2012-14159. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education ...

AGENCY:

Centers for Medicare and Medicaid Services (CMS), HHS.

ACTION:

Proposed rule, correction.

SUMMARY:

This document corrects technical and typographical errors in the proposed rule that appeared in the May 11, 2012 Federal Register entitled “Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers.”

FOR FURTHER INFORMATION CONTACT:

Tzvi Hefter, [phone].

SUPPLEMENTARY INFORMATION:

I. Background

In FR Doc. 2012-9985 of May 11, 2012 (77 FR 27870), there were a number of technical errors that are identified and corrected in the Correction of Errors section of this correcting document.

II. Summary of Errors

A. Errors in the Preamble

On pages 27871 and 27872, we inadvertently omitted a number of acronyms from the list of acronyms.

On page 27938, in our discussion of the fiscal year (FY) 2013 applications for new technology add-on payments, we made typographical errors regarding the drug combination administered during the treatment of methotrexate (MTX)-induced renal dysfunction.

On page 28021, we inadvertently cited the incorrect timeframe for when certain long-term care hospitals (LTCHs) and LTCH satellite facilities must comply with § 412.534 and § 412.536. We also cited the incorrect timeframe for when those LTCHs and LTCH satellite facilities would be under the proposed moratorium on the 25-percent adjustment threshold policy.

On page 28036, we made several typographical errors in our discussion of commenters' beliefs regarding the hospital inpatient quality reporting program (HIQR) and five Agency for Healthcare Research and Quality (AHRQ) measures.

On page 28039, in our discussion of the HIQR proposed new claims-based measure for the FY 2015 payment determination for hip/knee complication, we inadvertently repeated a sentence.

On page 28041, in our discussion of the HIQR proposed new claims-based measure for the FY 2015 payment determination for hip/knee readmission, we made a typographical error in a section heading.

On page 28072, in our discussion of the total amount available for value-based incentive payments under the Hospital VBP Program for a fiscal year, we inadvertently included estimated reductions to the base operating DRG payment amounts for Maryland hospitals in the calculation of the total estimate for FY 2013.

On pages 28085 and 28086, in our discussion of the proposed performance standards for the Hospital Value-Based Purchasing (VBP) Program, we inadvertently omitted data from the table entitled “Proposed Performance Standards for the FY 2015 Hospital VBP Program Clinical Process of Care and Outcome Domains, and the Medicare Spending per Beneficiary Measure.”

On pages 28107, 28108, and 28127 in our discussion of the Inpatient Psychiatric Facilities Quality Reporting Program (IPFQR), we made technical errors in our description of the IPF facility enrollment.

B. Errors in the Addendum

On page 28143, we made errors in our discussion of the proposed outlier fixed-loss cost threshold for FY 2013.

On pages 28144, 28148, 28149, 28150, 28151, 28159, and 28178, we made technical and typographical errors in our discussion of the proposed outlier adjustment factors which affected the proposed FY 2013 Puerto Rico (specific) operating standardized amount and capital Federal rates (national and Puerto Rico). Specifically, we inadvertently applied the incorrect adjustment factors to the operating and capital cost-to-charge ratios (CCRs) from the Provider-Specific File (PSF) when performing the calculation of the FY 2013 outlier fixed-loss cost threshold for the proposed rule. The correction of this error resulted in a decrease in the proposed outlier fixed-loss cost threshold of approximately $1,000. Under our established methodology for calculating the outlier fixed-loss cost threshold, which we have proposed to continue to use for FY 2013, the corrected proposed outlier fixed-loss cost threshold continues to result in operating outlier payments being projected to be 5.1 percent of total operating payments. However, a decrease in the proposed outlier threshold results in an increase of the Puerto Rico (specific) operating outlier payments and capital (national and Puerto Rico) outlier payments. This is because a lower outlier threshold allows more cases to qualify as outlier cases and results in higher outlier payments to such cases. Because outlier payments are budget neutral, a larger reduction (that is, an increase in the outlier offsets) to the Puerto Rico and capital (national and Puerto Rico) rates is necessary. Therefore, the application of the corrected Puerto Rico and capital outlier offsets (national and Puerto Rico) lowers the proposed FY 2013 Puerto Rico (specific) operating standardized amount and capital Federal rates (national and Puerto Rico).

On page 28189, in the impact analysis section for the inpatient Psychiatric Facilities Quality Reporting Program (IPFQR), we made technical errors in describing the IPF facility enrollment.

C. Summary of Errors in and Corrections to Tables Posted on the CMS Web site

On page 28158, we list Table 16, Proposed Hospital Inpatient Value-Based Purchasing (VBP) Program Adjustment Factors for FY 2013, as a table that will be available only through the Internet on the CMS Web site. The version of Table 16 that was posted via the Internet on the CMS Web site at the time the proposed rule was filed for public inspection at the Office of the Federal Register inadvertently included estimated reductions to the base operating DRG payment amounts for Maryland hospitals in the calculation of the proposed FY 2013 Hospital VBP Program adjustment factors.

We have corrected these errors and will post the corrected Table 16 on the CMS Web site at http://www.cms.hhs.gov/​AcuteInpatientPPS/​01_​overview.asp.

III. Correction of Errors

In FR Doc. 2012-9985 of May 11, 2012 (77 FR 27870), make the following corrections:

A. Corrections of Errors in the Preamble

1. On pages 27871 and 27872, second and third and first and second columns, respectively (Acronyms list), are corrected by adding the following acronyms in alphabetical order:

ACoS American College of Surgeons'

AJCC American Joint Commission on Cancer

ASCO American Society of Clinical Oncology

CAUTI Catheter-Associated Urinary Tract Infection

CLABSI Central Line-Associated Bloodstream Infection

CEO Chief Executive Officer

CCN CMS Certificate Number

CFR Code of Federal Regulations

CoC Commission on Cancer

DACA Data Accuracy and Completeness Acknowledgement

ESRD End-Stage Renal Disease

FR Federal Register

HAI Healthcare-Associated Infection

HBIPS Hospital-Based Inpatient Psychiatric Services

HICPAC Healthcare Infection Control Practices Advisory Committee

ICU Intensive Care Unit

IPFQR Inpatient Psychiatric Facilities Quality Reporting Program

MAP Measure Application Partnership

NCCN National Comprehensive Cancer Network

NOP Notice of Participation

OQR Outpatient Quality Reporting

QAPI Quality Assessment and Performance Improvement

QIP Quality Incentive Program

Q Quarter

TJC The Joint Commission

UTI Urinary Tract Infection

VTE Venous Thromboembolism

2. On page 27938, in the third column,

a. First partial paragraph—

(1). Line 5 the term “Thymidine” is corrected to read “leucovorin”.

(2). Line 9, the term “Thymidine” is corrected to read “leucovorin”.

(3). Lines 13 and 14, the phrase “19 to 94 years old.” is corrected to read “19 to 94 years old.^18a”

b. Footnoted text, before footnote 18, the footnoted text is corrected by adding the following:

^18a Green and Chamberlain, Cancer Chemotherapy and Pharmacology Volume 63, Number 4, 2009.

3. On page 28021, in the third column, first partial paragraph, lines 24 through 42, the sentences beginning with the phrase “Therefore, under our proposed policy” and ending with the phrase “proposed extension of the moratorium” are corrected to read “Therefore, under our proposed policy, there will be a period during which some of the above-described LTCHs and LTCH satellite facilities must comply with §§ 412.534 and 412.536 before becoming subject to the moratoria again. The above-described LTCHs and LTCH satellite facilities with a cost reporting period beginning on or after July 1, 2012, and before October 1, 2012 would comply with §§ 412.534 and 412.536 for discharges occurring in that respective cost reporting period. Then, those same LTCHs and LTCH satellite facilities would be subject to the proposed moratorium for discharges occurring in their first cost reporting period beginning on or after July 1, 2013 and before October 1, 2013.”

4. On page 28036, lower half of the page, first column, first paragraph, lines 7 through 8, the phrase “some commenters still believed that” is corrected to read “we recognize some commenters believe that”.

5. On page 28039, second column, third paragraph, lines 8 through 12, the sentence “Annual hospital charges are projected to increase by 340 percent to $17.4 billion for THA and by 450 percent to $40.8 billion for TKA by 2015” is corrected by deleting the sentence.

6. On page 28041, first column, second full paragraph, line 9, the heading that begins with the phrase “(ii) Hip/Knee Readmission:” is corrected by moving the phrase to line 10.

7. On page 28072, second column, first full paragraph, line 8, the figure “$956 million” is corrected to read “$917 million”.

8. On pages 28085 through 28086, lower third of the page, the table entitled Proposed Performance Standards for the FY 2015 Hospital VBP Program Clinical Process of Care and Outcome Domains, and the Medicare Spending per Beneficiary Measure” is corrected as follows:

Proposed Performance Standards for the FY 2015 Hospital VBP Program Clinical Process of Care and Outcome Domains, and the Medicare Spending per Beneficiary Measure

a. Revising the following entry:

Clinical Process of Care Measures

Measure ID	Description	Achievement threshold	Benchmark
AMI-10	Statin Prescribed at Discharge	0.90474	1.00000

b. Adding the following entry after line 3 (Measure ID, AMI-10):

Clinical Process of Care Measures

Measure ID	Description	Achievement threshold	Benchmark
HF-1	Discharge Instructions	0.92090	1.00000

9. On page 28107, third column, footnoted text (footnote 198), line 1, the phrase “IPFs, 450 are” is corrected to read “IPFs, approximately 450 are”.

10. On page 28108, first column, second full paragraph, line 6, the figure “1,100” is corrected to read “1,200”.

11. On page 28127, first column, fifth full paragraph—

a. Line 11, the figure “1,741” is corrected to read “estimated 1,700”.

b. Line 12, the figure “450” is corrected to read “approximately 450”.

c. Line 14, the figure “26.02” is corrected to read “approximately 26”.

B. Corrections of Errors in the Addendum

1. On page 28143, third column—

a. Second full paragraph, line 6, the figure “$27,425” is corrected to read “$26,337”

b. Third full paragraph, lines 2 and 3, the phrase “$5,040 (or 22.5 percent)” is corrected to read “$3,952 (or 17.7 percent)”.

2. On page 28144—

a. First column, first partial paragraph, lines 12 and 13, the phrase “welcomed comment on possible modifications to our current methodologies,” is corrected to read “welcome comment on possible modifications to our current methodology,”.

b. First column, second full paragraph, line 13, the figure “5.99” is corrected to read “6.43”

c. Second column, before the first paragraph, the untitled table is corrected to read as follows:

	Operating standardized amounts	Capital federal rate
National	0.948992	0.935720
Puerto Rico	0.953062	0.920266

3. On page 28148, second column, second full paragraph, line 6, the phrase “approximately 0.7 percent” is corrected to read “0.25 percent”.

4. On page 28149, third column—

a. First full paragraph, line 8, the figure “6.00” is corrected to read “6.43”

b. First full paragraph, line 12, the figure “0.9400” is corrected to read “0.9357”

c. First full paragraph, line 17, the phrase “lower than the percentage for FY 2012.” is corrected to read “higher than the percentage for FY 2012.”.

d. First full paragraph, lines 17 through 28, the sentences “This decrease in estimated capital outlier payments is primarily due to the proposed increase in the outlier threshold used to identify outlier cases for both inpatient operating and inpatient capital related payments, which is discussed in section II.A. of this Addendum. That is, because the outlier threshold used to identify outlier cases is higher, cases will receive lower outlier payments and fewer cases will qualify for outlier payments.” are corrected by deleting the sentences.

e. Second full paragraph, line 6, the phrase “0.9400 is 0.19 percent” is corrected to read “0.9357 is a −0.27 percent”

f. Second full paragraph, line 10, the phrase “1.0019 (0.9400/0.9832) is corrected to read “0.9973 (0.9357/0.9832)”

5. On page 28150, third column—

a. First partial paragraph, line 14, the figure “$424.42” is corrected to read “$422.47”.

b. Third bulleted paragraph, line 2, the figure “0.9400” is corrected to read “0.9357”.

c. Last paragraph—

(1) Line 14, the term “increasing” is corrected to read “decreasing”.

(2) Line 15, the figure “0.19” is corrected to read “0.27”.

(3) Line 26, the phrase “approximately 0.7 percent” is corrected to read “0.25 percent”.

6. On page 28151—

a. Top third of the page—

(1) In the chart entitled Comparison of Factors and Adjustments: FY 2012 Capital Federal Rate and Proposed FY 2013 Capital Federal Rate, the listed entries are corrected as set forth below.

(2) Immediately following the chart, footnote 2 is corrected and footnote 5 is republished as set forth below.

	FY 2012	Proposed FY 2013	Change	Percent change
Outlier Adjustment Factor 2	0.9382	0.9357	0.9973	−0.27
Capital Federal Rate 5	$421.42	$422.47	1.0025	0.25

* * * * *

² The outlier reduction factor is not built permanently into the capital rate; that is, the factor is not applied cumulatively in determining the capital rate. Thus, for example, the net change resulting from the application of the FY 2013 outlier adjustment factor is 0.9357/0.9382, or 0.9973.

* * * * *

⁵ Sum of percent change may not sum due to rounding.

b. Lower two-thirds of the page, second column—

(1) First full paragraph, last line, the figure “$206.82” is corrected to read “$206.01”.

(2) Third paragraph, last line, the figure “$27,425” is corrected to read “26,337”.

7. On page 28159—

a. Top half of the page, in Table 1C—Proposed Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor—FY 2013, the entries for Puerto Rico are corrected to read as follows:

Table 1C—Proposed Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor—   FY 2013

	Rates if wage index is greater than 1		Rates if wage index is less than or equal to 1
	Labor	Nonlabor	Labor	Nonlabor
Puerto Rico	$1,582.93	$966.07	$1,580.38	$968.62

b. Lower half of the page, first column, Table 1D—Proposed Capital Standard Federal Payment Rate—FY 2013, the table is corrected to read as follows:

Table 1D—Proposed Capital Standard Federal Payment Rate—FY 2013

	Rate
National	$422.47
Puerto Rico	206.01

8. On page 28178—

a. Second column, middle of the page, fourth bullet the figure “0.9400” is corrected to read “0.9357”

b. Third column, second full paragraph, line 6, the phrase “approximately 0.7” is corrected to read “0.25”.

c. Third column, third full paragraph, the paragraph that begins with the phrase “We also are estimating a slight decrease in” and ends with the phrase “Federal rate.” is corrected to read “We also are estimating an increase in outlier payments in FY 2013 as compared to FY 2012. This estimated increase in outlier payments is based on the FY 2011 claims from the December 2011 update of the MedPAR file, and we currently estimate that FY 2012 capital outlier payments are more than the projected 6.18 percent that we used to determine the outlier offset that we applied in determining the FY 2012 capital Federal rate”.

d. Last partial paragraph—

(1) Lines 2 and 3, the phrase “all hospitals are expected to experience a decrease” is corrected to read “hospitals are expected to experience either no change or a decrease”.

(2) Line 5, the sentence “These decreases are primarily due to proposed changes in the GAFs (primarily resulting from policies affecting the wage index)), and the estimated decrease in capital outlier payments.” is corrected to read “The decreases are primarily due to proposed changes in the GAFs (primarily resulting from policies affecting the wage index).”.

9. On page 28179,

a. Top third of the page,

(1) First column—

(a) First partial paragraph—

(i) Line 2, the sentence “Capital IPPS payments per case for large urban hospitals are estimated to decrease 0.1 percent, while other urban hospitals are expected to experience a 0.4 percent decrease.” is corrected to read “Large urban hospitals are not expected to experience any change in capital IPPS payments per case from FY 2012 to FY 2013, while other urban hospitals are expected to experience a 0.4 percent decrease.”.

(ii) Line 7, the phrase “not expected to experience any change” is corrected to read “are expected to experience a 0.2 percent decrease”.

(b) First full paragraph—

(i) Line 1, the sentence “The comparisons by region show that most urban regions, except for the Pacific region and Puerto Rico, will experience, on average, decreases in capital IPPS payments.” is corrected to read “The comparisons by region show that most urban regions, except for the Pacific, West North Central, and Puerto Rico regions, will experience, on average, decreases in capital IPPS payments”.

(ii) Line 8, the figure “1.0” is corrected to read “1.2”.

(iii) Line 10, the sentence “The two exceptions to decreases in capital payments per case are the Pacific urban region and the Puerto Rico urban region, which are expected to experience a 1.1 percent and 0.5 percent increase, respectively.” sentence is corrected to read “The three exceptions to estimated decreases in capital payments per case are Pacific urban region, West North Central urban region, and the Puerto Rico urban region, which are expected to experience a 1.3 percent, 0.5 percent, and 0.4 percent increase, respectively.”.

(2) Second column—

(a) First full paragraph—

(i) Line 3, the figure, “1.6” is corrected read “1.7”.

(ii) Line 4, the figure, “0.7” is corrected read “0.4”.

(iii) Line 6, the sentence “The East South Central and Mountain rural regions are not expected to experience any change in their capital payments per discharge from FY 2012 to FY 2013.” is corrected by removing the sentence.

(iv) Line 11, the figure “3.3” is corrected to read “2.9”.

(b) Second full paragraph, the paragraph “Hospitals of all type of ownership (that is, voluntary hospitals, government hospitals, and proprietary hospitals) are estimated to experience a 0.2 percent decrease in capital payments per case from FY 2012 to FY 2013.” is corrected to read “By type of ownership (that is, voluntary hospitals, government hospitals, and proprietary hospitals), all hospitals are estimated to experience a decrease in capital payments per case from FY 2012 to FY 2013. Voluntary hospitals and proprietary hospitals are expected to experience a 0.2 percent decrease in capital payments per case from FY 2012 to FY 2013, while government-run hospitals are expected to experience a 0.1 percent decrease in capital payments per case from FY 2012 to FY 2013.”.

(3) Third column, first paragraph, lines 14 through 26, the sentences beginning with the phrase “Urban non-reclassified hospitals are” and ending with the phrase “from FY 2012 to FY 2013.” are corrected to read “Both urban non-reclassified hospitals and rural reclassified hospitals are estimated to experience a decrease of 0.2 percent in capital payments per discharge from FY 2012 to FY 2013. Rural non-reclassified hospitals are estimated to have a 0.3 percent decrease in capital payments per case. Other reclassified hospitals (that is, hospitals reclassified under section 1886(d)(8)(B) of the Act) are expected to experience a decrease of 0.4 percent in capital payments from FY 2012 to FY 2013.”.

b. Lower two-thirds of the page, Table III—Comparison of Total Payments per Case, the table is corrected to read as follows:

Table III—Comparison of Total Payments per Case

[FY 2012 payments compared to FY 2013 payments]

	Number of hospitals	Average FY 2012 payments/case	Average FY 2013 payments/case	Change
By Geographic Location:
All hospitals	3,405	799	797	^0.2
Large urban areas (populations over 1 million)	1,365	880	880	0.0
Other urban areas (populations of 1 million or fewer)	1,120	784	780	−0.4
Rural areas	920	552	551	−0.2
Urban hospitals	2,485	837	835	−0.2
0-99 beds	627	670	667	−0.5
100-199 beds	773	722	720	−0.3
200-299 beds	448	769	769	0.0
300-499 beds	432	848	848	0.0
500 or more beds	205	1,016	1,013	−0.3
Rural hospitals	920	552	551	−0.2
0-49 beds	317	438	437	−0.2
50-99 beds	346	505	504	−0.2
100-149 beds	152	545	543	−0.4
150-199 beds	58	619	617	−0.4
200 or more beds	47	672	672	0.0
By Region:
Urban by Region	2,485	837	835	−0.2
New England	120	907	896	−1.2
Middle Atlantic	318	886	883	−0.4
South Atlantic	377	781	777	−0.5
East North Central	396	804	804	−0.1
East South Central	151	730	725	−0.7
West North Central	165	836	840	0.5
West South Central	370	796	792	−0.5
Mountain	157	868	865	−0.4
Pacific	380	1,016	1,029	1.3
Puerto Rico	51	384	386	0.4
Rural by Region	920	552	551	−0.2
New England	23	744	744	−0.1
Middle Atlantic	69	569	571	0.4
South Atlantic	164	541	539	−0.4
East North Central	120	576	575	−0.1
East South Central	170	507	506	−0.2
West North Central	98	585	581	−0.6
West South Central	181	491	490	−0.1
Mountain	65	580	579	−0.1
Pacific	29	723	711	−1.7
Puerto Rico	1	150	154	2.9
By Payment Classification:
All hospitals	3,405	799	797	−0.2
Large urban areas (populations over 1 million)	1,375	879	879	0.0
Other urban areas (populations of 1 million or fewer)	1,125	783	780	−0.3
Rural areas	905	563	560	−0.4
Teaching Status:
Non-teaching	2,376	680	678	−0.2
Fewer than 100 Residents	789	790	789	−0.1
100 or more Residents	240	1,137	1,135	−0.2
Urban DSH:
100 or more beds	1,523	863	862	−0.1
Less than 100 beds	327	583	584	0.0
Rural DSH:
Sole Community (SCH/EACH)	269	519	516	−0.6
Referral Center (RRC/EACH)	210	624	622	−0.4
Other Rural:	32	506	503	−0.7
100 or more beds
Less than 100 beds	286	446	446	−0.1
Urban teaching and DSH:
Both teaching and DSH	815	933	933	−0.1
Teaching and no DSH	147	812	808	−0.4
No teaching and DSH	1,035	720	720	0.0
No teaching and no DSH	503	741	736	−0.7
Rural Hospital Types:
Non special status hospitals	2,391	841	839	−0.2
RRC/EACH	61	733	735	0.3
SCH/EACH	34	722	723	0.1
SCH, RRC and EACH	16	769	764	−0.7
Hospitals Reclassified by the Medicare Geographic Classification Review Board:
FY2013 Reclassifications:
All Urban Reclassified	420	833	834	0.1
All Urban Non-Reclassified	2,025	840	838	−0.2
All Rural Reclassified	335	596	595	−0.2
All Rural Non-Reclassified	524	482	480	−0.3
Other Reclassified Hospitals (Section 1886(d)(8)(B))	55	550	548	−0.4
Type of Ownership:
Voluntary	1,970	813	812	−0.2
Proprietary	866	718	717	−0.2
Government	560	817	816	−0.1
Medicare Utilization as a Percent of Inpatient Days:
0-25	377	1,044	1,047	0.4
25-50	1,834	839	838	−0.2
50-65	968	666	664	−0.3
Over 65	168	611	610	−0.2

10. On page 28189, second column, last paragraph, lines 6 and 7, the phrase “1,741 existing IPFs, of which 450” is corrected to read “approximately 1,700 existing IPFs, of which approximately 450”.

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

Dated: June 5, 2012.

Jennifer M. Cannistra,

Executive Secretary to the Department, Department of Health and Human Services.