
using the provider-specific file and the intermediary audit file.
(We used the cumulative provider-specific file, which includes all
updates to each hospital's records, and chose the latest record for
each fiscal year.) We checked the consistency between the provider-
specific file and the intermediary audit file. We ensured that
increases in the hospital-specific rates were at least as large as
the published updates (increases) for the hospital-specific rates
each year. We were able to match hospitals to the files as shown in
the following table:
------------------------------------------------------------------------
Number of
Source hospitals
------------------------------------------------------------------------
Neither File............................................... 1
Audit File only............................................ 53
Provider-Specific File Only................................ 103
Provider-Specific and Audit File........................... 4717
------------
Total.................................................. 4874
------------------------------------------------------------------------
Sixty-three of the 4,874 hospitals had unusable or missing data,
or had no cost reports available. For 21 of the 63 hospitals, we
were unable to determine a hospital-specific rate from the available
cost reports. However, there was adequate cost information to
determine that these hospitals were paid under the hold-harmless
methodology. Since the hospital-specific rate is not used to
determine payments for hospitals paid under the hold-harmless
methodology, there was sufficient cost report information available
to include these 21 hospitals in the analysis. We were able to
estimate hospital-specific amounts from the PPS-IX cost report data
for an additional 2 hospitals. Hence, we were able to use 23 of the
63 hospitals. We used 4,834 hospitals for the analysis. Forty
hospitals could not be used in the analysis because of insufficient
information. These hospitals account for less than 0.2 percent of
admissions. Therefore, any effects from the elimination of their
cost report data should be minimal.
We analyzed changes in capital-related costs (depreciation,
interest, rent, leases, insurance, and taxes) reported in the cost
reports. We found a wide variance among hospitals in the growth of
these costs. For hospitals with more than 100 beds, the distribution
and mean of these cost increases were different for large changes in
bed-size (greater than 20 percent). We also analyzed
changes in the growth in old capital and new capital for cost
reports that provided this information. For old capital, we limited
the analysis to decreases in old capital. We did this since the
opportunity for most hospitals to treat ``obligated'' capital put
into service as old capital has expired. Old capital costs should
decrease as assets become fully depreciated and as interest costs
decrease as the loan is amortized.
The new capital cost model separates the hospitals into three
mutually exclusive groups. Hold-harmless hospitals with data on old
capital were placed in the first group. Of the remaining hospitals,
those hospitals with fewer than 100 beds comprise the second group.
The third group consists of all hospitals that did not fit into
either of the first two groups. Each of these groups displayed
unique patterns of growth in capital costs. We found that the gamma
distribution is useful in explaining and describing the patterns of
increase in capital costs. A gamma distribution is a statistical
distribution that can be used to describe patterns of growth rates,
with the greatest proportion of rates being at the low end. We use
the gamma distribution to estimate individual hospital rates of
increase as follows:
(1) For hold-harmless hospitals, old capital cost changes were
fitted to a truncated gamma distribution, that is, a gamma
distribution covering only the distribution of cost decreases. New
capital costs changes were fitted to the entire gamma distribution,
allowing for both decreases and increases.
(2) For hospitals with fewer than 100 beds (small), total
capital cost changes were fitted to the gamma distribution, allowing
for both decreases and increases.
(3) Other (large) hospitals were further separated into three
groups:
Bed-size decreases over 20 percent (decrease).
Bed-size increases over 20 percent (increase).
Other (no change).
Capital cost changes for large hospitals were fitted to gamma
distributions for each bed-size change group, allowing for both
decreases and increases in capital costs. We analyzed the
probability distribution of increases and decreases in bed size for
large hospitals. We found the probability somewhat dependent on the
prior year change in bed size and factored this dependence into the
analysis. Probabilities of bed-size change were determined. Separate
sets of probability factors were calculated to reflect the
dependence on prior year change in bed size (increase, decrease, and
no change).
The gamma distributions were fitted to changes in aggregate
capital costs for the entire hospital. We checked the relationship
between aggregate costs and Medicare per discharge costs. For large
hospitals, there was a small variance, but the variance was larger
for small hospitals. Since costs are used only for the hold-harmless
methodology and to determine exceptions, we decided to use the gamma
distributions fitted to aggregate cost increases for estimating
distributions of cost per discharge increases.
Capital costs per discharge calculated from the cost reports
were increased by random numbers drawn from the gamma distribution
to project costs in future years. Old and new capital were projected
separately for hold-harmless hospitals. Aggregate capital per
discharge costs were projected for all other hospitals. Because the
distribution of increases in capital costs varies with changes in
bed size for large hospitals, we first projected changes in bed size
for large hospitals before drawing random numbers from the gamma
distribution. Bed-size changes were drawn from the uniform
distribution with the probabilities dependent on the previous year
bed-size change. The gamma distribution has a shape parameter and a
scaling parameter. (We used different parameters for each hospital
group, and for old and new capital.)
We used discharge counts from the cost reports to calculate
capital cost per discharge. To estimate total capital costs for FY
1998 (the MedPAR data year) and later, we use the number of
discharges from the MEDPAR data. Some hospitals have considerably
more discharges in FY 1998 than in the years for which we calculated
cost per discharge from the cost report data. Consequently, a
hospital with few cost report discharges would have a high capital
cost per discharge, since fixed
[[Page 24846]]
costs would be allocated over only a few discharges. If discharges
increase substantially, the cost per discharge would decrease
because fixed costs would be allocated over more discharges. If the
projection of capital cost per discharge is not adjusted for
increases in discharges, the projection of exceptions would be
overstated. We address this situation by recalculating the cost per
discharge with the MedPAR discharges if the MedPAR discharges exceed
the cost report discharges by more than 20 percent. We do not adjust
for increases of less than 20 percent because we have not received
all of the FY 1998 discharges, and we have removed some discharges
from the analysis because they are statistical outliers. This
adjustment reduces our estimate of exceptions payments, and
consequently, the reduction to the Federal rate for exceptions is
smaller. We will continue to monitor our modeling of exceptions
payments and make adjustments as needed.
The average national capital cost per discharge generated by
this model is the combined average of many randomly generated
increases. This average must equal the projected average national
capital cost per discharge, which we projected separately (outside
this model). We adjusted the shape parameter of the gamma
distributions so that the modeled average capital cost per discharge
matches our projected capital cost per discharge. The shape
parameter for old capital was not adjusted since we are modeling the
aging of ``existing'' assets. This model provides a distribution of
capital costs among hospitals that is consistent with our aggregate
capital projections.
Once each hospital's capital-related costs are generated, the
model projects capital payments. We use the actual payment
parameters (for example, the case-mix index and the geographic
adjustment factor) that are applicable to the specific hospital.
To project capital payments, the model first assigns the
applicable payment methodology (fully prospective or hold-harmless)
to the hospital as determined from the provider-specific file and
the cost reports. The model simulates Federal rate payments using
the assigned payment parameters and hospital-specific estimated
outlier payments. The case-mix index for a hospital is derived from
the FY 1998 MedPAR file using the proposed FY 2000 DRG relative
weights included in section VI. of the Addendum to this proposed
rule. The case-mix index is increased each year after FY 1998 based
on analysis of past experiences in case-mix increases. Based on
analysis of recent case-mix increases, we estimate that case-mix
will increase 0.5 percent in FY 1999 and 0.5 percent in FY 2000.
(Since we are using FY 1998 cases for our analysis, the FY 1998
increase in case mix has no effect on projected capital payments.)
Changes in geographic classification and revisions to the
hospital wage data used to establish the hospital wage index affect
the geographic adjustment factor. Changes in the DRG classification
system and the relative weights affect the case-mix index.
Section 412.308(c)(4)(ii) requires that the estimated aggregate
payments for the fiscal year, based on the Federal rate after any
changes resulting from DRG reclassifications and recalibration and
the geographic adjustment factor, equal the estimated aggregate
payments based on the Federal rate that would have been made without
such changes. For FY 1999, the budget neutrality adjustment factors
were 1.00294 for the national rate and 1.00233 for the Puerto Rico
rate.
Since we implemented a separate geographic adjustment factor for
Puerto Rico, we applied separate budget neutrality adjustments for
the national geographic adjustment factor and the Puerto Rico
geographic adjustment factor. We applied the same budget neutrality
factor for DRG reclassifications and recalibration nationally and
for Puerto Rico. Separate adjustments were unnecessary for FY 1998
since the geographic adjustment factor for Puerto Rico was
implemented in 1998.
To determine the factors for FY 2000, we first determined the
portions of the Federal national and Puerto Rico rates that would be
paid for each hospital in FY 2000 based on its applicable payment
methodology. Using our model, we then compared, separately for the
national rate and the Puerto Rico rate, estimated aggregate Federal
rate payments based on the FY 1999 DRG relative weights and the FY
1999 geographic adjustment factor to estimated aggregate Federal
rate payments based on the FY 1999 relative weights and the FY 2000
geographic adjustment factor. In making the comparison, we held the
FY 2000 Federal rate portion constant and set the other budget
neutrality adjustment factor and the exceptions reduction factor to
1.00. We determined that, to achieve budget neutrality for the
changes in the national geographic adjustment factor, an incremental
budget neutrality adjustment of 0.99845 for FY 2000 should be
applied to the previous cumulative FY 1999 adjustment of 1.00294,
yielding a cumulative adjustment of 1.00139 through FY 2000. For the
Puerto Rico geographic adjustment factor, an incremental budget
neutrality adjustment of 1.00151 for FY 2000 should be applied to
the previous cumulative FY 1999 adjustment of 1.00233, yielding a
cumulative adjustment of 1.00384 through FY 2000. We apply these new
adjustments, then compare estimated aggregate Federal rate payments
based on the FY 1999 DRG relative weights and the FY 2000 geographic
adjustment factors to estimated aggregate Federal rate payments
based on the FY 2000 DRG relative weights and the FY 2000 geographic
adjustment factors. The incremental adjustment for DRG
classifications and changes in relative weights would be 1.00014
nationally and for Puerto Rico. The cumulative adjustments for DRG
classifications and changes in relative weights and for changes in
the geographic adjustment factors through FY 2000 would be 1.00153
nationally, and 1.00398 for Puerto Rico. The following table
summarizes the adjustment factors for each fiscal year:
Budget Neutrality Adjustment for DRG Reclassifications and Recalibration and the Geographic Adjustment Factors
--------------------------------------------------------------------------------------------------------------------------------------------------------
National Puerto Rico
-------------------------------------------------------------------------------------------------------------------
Incremental adjustment Incremental adjustment
Fiscal year --------------------------------------------- ---------------------------------------------
Geographic DRG Cumulative Geographic DRG Cumulative
adjustment reclassifications Combined adjustment reclassifications Combined
factor and recalibration factor and recalibration
--------------------------------------------------------------------------------------------------------------------------------------------------------
1992................................ ........... ................. ........... 1.00000 ........... ................. ........... ...........
1993................................ ........... ................. 0.99800 0.99800 ........... ................. ........... ...........
1994................................ ........... ................. 1.00531 1.00330 ........... ................. ........... ...........
1995................................ ........... ................. 0.99980 1.00310 ........... ................. ........... ...........
1996................................ ........... ................. 0.99940 1.00250 ........... ................. ........... ...........
1997................................ ........... ................. 0.99873 1.00123 ........... ................. ........... ...........
1998................................ ........... ................. 0.99892 1.00015 ........... ................. ........... 1.00000
1999................................ 0.99944 1.00335 1.00279 1.00294 0.99898 1.00335 1.00233 1.00233
2000................................ 0.99845 1.00014 0.99859 1.00153 1.00151 1.00014 1.00165 1.00398
--------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 24847]]
The methodology used to determine the recalibration and
geographic (DRG/GAF) budget neutrality adjustment factor is similar
to that used in establishing budget neutrality adjustments under the
prospective payment system for operating costs. One difference is
that, under the operating prospective payment system, the budget
neutrality adjustments for the effect of geographic
reclassifications are determined separately from the effects of
other changes in the hospital wage index and the DRG relative
weights. Under the capital prospective payment system, there is a
single DRG/GAF budget neutrality adjustment factor (the national
rate and the Puerto Rico rate are determined separately) for changes
in the geographic adjustment factor (including geographic
reclassification) and the DRG relative weights. In addition, there
is no adjustment for the effects that geographic reclassification
has on the other payment parameters, such as the payments for
serving low-income patients or the large urban add-on payments.
In addition to computing the DRG/GAF budget neutrality
adjustment factor, we used the model to simulate total payments
under the prospective payment system.
Additional payments under the exceptions process are accounted
for through a reduction in the Federal and hospital-specific rates.
Therefore, we used the model to calculate the exceptions reduction
factor. This exceptions reduction factor ensures that aggregate
payments under the capital prospective payment system, including
exceptions payments, are projected to equal the aggregate payments
that would have been made under the capital prospective payment
system without an exceptions process. Since changes in the level of
the payment rates change the level of payments under the exceptions
process, the exceptions reduction factor must be determined through
iteration.
In the August 30, 1991 final rule (56 FR 43517), we indicated
that we would publish each year the estimated payment factors
generated by the model to determine payments for the next 5 years.
The table below provides the actual factors for FYs 1992 through
1999, the proposed factors for FY 2000, and the estimated factors
that would be applicable through FY 2004. We caution that these are
estimates for FYs 2000 and later, and are subject to revisions
resulting from continued methodological refinements, receipt of
additional data, and changes in payment policy changes. We note that
in making these projections, we have assumed that the cumulative
national DRG/GAF budget neutrality adjustment factor will remain at
1.00153 (1.00398 for Puerto Rico) for FY 2000 and later because we
do not have sufficient information to estimate the change that will
occur in the factor for years after FY 2000.
The projections are as follows:
--------------------------------------------------------------------------------------------------------------------------------------------------------
Federal
Update Exceptions Budget DRG/GAF Outlier Federal rate (after
Fiscal year factor reduction neutrality adjustment adjustment rate outlier)
factor factor factor 1 factor adjustment reduction
--------------------------------------------------------------------------------------------------------------------------------------------------------
1992......................................................... N/A 0.9813 0.9602 ........... .9497 ........... 415.59
1993......................................................... 6.07 .9756 .9162 .9980 .9496 ........... 417.29
1994......................................................... 3.04 .9485 .8947 1.0053 .9454 2 .9260 378.34
1995......................................................... 3.44 .9734 .8432 .9998 .9414 ........... 376.83
1996......................................................... 1.20 .9849 N/A .9994 .9536 3 .9972 461.96
1997......................................................... 0.70 .9358 N/A .9987 .9481 ........... 438.92
1998......................................................... 0.90 .9659 N/A .9989 .9382 4 .8222 371.51
1999......................................................... 0.10 .9783 N/A 1.0028 .9392 ........... 378.10
2000......................................................... -0.60 .9752 N/A .9986 .9397 ........... 374.31
2001......................................................... 0.50 .9645 N/A 5 1.0000 5 .9397 ........... 372.06
2002......................................................... 0.50 6 1.0000 N/A 1.0000 .9397 ........... 387.68
2003......................................................... 0.50 6 1.0000 N/A 1.0000 .9397 4 1.0255 399.57
2004......................................................... 0.60 6 1.0000 N/A 1.0000 .9397 ........... 401.97
--------------------------------------------------------------------------------------------------------------------------------------------------------
1 Note: The incremental change over the previous year.
2 Note: OBRA 1993 adjustment.
3 Note: Adjustment for change in the transfer policy.
4 Note: Balanced Budget Act of 1997 adjustment.
5 Note: Future adjustments are, for purposes of this projection, assumed to remain at the same level.
6 Note: We are unable to estimate exceptions payments for the year under the special exceptions provision (Sec. 412.348(g) of the regulations) because
the regular exceptions provision (Sec. 412.348(e)) expires.
Appendix C: Report to Congress
BILLING CODE 4120-01-P
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[GRAPHIC] [TIFF OMITTED] TP07MY99.003
BILLING CODE 4120-01-C
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Appendix D: Recommendation of Update Factors for Operating Cost Rates
of Payment for Inpatient Hospital Services
I. Background
Several provisions of the Act address the setting of update
factors for inpatient services furnished in FY 2000 by hospitals
subject to the prospective payment system and those excluded from
the prospective payment system. Section 1886(b)(3)(B)(i)(XV) of the
Act sets the FY 2000 percentage increase in the operating cost
standardized amounts equal to the rate of increase in the hospital
market basket minus 1.8 percent for prospective payment hospitals in
all areas. Section 1886(b)(3)(B)(iv) of the Act sets the FY 2000
percentage increase in the hospital-specific rates applicable to
sole community and Medicare-dependent, small rural hospitals equal
to the rate set forth in section 1886(b)(3)(B)(i) of the Act, that
is, the same update factor as all other hospitals subject to the
prospective payment system, or the rate of increase in the market
basket minus 1.8 percentage points. Under section 1886(b)(3)(B)(ii)
of the Act, the FY 2000 percentage increase in the rate of increase
limits for hospitals excluded from the prospective payment system
ranges from the percentage increase in the excluded hospital market
basket to 0 percent, depending on the hospital's costs in relation
to its limit for the most recent cost reporting period for which
information is available.
In accordance with section 1886(d)(3)(A) of the Act, we are
proposing to update the standardized amounts, the hospital-specific
rates, and the rate-of-increase limits for hospitals excluded from
the prospective payment system as provided in section 1886(b)(3)(B)
of the Act. Based on the first quarter 1999 forecast of the FY 2000
market basket increase of 2.7 percent for hospitals subject to the
prospective payment system, the proposed updates to the standardized
amounts are 0.9 percent (that is, the market basket rate of increase
minus 1.8 percent percentage points) for hospitals in both large
urban and other areas. The proposed update to the hospital-specific
rate applicable to sole community and Medicare-dependent, small
rural hospitals is also 0.9 percent. The proposed update for
hospitals excluded from the prospective payment system would range
from 0 percent to the percentage increase in the excluded hospital
market basket (currently estimated at 2.6 percent).
Section 1886(e)(4) of the Act requires that the Secretary,
taking into consideration the recommendations of the Medicare
Payment Advisory Commission (MedPAC), recommend update factors for
each fiscal year that take into account the amounts necessary for
the efficient and effective delivery of medically appropriate and
necessary care of high quality. 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 MedPAC
recommendations concerning the update factors.
In its March 1, 1999 report, MedPAC stated that the legislated
update of market basket increase minus 1.8 percentage points would
provide a reasonable level of payment to hospitals. Although MedPAC
suggests that a somewhat lower update could be justified in light of
changes in the utilization and provision of hospital inpatient care,
the Commission does not believe it is necessary to recommend a lower
update for FY 2000. MedPAC did not make a separate recommendation
for the hospital-specific rates applicable to sole community and
Medicare-dependent, small rural hospitals. We discuss MedPAC's
recommendations concerning the update factors and our responses to
these recommendations below.
II. Secretary's Recommendations
Under section 1886(e)(4) of the Act, we are recommending that an
appropriate update factor for the standardized amounts is 0.0
percentage points for hospitals located in large urban and other
areas. We are also recommending an update of 0.0 percentage points
to the hospital-specific rate for sole community hospitals and
Medicare-dependent, small rural hospitals. These figures are
consistent with the President's FY 2000 budget recommendations. We
believe these recommended update factors would ensure that Medicare
acts as a prudent purchaser and provide incentives to hospitals for
increased efficiency, thereby contributing to the solvency of the
Medicare Part A Trust Fund. When the President's budget was
submitted, the market basket rate of increase was projected at 2.7
percent. This proposed recommendation is based on a more recent
forecast of the market basket, although still 2.7 percent.
We recommend that hospitals excluded from the prospective
payment system receive an update of between 0 and 2.6 percentage
points. The update for excluded hospitals and units is equal to the
increase in the excluded hospital operating market basket less a
percentage between 0 and 2.5 percentage points, or 0 percentage
points, depending on the hospital's or unit's costs in relation to
its rate-of-increase limit. The market basket rate of increase is
currently forecast at 2.6 percent. This recommendation is consistent
with the President's FY 2000 budget, although we note that the
market basket rate of increase was forecast at 2.7 percent when the
budget was submitted.
As required by section 1886(e)(4) of the Act, we have taken into
consideration the recommendations of MedPAC in setting these
recommended update factors. Our responses to the MedPAC
recommendations concerning the update factors are discussed below.
III. MedPAC Recommendations for Updating the Prospective Payment System
Standardized Amounts
For FY 2000, MedPAC's update framework would support an update
to the standardized amounts under the prospective payment system
between the increase in the hospital market basket minus 2.5
percentage points and the increase in the hospital market basket
plus 0.1 percentage points. MedPAC notes that hospital total revenue
margins have continued to increase this decade and the percentage of
hospitals with negative total revenue margins remains much lower
than it was a decade ago. Thus, MedPAC believes the statutory update
of market basket increase minus 1.8 percentage points for FY 2000 is
reasonable and appropriate.
MedPAC's estimate of the market basket increase is 2.3 percent,
based on the fourth quarter 1998 estimate. MedPAC's market basket
estimate focuses on employee compensation changes in the hospital
industry and the economy in general, while HCFA's market basket
forecast gives less weight to the projected changes in the hospital
industry's wages. When MedPAC published its recommendations, HCFA's
market basket forecast was 2.5 percent. Thus, MedPAC's update
framework reflects a 0.2 percent adjustment for this difference.
Response: Our update recommendation of 0.0 percent is within the
range of updates MedPAC has suggested for the prospective payment
system hospitals, albeit at the low end. 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:
a. 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. MedPAC's predecessor, the
Prospective Payment Assessment Commission (ProPAC), estimated
cumulative service productivity growth to be 4.9 percent from 1985
through 1989, or 1.2 percent annually. At the same time, ProPAC
estimated total output growth at 3.4 percent annually, implying a
ratio of service productivity growth to output growth of 0.35.
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
[[Page 24853]]
a 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 historical averages in years that output growth is
relatively low and larger in years that output growth is higher than
the historical averages. 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, expected quality
enhancing intensity growth, and 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 (1.0 percent
for FY 2000), and projected real case-mix growth (0.5 percent), or
1.5 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
(1.5 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 61.4, provides our productivity standard of 0.3
percent, thus our recommendation includes a -0.3 percent update for
improved productivity.
In past years, MedPAC's recommendation has taken into account
product change. This year, while there is not a specific mention of
product change in MedPAC's recommendation, similar factors do appear
in their discussion of ``site of service substitution.'' HCFA takes
this factor into account when measuring change in intensity, as
discussed below. In addition, MedPAC's update framework contains a
productivity adjustment of between -1.0 to 0.0 percent, which is
slightly more optimistic than our estimate.
b. 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 2000, 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. A study published in the
Winter 1992 issue of the Health Care Financing Review,
``Contributions of case mix and intensity change to hospital cost
increases'' (pp. 151-163), suggests that one-third of the intensity
change is attributable to high-cost technology. The balance was
unexplained but the authors speculated that it is attributable to
fixed costs in service delivery.
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.
All things being equal, per-discharge fixed costs tend to
fluctuate in inverse proportion to changes in volume. Fixed costs
exist whether patients are treated or not. If volume is declining,
per-discharge fixed costs will rise, but the reverse is true if
volume is increasing.
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 FYs 1994 through 1998 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 FYs 1994 through 1998, observed case-mix index change ranged
from a low of -.04 percent to a high of 1.7 percent, with a 5-year
average change of 1.0 percent. Based on evidence from past studies
of case-mix change, we estimate that real case-mix change fluctuates
between 1.0 and 1.4 percent and the observed values generally fall
in this range, although some years the figures fall outside this
range. The average percentage change in charge per discharge was 2.9
percent and the average annual change in the medical CPI was 4.6
percent. Dividing the change in charge per discharge by the quantity
of the real case-mix index change and the medical CPI, yields an
average annual change in intensity of -2.9 percent. Assuming the
technology/fixed cost ratio still holds, technology would account
for a -1.0 percent annual decline while fixed costs would account
for a -1.9 percent annual decline. The decline in fixed costs per
discharge makes intuitive sense as volume, measured by total
discharges, has increased during the period. Since we estimate that
intensity has declined during that period, we are recommending a 0.0
percent intensity adjustment for FY 2000.
MedPAC does not make an intensity recommendation per se, but its
recommendation for the FY 2000 update includes two categories that
we consider to be comparable with our intensity recommendation.
MedPAC is recommending a 0.5 to 1.0 update for scientific and
technological advances to account for increased costs of systems
conversions necessary for computer compliance on January 1, 2000.
MedPAC's recommendation also takes into account the increasingly
apparent trend of some acute care providers to shift care to a
postacute care facility. While this can occur for many reasons,
there is good reason to suspect prospective payment system payment
limits. Accordingly, MedPAC recommends an adjustment of -1.8 to -0.9
for site-of-care substitution.
As we mentioned in last year's final rule, higher input prices
that hospitals incur to convert computer systems to be complaint on
January 1, 2000, will be accounted for through the market basket. We
agree with MedPAC that the site of care substitution effect is real
and believe that it is factored into our intensity recommendation.
c. 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 2000 update recommendation, we are
projecting a 0.5 percent increase in the case-mix index. Unlike in
past years, where we differentiated between ``real'' case-mix
increase and increases attributable to changes in coding behavior,
we do not feel changes in coding behavior will impact the overall
case-mix in FY 2000. As such, we project the entire change will be
``real.''
MedPAC also does not expect any case-mix change due to coding
changes. MedPAC's estimate of overall case-mix change ranges from
0.0 to 0.2 percentage points for FY 2000.
d. Effect of FY 1998 DRG Reclassification and Recalibration. We
estimate that DRG reclassification and recalibration for FY 1998
resulted in a 0.7 percent decrease 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. MedPAC does not make an adjustment for DRG reclassification
and recalibration in its update recommendation.
We make a forecast error correction if the actual market basket
change for a previous fiscal year differs from the forecasted market
basket by 0.25 percentage points or more. Our update framework for
FY 2000 does not reflect a forecast error correction because, for FY
1998, there was less than a 0.25 percentage point difference between
the actual market basket and the forecasted market basket.
[[Page 24854]]
Table 1.--Comparison of FY 2000 Update Recommendations
----------------------------------------------------------------------------------------------------------------
HHS MedPAC
----------------------------------------------------------------------------------------------------------------
Market Basket......................... MB................................. MB
Difference between HCFA & MedPAC ................................... -0.4
Market Baskets.
-------------------------------------------------------------------------
Subtotal.......................... MB................................. MB
Policy Adjustments Factors:
Productivity...................... -0.3............................... -1.0 to 0.0
Site of Service Substitution...... (\3\).............................. -1.8 to -0.9
Intensity......................... 0.0................................
Science & Technology.......... ................................... 0.5 to 1.0
Practice Patterns............. ................................... (\1\)
Real Within DRG Change........ ................................... (\2\)
-------------------------------------------------------------------------
Subtotal.................. -0.3............................... -2.3 to 0.1
Case-Mix Adjustment Factors:
Projected Case-Mix Change......... -0.5...............................
Real Across DRG Change............ 0.5................................ 0.0
Real Within DRG Change............ (\3\).............................. 0.0 to 0.2
-------------------------------------------------------------------------
Subtotal...................... 0.0................................ 0.0 to 0.2
Effect of 1998 Reclassification & -0.7...............................
Recalibration.
Forecast Error Correction............. 0.0................................ 0.0
Total Recommended Update.............. MB -1.0............................ MB -2.7 to MB 0.1
----------------------------------------------------------------------------------------------------------------
\1\ Included in MedPAC's Productivity Measure.
\2\ Included in MedPAC's Case-Mix Adjustment.
\3\ Included in HHS' Intensity Factor.
While the above analysis would support a recommendation that the
update be no less than the market basket minus 1.0 percentage
points, we are recommending an update of 0.0 percentage points. We
note that had our framework included the negative intensity
adjustment, the framework would have suggested an update in the
range of market basket increase minus 3.9 percentage points and
market basket increase minus 2.0 percentage points. However,
consistent with past update recommendations, we did not make a
negative adjustment for intensity this year. A negative intensity
adjustment would capture the site of care substitution adjustment in
MedPAC's recommendation. In conjunction with our Office of Actuary,
we do intend to reexamine our update framework and the
appropriateness of a negative intensity adjustment.
For FY 2000, we believe that a 0.0 update factor appropriately
reflects current trends in health care delivery, including the
recent decreases in the use of hospital inpatient services and the
corresponding increase in the use of hospital outpatient and
postacute care services. Our recommendation is within the range of
MedPAC's recommendation. We also recommend that the hospital-
specific rates applicable to sole community hospitals be increased
by the same update, 0.0 percentage points.
IV. MedPAC Recommendation for Updating the Rate-of-Increase Limits for
Excluded Hospitals and Hospital Units (Recommendation 4A)
For hospitals and units excluded from the prospective payment
system, MedPAC's recommendation is that the Secretary ``should
increase the market basket amount in the target amount update
formula by 0.4 percentage points for fiscal year 2000.'' For cost
reporting periods beginning in FY 2000, the statute provides that
the update to the target amounts for excluded hospitals or units is
equal to the increase in the excluded hospital operating market
basket less a percentage between 0 and 2.5 percentage points, or 0
percent, depending on the hospital's or unit's costs in relation to
its target amount for the most recent cost reporting period for
which information is available. MedPAC believes that the update
formula for excluded hospitals should be adjusted upward by 0.4
percentage points, to reflect (1) a -0.1 percent adjustment for
differences between HCFA's and MedPAC's market baskets and (2) a 0.5
percent adjustment for scientific and technological advances.
Response: We believe that the statutory update is adequate and
that an upward adjustment to the statutory formula is unnecessary.
Thus, we recommend that hospitals excluded from the prospective
payment system receive an update between 0 percent and the increase
in the market basket for excluded hospitals. Overall declines in
inpatient operating costs and high levels of Medicare profit margins
support our recommendation. We believe this update would ensure that
Medicare acts as a prudent purchaser and would provide incentives to
hospitals for increased efficiency, thereby contributing to the
solvency of the Medicare Part A Trust Fund.
[FR Doc. 99-11200 Filed 5-6-99; 8:45 am]
BILLING CODE 4120-01-P
