[Federal Register Volume 62, Number 105 (Monday, June 2, 1997)]
[Proposed Rules]
[Pages 29902-30169]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-14248]
[[Page 29901]]
_______________________________________________________________________
Part III
Department of Health and Human Services
_______________________________________________________________________
Health Care Financing Administration
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42 CFR Parts 412, 413, and 489
Medicare Program; Changes to the Hospital Inpatient Prospective Payment
Systems and Fiscal Year 1998 Rates; Proposed Rule
Federal Register / Vol. 62, No. 105 / Monday, June 2, 1997 / Proposed
Rules
[[Page 29902]]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
42 CFR Parts 412, 413, and 489
[BPD-878-P]
RIN 0938-AH55
Medicare Program; Changes to the Hospital Inpatient Prospective
Payment Systems and Fiscal Year 1998 Rates
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Proposed rule.
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SUMMARY: We are proposing to revise the Medicare hospital inpatient
prospective payment systems for operating costs and capital-related
costs to implement necessary changes arising from our continuing
experience with the systems. In addition, in the addendum to this
proposed rule, we are describing proposed changes in the amounts and
factors necessary to determine prospective payment rates for Medicare
hospital inpatient services for operating costs and capital-related
costs. These changes would be applicable to discharges occurring on or
after October 1, 1997. We are also setting forth proposed rate-of-
increase limits as well as proposing changes for hospitals and hospital
units excluded from the prospective payment systems.
DATES: Comments will be considered if received at the appropriate
address, as provided below, no later than 5 p.m. on August 1, 1997.
ADDRESSES: Mail written comments (an original and three copies) to the
following address:
Health Care Financing Administration, Department of Health and Human
Services, Attention: BPD-878-P, P.O. Box 7517, Baltimore, MD 21207-
0517.
If you prefer, you may deliver your written comments (an original
and three copies) to one of the following addresses:
Room 309-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW.,
Washington, DC 20201, or
Room C5-09-26, Central Building, 7500 Security Boulevard, Baltimore, MD
21244-1850.
Because of staffing and resource limitations, we cannot accept
comments by facsimile (FAX) transmission. In commenting, please refer
to file code BPD-878-P. Comments received timely will be available for
public inspection as they are received, generally beginning
approximately three weeks after publication of a document, in Room 309-
G of the Department's offices at 200 Independence Avenue, SW.,
Washington, DC, on Monday through Friday of each week from 8:30 a.m. to
5 p.m. (phone: (202) 690-7890).
For comments that relate to information collection requirements,
mail a copy of comments to:
Office of Information and Regulatory Affairs, Office of Management and
Budget, Room 10235, New Executive Office Building, Washington, DC
20503.
Attn: Allison Herron Eydt, HCFA Desk Officer; and Office of
Financial and Human Resources,
Management Planning and Analysis Staff, Room C2-26-17, 7500 Security
Boulevard, Baltimore, MD 21244-1850.
Copies: To order copies of the Federal Register containing this
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Register.
FOR FURTHER INFORMATION CONTACT:
Nancy Edwards, (410) 786-4531, Operating Prospective Payment, DRG, and
Wage Index Issues.
Frank Emerson, (410) 786-4656, Capital Prospective Payment, Excluded
Hospitals, and Graduate Medical Education Issues.
SUPPLEMENTARY INFORMATION:
I. Background
A. Summary
Under section 1886(d) of the Social Security Act (the Act), a
system of payment for the operating costs of acute care hospital
inpatient stays under Medicare Part A (Hospital Insurance) based on
prospectively-set rates was established effective with hospital cost
reporting periods beginning on or after October 1, 1983. Under this
system, Medicare payment for hospital inpatient operating costs is made
at a predetermined, specific rate for each hospital discharge. All
discharges are classified according to a list of diagnosis-related
groups (DRGs). The regulations governing the hospital inpatient
prospective payment system are located in 42 CFR Part 412. On August
30, 1996, we published a final rule (61 FR 46166) to implement changes
to the prospective payment system for hospital operating costs
beginning with Federal fiscal year (FY) 1997.
As required by section 1886(g) of the Act, effective with cost
reporting periods beginning on or after October 1, 1991, we implemented
a prospective payment methodology for hospital inpatient capital-
related costs. Under the new methodology, a predetermined payment
amount per discharge is made for Medicare inpatient capital-related
costs.
B. Major Contents of This Proposed Rule
In this proposed rule, we are setting forth proposed changes to the
Medicare hospital inpatient prospective payment systems for both
operating costs and capital-related costs. This proposed rule would be
effective for discharges occurring on or after October 1, 1997.
Following is a summary of the major changes that we are proposing to
make:
1. Changes to the DRG Classifications and Relative Weights
As required by section 1886(d)(4)(C) of the Act, we must adjust the
DRG classifications and relative weights at least annually. Our
proposed changes for FY 1998 are set forth in section II. of this
preamble.
2. 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:
FY 1998 wage index update.
Revisions to the wage index based on hospital
redesignations.
Revised process for wage data verification.
3. Revision of the Operating Hospital Market Baskets
In section IV. of this preamble, we discuss our proposal to use a
revised hospital market basket in developing the FY 1998 update factor
for the operating prospective payment rates and the excluded hospital
rate-of-increase limits.
[[Page 29903]]
4. Other Changes to the Prospective Payment System for Inpatient
Operating Costs
In section V. of this preamble, we discuss several provisions of
the regulations in 42 CFR Parts 412 and 413 and set forth certain
proposed changes concerning the following:
Elimination of day outlier payments.
Rural referral centers.
Indirect medical education.
Direct graduate medical education programs.
5. Changes to the Prospective Payment System for Capital-Related Costs
In section VI. of this preamble, we discuss several provisions of
the regulations in 42 CFR part 412, 413, and 489 and set forth certain
proposed changes and clarifications concerning the following:
Possible adjustments to capital minimum payment levels.
Special exceptions application process.
6. Changes for Hospitals and Hospital Units Excluded From the
Prospective Payment Systems
In section VII. of this preamble, we discuss the criteria for
``hospitals within hospitals'' seeking exclusion from the prospective
payment system. We also discuss technical clarifications concerning
exclusion of rehabilitation units.
7. Determining Prospective Payment Operating and Capital Rates and
Rate-of-Increase Limits
In the addendum to this proposed rule, we set forth proposed
changes to the amounts and factors for determining the FY 1998
prospective payment rates for operating costs and capital-related
costs. We also are proposing update factors for determining the rate-
of-increase limits for cost reporting periods beginning in FY 1998 for
hospitals and hospital units excluded from the prospective payment
system.
8. 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.
9. Capital Acquisition Model
Appendix B contains the technical appendix on the proposed FY 1998
capital cost model.
10. Revised Market Basket Data Sources
Appendix C sets forth the data sources used to determine the market
basket relative weights and choice of price proxies.
11. Report to Congress on the Update Factor for Prospective Payment
Hospitals and Hospitals Excluded From the Prospective Payment System
Section 1886(e)(3)(B) of the Act requires that the Secretary report
to Congress on our initial estimate of an update factor for FY 1998 for
both hospitals included in and hospitals excluded from the prospective
payment systems. This report is included as Appendix D to this proposed
rule.
12. Proposed Recommendation of Update Factor for Hospital Inpatient
Operating Costs
As required by sections 1886 (e)(4) and (e)(5) of the Act, Appendix
E provides our recommendation of the appropriate percentage change for
FY 1998 for the following:
Large urban area and other area average standardized
amounts (and hospital-specific rates applicable to sole community
hospitals) for hospital inpatient services paid for under the
prospective payment system for operating costs.
Target rate-of-increase limits to the allowable
operating costs of hospital inpatient services furnished by
hospitals and hospital units excluded from the prospective payment
system.
13. Discussion of Prospective Payment Assessment Commission
Recommendations
The Prospective Payment Assessment Commission (ProPAC) is directed
by section 1886(e)(2)(A) of the Act to make recommendations on the
appropriate percentage change factor to be used in updating the average
standardized amounts. In addition, section 1886(e)(2)(B) of the Act
directs ProPAC to make recommendations regarding changes in each of the
Medicare payment policies under which payments to an institution are
prospectively determined. In particular, the recommendations relating
to the hospital inpatient prospective payment systems are to include
recommendations concerning the number of DRGs used to classify
patients, adjustments to the DRGs to reflect severity of illness, and
changes in the methods under which hospitals are paid for capital-
related costs. Under section 1886(e)(3)(A) of the Act, the
recommendations required of ProPAC under sections 1886(e)(2) (A) and
(B) of the Act are to be reported to Congress not later than March 1 of
each year.
We are printing ProPAC's March 1, 1997 report, which includes its
recommendations, as Appendix F of this document. The recommendations,
and the actions we are proposing to take with regard to them (when an
action is recommended), are discussed in detail in the appropriate
sections of this preamble, the addendum, or the appendices to this
proposed rule. See section VIII. of this preamble for specific
information concerning where individual recommendations are addressed.
For a brief summary of the ProPAC recommendations, we refer the reader
to the beginning of the ProPAC report as set forth in Appendix F of
this proposed rule. For further information relating specifically to
the ProPAC report, contact ProPAC at (202) 401-8986.
II. Proposed Changes to DRG Classifications and Relative Weights
A. Background
Under the prospective payment system, we pay for inpatient hospital
services on the basis of a rate per discharge that varies by the DRG to
which a beneficiary's stay is assigned. The formula used to calculate
payment for a specific case takes an individual hospital's payment rate
per case and multiplies it by the weight of the DRG to which the case
is assigned. Each DRG weight represents the average resources required
to care for cases in that particular DRG relative to the average
resources used to treat cases in all DRGs.
Congress recognized that it would be necessary to recalculate the
DRG relative weights periodically to account for changes in resource
consumption. Accordingly, section 1886(d)(4)(C) of the Act requires
that the Secretary adjust the DRG classifications and relative weights
annually. These adjustments are made to reflect changes in treatment
patterns, technology, and any other factors that may change the
relative use of hospital resources. The proposed changes to the DRG
classification system and the proposed recalibration of the DRG weights
for discharges occurring on or after October 1, 1997 are discussed
below.
B. DRG Reclassification
1. General
Cases are classified into DRGs for payment under the prospective
payment system based on the principal diagnosis, up to eight additional
diagnoses, and up to six procedures performed during the stay, as well
as age, sex, and discharge status of the patient. The diagnosis and
procedure information is reported by the hospital using codes from the
International Classification of Diseases, Ninth Edition, Clinical
Modification (ICD-9-CM). The Medicare fiscal intermediary enters the
information into its claims system and subjects it to a
[[Page 29904]]
series of automated screens called the Medicare Code Editor (MCE).
These screens are designed to identify cases that require further
review before classification into a DRG can be accomplished.
After screening through the MCE and any further development of the
claims, cases are classified by the GROUPER software program into the
appropriate DRG. The GROUPER program was developed as a means of
classifying each case into a DRG on the basis of the diagnosis and
procedure codes and demographic information (that is, sex, age, and
discharge status). It is used both to classify past cases in order to
measure relative hospital resource consumption to establish the DRG
weights and to classify current cases for purposes of determining
payment. The records for all Medicare hospital inpatient discharges are
maintained in the Medicare Provider Analysis and Review (MedPAR) file.
The data in this file are used to evaluate possible DRG classification
changes and to recalibrate the DRG weights.
Currently, cases are assigned to one of 492 DRGs in 25 major
diagnostic categories (MDCs). Most MDCs are based on a particular organ
system of the body (for example, MDC 6, Diseases and Disorders of the
Digestive System); however, some MDCs are not constructed on this basis
since they involve multiple organ systems (for example, MDC 22, Burns).
In general, principal diagnosis determines MDC assignment. However,
there are five DRGs to which cases are assigned on the basis of
procedure codes rather than first assigning them to an MDC based on the
principal diagnosis. These are the DRGs for liver, bone marrow, and
lung transplant (DRGs 480, 481, and 495, respectively) and the two DRGs
for tracheostomies (DRGs 482 and 483). Cases are assigned to these DRGs
before classification to an MDC.
Within most MDCs, cases are then divided into surgical DRGs (based
on a surgical hierarchy that orders individual procedures or groups of
procedures by resource intensity) and medical DRGs. Medical DRGs
generally are differentiated on the basis of diagnosis and age. Some
surgical and medical DRGs are further differentiated based on the
presence or absence of complications or comorbidities (hereafter CC).
Generally, GROUPER does not consider other procedures; that is,
nonsurgical procedures or minor surgical procedures generally not
performed in an operating room are not listed as operating room (OR)
procedures in the GROUPER decision tables. However, there are a few
non-OR procedures that do affect DRG assignment for certain principal
diagnoses, such as extracorporeal shock wave lithotripsy for patients
with a principal diagnosis of urinary stones.
The changes we are proposing to make to the DRG classification
system for FY 1998 and other decisions concerning DRGs are set forth
below. Unless otherwise noted, our DRG analysis is based on a 10
percent random sample of the FY 1996 MedPAR file.
2. MDC 1 (Diseases and Disorders of the Nervous System)
a. Stereotactic Radiosurgery. Effective October 1, 1995, procedure
code 92.3 (stereotactic radiosurgery) was created and classified as a
non-OR procedure. However, because this procedure had previously been
coded to procedure codes that are classified as operating room
procedures, we assigned procedure code 92.3 to the same surgical DRGs
as the predecessor codes. Therefore, in the following DRGs,
stereotactic radiosurgery is considered a non-OR procedure that affects
DRG assignment: In MDC 1, DRG 1 (Craniotomy Age >17 Except for Trauma),
DRG 2 (Craniotomy for Trauma Age >17), and DRG 3 (Craniotomy Age 0-17)
and, in MDC 10 (Endocrine, Nutritional and Metabolic Diseases and
Disorders), DRG 286 (Adrenal and Pituitary Procedures). In addition, in
MDC 17 (Myeloproliferative Diseases and Disorders and Poorly
Differentiated Neoplasms), procedure code 92.3 is considered a major OR
procedure for purposes of assignment to DRG 400 (Lymphoma and Leukemia
with Major OR Procedure) and DRGs 406 and 407 (Myeloproliferative
Disorders or Poorly Differentiated Neoplasms with Major OR
Procedure).1 We stated in the June 2, 1995 proposed rule (60
FR 29207) that we would analyze the stereotactic radiosurgery cases as
soon as the FY 1996 cases were available to ensure that these DRG
assignments were appropriate.
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\1\ A single title combined with two DRG numbers is used to
signify pairs. Generally, the first DRG is for cases with CC and the
second DRG is for cases without CC. If a third number is included,
it represents cases of patients who are age 0-17. Occasionally, a
pair of DRGs is split on age >17 and age 0-17.
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In analyzing the FY 1996 MedPAR file, we find that there were
stereotactic radiosurgery cases assigned to DRGs 1, 286, 400, and 407.
In DRG 1, the average standardized charges for these cases is
approximately $16,400 compared to approximately $27,800 for DRG 1
overall and the lengths of stay are about 3 days and 10 days,
respectively. In DRG 286, the average charges for procedure code 92.3
are also much lower than all cases in that DRG, about $11,900 versus
$19,400. Again the length of stay is also much lower for stereotactic
radiosurgery, just over 1 day compared to almost 7 days for all DRG 286
cases.
Clearly, the cases associated with procedure code 92.3 are much
less resource intensive than the other cases in the DRGs to which it is
assigned. There are two courses of action that we could take. One, we
could continue to consider code 92.3 a non-OR procedure that affects
DRG assignment and reassign it to more appropriate surgical DRGs in MDC
1 and 11. On the other hand, we could consider it a non-OR code that
does not affect DRG assignment. In the latter situation, cases
currently assigned to surgical DRGs because of the performance of
stereotactic radiosurgery would be reassigned to medical DRGs in the
same MDC.
A review of the average charges for the medical DRGs in MDCs 1 and
11 to which these cases would be assigned reveals that these DRGs are
not as resource intensive as the stereotactic radiosurgery cases.
Therefore, due to the higher charges associated with these cases, we
are proposing to reassign procedure code 92.3 to DRGs 7 and 8
(Peripheral and Cranial Nerve and Other Nervous System Procedures) in
MDC 1 and DRGs 292 and 293 (Other Endocrine, Nutrition and Metabolic OR
Procedures).
We are also proposing to remove procedure code 92.3 from the list
of major OR procedures in MDC 17. Again the average charges of those
cases are lower than the other cases assigned to those DRGs. Therefore,
these cases would be assigned to DRGs 401 and 402 (Lymphoma and Non-
Acute Leukemia with Other OR Procedure) and DRG 408 (Myeloproliferative
Disorders or Poorly Differentiated Neoplasms with Other OR Procedure).
b. Sleep Apnea. In our August 30, 1996 final rule (61 FR 46168), we
discussed our review of the DRG assignment of cases in which surgery is
performed to correct obstructive sleep apnea (diagnosis code 780.57).
When coded as the principal diagnosis, sleep apnea is assigned to DRGs
34 and 35 (Other Disorders of the Nervous System) in MDC 1.
The result of our review was to assign several surgical procedures
used to correct sleep apnea to DRGs 7 and 8 (Peripheral and Cranial
Nerve and Other Nervous System Procedures). These procedures involved
repair of the palate
[[Page 29905]]
or pharynx (procedure codes 27.69, 29.4, and 29.59). Previously, since
none of these surgical procedures had been assigned to MDC 1, cases of
sleep apnea treated with one of these procedures had been assigned to
DRG 468 (Extensive OR Procedure Unrelated to Principal Diagnosis) or
DRG 477 (Nonextensive OR Procedure Unrelated to Principal Diagnosis).
An associated procedure that is also used to treat sleep apnea is
correction of cleft palate (procedure code 27.62). Currently,
correction of cleft palate is assigned only to DRG 52 (Cleft Lip and
Palate Repair) in MDC 3 (Diseases and Disorders of the Ear, Nose,
Mouth, and Throat). Thus, when this procedure is performed for sleep
apnea cases, the cases would be assigned to DRG 477. We are proposing
to add this surgical procedure to MDC 1. Like the palate and pharynx
repair procedures that were addressed last year, these cases are not
clinically similar to the other surgical DRGs in MDC 1; thus, we are
proposing to include them in DRGs 7 and 8.
c. Geniculate Herpes Zoster. Geniculate herpes zoster (diagnosis
code 053.11) is an acute viral disease characterized by inflammation of
spinal ganglia and by a vesicular eruption along the area of
distribution of a sensory nerve. In the August 30, 1996 final rule (61
FR 27447), we moved diagnosis codes 053.10 and 053.19 (Herpes zoster
with unspecified nervous system complication and Other herpes zoster,
respectively) from DRG 20 (Nervous System Infection Except Viral
Meningitis) to DRGs 18 and 19 (Cranial and Peripheral Nerve Disorders).
We considered moving diagnosis code 053.11 at that time, however, the
higher average charges associated with geniculate herpes zoster and
slightly higher length of stay led us to decide instead to leave 053.11
in DRG 20 and to reassess this decision in upcoming years.
We conducted an analysis of the cases assigned to DRG 20 using the
FY 1996 MedPAR file. The average standardized charges for these cases
is approximately $8,430, which is significantly lower than the average
charges for the DRG, approximately $21,180. The average length of stay
for the geniculate herpes zoster cases, approximately 6 days, is also
less than the average length of stay for the DRG, approximately 10
days. Based on these data, we are proposing to reassign diagnosis code
053.11 to DRGs 18 and 19, which have average charges of approximately
$8,460 and $5,460, respectively. The average length of stay for DRGs 18
and 19 are approximately 6 days and 4 days, respectively.
3. MDC 5 (Diseases and Disorders of the Circulatory System)
a. Heart Assist Devices. In November 1995, we amended our general
noncoverage decision concerning artificial hearts and related devices.
Section 65-15 of the Medicare Coverage Issues manual was revised to
allow coverage of the HeartMate Implantable Pneumatic Left Ventricular
Assist System (HeartMate IP LVAS) in accordance with its Food and Drug
Administration-approved use as a temporary mechanical circulation
support in nonreversible left ventricular failure as a bridge to
cardiac transplant. In order to receive Medicare coverage, all of the
following conditions must be met:
The patient is listed as an approved heart transplant
candidate by a Medicare-approved heart transplant center.
The implantation of the system is done in a Medicare-
approved heart transplant center. Written permission from the
listing center is needed if the patient has the implantation done at
another Medicare-approved center.
The patient is on inotropes.
The patient is on an intra-aortic balloon pump (if
possible).
The patient has left atrial pressure or pulmonary
capillary wedge pressure 20mm Hg with either--
--Systolic blood pressure 80 mm Hg; or
--Cardiac index of 2.0 1/min/m \2\.
A procedure code for implant of an implantable, pulsatile heart
assist system (37.66), which includes the HeartMate IP LVAS, was
created effective October 1, 1995. At that time, the procedure code was
assigned to DRGs 110 and 111 (Major Cardiovascular Procedures). Because
we now have a full year of cases coded with this procedure (FY 1996
MedPAR file), we have analyzed them to determine if this DRG assignment
remains appropriate.
In the full (100 percent) FY 1996 MedPAR file, there are 51 cases
of implant of an internal heart assist system (procedure code 37.66) in
MDC 5. Of these 51 cases, 18 were assigned to DRG 110 and none to DRG
111. The other 33 cases were assigned to DRG 103 (Heart Transplant),
DRG 104 (Cardiac Valve Procedures with Cardiac Cath), DRGs 106 and 107
(Coronary Bypass), and DRG 108 (Other Cardiothoracic Procedures). Of
the 18 cases assigned to DRG 110, the average charge is about $96,000
and the average length of stay is 22.5 days. The average charges for
all cases assigned to DRG 110 is about $36,500 and the average length
of stay is 10.1 days.
Thus, the cases coded with procedure code 37.66 are much more
resource intensive than the other cases assigned to DRG 110. In
reviewing the other surgical DRGs in MDC 5 for possible reassignment of
this procedure, we find there are two DRGs that contain cases that are
clinically similar to implant of heart assist device cases: DRG 103 and
DRG 108. For FY 1996, the average charge of cases in DRG 103 is
approximately $164,000 and the length of stay is 46 days. For DRG 108,
these statistics are about $54,000 and 12.1 days. Thus, the average
charge for DRG 103 is approximately $68,000 higher than the average
charge of the heart assist device cases and the average charge for DRG
108 is approximately $42,000 lower.
Because our general policy is to assign a procedure code to a DRG
with clinically similar cases that is the best match in terms of
resource use, we are proposing to assign procedure code 37.66 to DRG
108. We realize that there is still a large difference in the resource
use for DRG 108 and the heart assist device cases; however, there is
not a more appropriate assignment in MDC 5 for these cases. Our
proposal would improve the payment for these cases by approximately 46
percent. We note that because DRG 108 is ranked above DRGs 106 and 107
in the MDC 5 surgical hierarchy, the cases coded with 37.66 that would
have been classified to these DRGs would be assigned to DRG 108
beginning in FY 1998.
b. Automatic Implantable Cardioverter Defibrillators (AICD). For
several years, we have received correspondence concerning the
appropriate DRG assignment of procedures involving automatic
implantable cardioverter defibrillators (AICDs). These cases are
currently assigned to DRG 116 (Other Permanent Cardiac Pacemaker
Implant or AICD Generator or Lead Procedure), and are represented by
the following procedure codes:
37.95 Implantation of automatic cardioverter/defibrillator lead(s)
only
37.96 Implantation of automatic cardioverter/defibrillator pulse
generator only
37.97 Replacement of automatic cardioverter/defibrillator lead(s)
only
37.98 Replacement of automatic cardioverter/defibrillator pulse
generator only
As explained in detail in the September 1, 1992 final rule (57 FR
39749), the clinical composition and relative weights of the surgical
DRGs in MDC 5 do not offer a perfect match with the AICD cases.
However, review of those DRGs in terms of clinical coherence and
similar resource consumption led to the determination
[[Page 29906]]
that DRG 116 was the best possible fit. In that document, we stated
that we would continue to monitor these cases.
We last discussed this issue in the September 1, 1995 final rule
(60 FR 45780). At that time, we concluded that, although the average
charge for AICD cases was much higher than the average charge for DRG
116 overall, the AICD cases were clinically similar to the DRG 116
cases and should not be moved. In addition, a slight decrease in the
average charge for the cases between the FY 1993 and FY 1994 MedPAR
files led us to believe further reductions might be forthcoming since
there were new AICD devices entering the market that might lead to
increased price competition.
We reviewed the most current AICD cases as contained in the FY 1996
MedPAR file and found that the average standardized charge for AICD
cases assigned to DRG 116 was $28,777 compared to an average charge of
$21,330 for all cases in DRG 116. These data demonstrate that the
average charge for AICD cases continues to be much higher than the
average charge for all other DRG 116 cases. Therefore, in order to more
appropriately compensate hospitals for these cases, we are proposing to
move them to DRG 115 (Permanent Cardiac Pacemaker Implantation with
AMI, Heart Failure or Shock). Although the resource consumption of DRG
115 cases is similar to the AICD cases, they are not clinically
similar. In general, the patients classified to DRG 115 are seriously
ill and have a relatively long length of stay (10.2 days). However,
there are no other suitable DRGs in MDC 5 and we do not wish to create
a separate DRG for the AICD cases. As we have often stated in the past,
we are reluctant to create device-specific DRGs where the cost of the
device dominates the charges. We continue to believe that it is the
cost of the AICD device which is responsible for the high average
charge for these cases and not the intensity of hospital services
required to treat the patient. We are also proposing to revise the
title of DRG 115 to ``Permanent Cardiac Pacemaker Implant with AMI,
Heart Failure or Shock or AICD Lead or Generator Procedure.''
c. Coronary Artery Stent. Effective October 1, 1995, procedure code
36.06 (Insertion of coronary artery stent(s)) was introduced. As
dictated by our longstanding practice, we assigned this code to the
same DRG category as its predecessor codes. Therefore, procedure code
36.06 was assigned to DRG 112 (Percutaneous Cardiovascular Procedures),
as insertion of a stent is usually performed in conjunction with
percutaneous transluminal coronary angioplasty (PTCA).
We discussed this assignment and public comments we received in
both the September 1, 1995 final rule (60 FR 45785) and the August 30,
1996 final rule (61 FR 46171). Commenters protested the assignment of
procedure code 36.06 to DRG 112 because the hospital costs for
inserting coronary stents along with an angioplasty are significantly
greater than those for conventional angioplasty alone. The commenters
presented an analysis of the average charges and length of stay for
stent and nonstent cases assigned to DRG 112. Our response to these
commenters was that we would review the stent cases as soon as the FY
1996 MedPAR file was available, as these would be the first Medicare
data available for these cases.
Our analysis of the FY 1996 MedPAR data on coronary stent
implantation in Medicare beneficiaries has shown the following
findings:
The difference between the average length of stay for
the stent cases and the nonstent cases is 0.19 days (4.39 days
versus 4.20 days).
Charges for patients receiving a stent were
approximately $23,650, while charges for patients without stent
implant were approximately $17,480, for a difference of $6,170.
Of those beneficiaries who had a PTCA procedure in FY
1996, approximately 34 percent received a stent.
As review of stent cases in DRG 112 has shown a significant
variation in hospital charges, we are proposing to move these cases out
of that DRG. Although the coronary artery stent cases are not
clinically similar to the pacemaker cases in DRG 116, the resource
consumption of those cases is very similar. Therefore, absent any other
appropriate DRG, we are proposing to add cases including procedure
codes for PTCA in combination with insertion of coronary stent into DRG
116. Therefore, we are proposing to move into DRG 116 the following
procedure codes when performed in conjunction with procedure code
36.06:
35.96 Percutaneous valvuloplasty
36.01 Single vessel percutaneous transluminal coronary angioplasty
[PTCA] or coronary atherectomy without mention of thrombolytic agent
36.02 Single vessel percutaneous transluminal coronary angioplasty
[PTCA] or coronary atherectomy with mention of thrombolytic agent
36.05 Multiple vessel percutaneous transluminal coronary
angioplasty [PTCA] or coronary atherectomy performed during the same
operation, with or without mention of thrombolytic agent
36.09 Other removal of coronary artery obstruction
37.34 Catheter ablation of lesion or tissues of the heart
We further propose to change the title of DRG 116 to ``Other
Permanent Cardiac Pacemaker Implant or PTCA with Coronary Artery Stent
Implant.''
We will continue to monitor the stent cases and their assignment to
DRG 116. If PTCA cases with stent become a higher percentage of the
PTCA cases or the average charge for stent cases falls, we may
reconsider this assignment.
d. Circulatory Disorders (DRGs 121 and 122). In response to a
comment on the May 31, 1996 proposed rule, we stated in the August 30,
1996 final rule (61 FR 46172) that we would conduct a comprehensive
review of cases currently assigned to DRG 121 (Circulatory Disorders
with Acute Myocardial Infarction (AMI) and Cardiovascular
Complications, Discharged Alive) and DRG 122 (Circulatory Disorders
with AMI without Cardiovascular Complications, Discharged Alive) to
determine whether changes were needed to the list of complicating
conditions that can result in assignment to DRG 121. To carry out this
review, we analyzed the cases in the FY 1996 MedPAR file that were
assigned to either DRG 121 or 122. Through a variety of statistical
analyses of length of stay and standardized charge data, we assessed
the impact on resource use of all coded secondary diagnoses.
Our analysis of these secondary diagnosis codes revealed many cases
now assigned to DRG 122 in which certain secondary diagnoses are
associated with resource use comparable to cases assigned to DRG 121.
Although many of these cases involve secondary diagnoses that are not
strictly cardiovascular in nature, such as diagnosis code category 482
(Other bacterial pneumonia), we now believe that it is appropriate to
expand DRG 121 to include such major complications when they are
represented in significant volume among the cases in the DRG.
Continuing to limit DRG 121 only to cases involving the existing list
of cardiovascular complications would contribute to large variations in
the charges and lengths of stay for cases in DRG 122.
Therefore, we are proposing to change the title of DRG 121 to
``Circulatory Disorders with AMI and Major Complications, Discharged
Alive,'' and to add the following diagnosis codes to the list of
complications that would produce assignment to DRG 121 when present in
conjunction with the existing list of AMI diagnoses:
[[Page 29907]]
398.91 Rheumatic heart failure
416.0 Primary pulmonary hypertension
430 Subarachnoid hemorrhage
431 Intracerebral hemorrhage
432.0 Nontraumatic extradural hemorrhage
432.1 Subdural hemorrhage
432.9 Unspecified intracranial hemorrhage
433.01 Occluded basilar artery with cerebral infarction
433.11 Occluded carotid artery with cerebral infarction
433.21 Occluded vertebral artery with cerebral infarction
433.31 Occluded multiple and bilateral artery with cerebral
infarction
433.81 Occluded specified precerebral artery with cerebral
infarction
433.91 Occluded precerebral artery NOS with cerebral infarction
434.00 Cerebral thrombosis
434.01 Cerebral thrombosis with cerebral infarction
434.10 Cerebral embolism
434.11 Cerebral embolism with cerebral infarction
434.90 Cerebral artery occlusion
434.91 Cerebral artery occlusion with cerebral infarction
436 Acute, but ill-defined, cerebrovascular disease
481 Pneumococcal pneumonia
482.xx Other bacterial pneumonia (all 4th and 5th digits)
483.x Pneumonia due to other specified organism (all 4th digits)
484.x Pneumonia in infectious diseases classified elsewhere (all
4th digits)
485 Bronchopneumonia, organism unspecified
486 Pneumonia, organism unspecified
487.0 Influenza with pneumonia
507.x Pneumonitis due to solids and liquids (all 4th digits)
518.0 Pulmonary collapse
518.5 Pulmonary insufficiency following trauma and surgery
518.81 Respiratory failure
707.0 Decubitus ulcer
996.62 Infection and inflammatory reaction due to other vascular
device, implant, and graft
996.72 Other complications due to other cardiac device, implant,
and graft
In conjunction with these proposed changes, we note that the title
of DRG 122 would be revised to read ``Circulatory Disorders with AMI
without Major Complications, Discharged Alive.''
4. MDC 8 (Diseases and Disorders of the Musculoskeletal System and
Connective Tissue)
a. Introduction. As discussed in detail below, we are proposing to
create several new DRGs in MDC 8 effective for discharges on or after
October 1, 1997. Specifically, we would replace current DRGs 214 and
215 (Back and Neck Procedures) with the following new DRGs:
DRG 496 Combined Anterior/Posterior Spinal Fusion
DRG 497 Spinal Fusion with CC
DRG 498 Spinal Fusion without CC
DRG 499 Back and Neck Procedures Except Spinal Fusion with CC
DRG 500 Back and Neck Procedures Except Spinal Fusion without CC
In addition, we are proposing to replace existing DRGs 221 and 222
(Knee Procedures) with new DRGs 501 and 502 (Knee Procedures with
Principal Diagnosis of Infection) and DRG 503 (Knee Procedures without
Principal Diagnosis of Infection). We believe that both of these
proposals would improve payment equity by increasing the DRG system's
ability to capture variations in resource costs for these cases.
b. Back and Neck Procedures. Currently, hospital inpatient cases
involving back and neck procedures generally are assigned to DRGs 214
and 215 (assuming a principal diagnosis that groups the case to MDC 8).
We have received correspondence indicating that within these DRGs,
cases involving spinal fusion procedures represent a distinctly more
complex and resource-intensive subset, and that payment under DRGs 214
and 215 is inadequate to cover the costs of treating patients that
require spinal fusion. Therefore, we conducted an analysis of the cases
assigned to DRGs 214 and 215 using the FY 1996 MedPAR file.
Within our sample, cases involving fusion procedures (procedure
codes 81.00-81.09) constituted approximately 35 percent of cases in DRG
214 (Back and Neck Procedures with CC) and 23 percent of those in DRG
215 (Back and Neck Procedures without CC). In DRG 214, the average
standardized charges for the fusion cases were nearly double the
charges of the nonfusion cases (approximately $25,300 versus $12,900).
There were also significant differences in charges in DRG 215; $14,400
for fusion cases and $8,500 for nonfusion cases. Lengths of stay for
fusion cases were also longer, although not dramatically so; 7.1 days
for fusion cases versus 5.4 days for other cases in DRG 214, and 3.8
days versus 3.1 days in DRG 215. In view of the volume of cases
involved and the clear differences in resource use, we concluded that
it would be appropriate to create additional DRGs to separate spinal
fusion cases from the other back and neck procedures.
Next, we expanded our analysis to determine whether it would be
appropriate to subdivide the spinal fusion cases according to whether
both anterior and posterior spinal fusion were performed. This
combination of procedures, which involves fusing both the front and
rear of the vertebrae, typically is performed on patients who have had
previous fusions that have not bonded effectively or who have several
vertebrae that need extensive fusion on both sides of the spine. As the
table below illustrates, the average charges and lengths of stay for
the cases involving both anterior and posterior spinal fusion were
markedly greater than for the other spinal fusion cases in either DRG
214 or 215.
------------------------------------------------------------------------
Avg.
Avg. length of
Type of case charges stay (in
days)
------------------------------------------------------------------------
Anterior and Posterior Spinal Fusion............ $51,200 12.3
DRG 214--Other Spinal Fusion.................... 24,300 6.9
DRG 215--Other Spinal Fusion.................... 14,300 3.8
------------------------------------------------------------------------
Even though the cases in which both anterior and posterior spinal
fusions were performed represented only about 3 percent of all spinal
fusion cases in our sample, we concluded that the magnitude of the
differences in both average charges and lengths of stay warranted a
further subdivision of the spinal fusion cases.
Based on this analysis, we are proposing to replace the two
existing DRGs for back and neck procedures with five new DRGs. For ease
of reference and classification, current DRGs 214 and 215 would be made
invalid and we would establish new DRGs 496 through 500 to contain all
the cases that are currently grouped in DRGs 214 and 215. We believe
that the division of these cases into the new DRGs would improve
clinical coherence and provide for more appropriate payment for both
spinal fusion cases and cases involving other back and neck procedures.
Discharges would be assigned to each of the five proposed DRGs as
follows:
DRG 496 Combined Anterior/Posterior Spinal Fusion
DRG 496 would include any combination of procedure codes as
follows:
One or more of the following procedure codes--
81.02 Other cervical fusion anterior
81.04 Dorsal/dorsulum fusion anterior
81.06 Lumbar/lumbosac fusion anterior
AND
One or more of the following procedure codes--
81.03 Other cervical fusion posterior
81.05 Dorsal/dorsulum fusion posterior
81.08 Lumbar/lumbosac fusion posterior
[[Page 29908]]
DRGs 497 and 498 Spinal Fusion With and Without CC
DRGs 497 and 498 would include any of the following procedure
codes, as long as any combination of procedure codes would not
otherwise result in assignment to proposed DRG 496--
81.00 Spinal fusion NOS
81.01 Atlas-axis fusion
81.02 Other cervical fusion anterior
81.03 Other cervical fusion posterior
81.04 Dorsal/dorsulum fusion anterior
81.05 Dorsal/dorsulum fusion posterior
81.06 Lumbar/lumbosac fusion anterior
81.07 Lumbar/lumbosac fusion lateral
81.08 Lumbar/lumbosac fusion posterior
81.09 Refusion of spine
DRGs 499 and 500 Back and Neck Procedures Except Spinal Fusion With
and Without CC
All procedure codes in current DRGs 214 and 215 other than
procedure codes 81.00 through 81.09 would be assigned to DRGs 499 and
500.
c. Knee Procedures. On several occasions, most recently in our
September 1, 1993 final rule (58 FR 46286), we have examined cases in
DRG 209 (Major Joint and Limb Reattachment of the Lower Extremity) to
see whether hip replacement cases that involve infections or other
complications should be classified separately from the less complicated
cases in DRG 209. We have found that the average charges and lengths of
stay for cases with principal diagnoses of infection or complications
were only slightly higher than for all cases in DRG 209. When we
limited our analysis to cases with a principal diagnosis of infection,
we found that the cases had significantly higher charges than for DRG
209 overall, but in view of the small volume of cases (less than 0.5
percent of the total DRG 209 cases), we decided that changes in the
classification of cases in DRG 209 were not warranted.
In recent months, we have received several letters asking that we
revisit the issue of whether DRG refinements are needed to address
differences in resource use associated with orthopedic procedures where
deep infections are present. Our correspondents stated that these cases
are extremely resource intensive, and, because these complex cases are
often referred to specialty hospitals, such hospitals routinely receive
DRG payments for these cases that are much lower than the costs
incurred by the hospital. They believe that we should investigate the
possibility of creating a separate DRG for orthopedic surgical cases
that have serious infections, specifically, a new DRG for cases
involving orthopedic procedures of the lower extremities or spine with
a principal diagnosis of deep orthopedic infection of the lower
extremity or spine.
To evaluate this issue, we analyzed various classifications of
cases in MDC 8. We began by identifying all cases with a principal
diagnosis indicating deep orthopedic infection of the lower extremities
or spine. The diagnosis codes used were as follows:
711.05 Pyogenic arthritis pelvic region and thigh
711.06 Pyogenic arthritis lower leg
711.07 Pyogenic arthritis ankle and foot
711.08 Pyogenic arthritis other specified sites
730.05 Acute osteomyelitis pelvic region and thigh
730.06 Acute osteomyelitis lower leg
730.07 Acute osteomyelitis ankle and foot
730.08 Acute osteomyelitis other specified sites
730.15 Chronic osteomyelitis pelvic region and thigh
730.16 Chronic osteomyelitis lower leg
730.17 Chronic osteomyelitis ankle and foot
730.18 Chronic osteomyelitis other specified sites
730.25 Unspecified osteomyelitis pelvic region and thigh
730.26 Unspecified osteomyelitis lower leg
730.27 Unspecified osteomyelitis ankle and foot
730.28 Unspecified osteomyelitis other specified sites
996.66 Infection and inflammatory reaction due to internal joint
prosthesis
996.67 Infection and inflammatory reaction due to other internal
orthopedic device
For each of the DRGs into which these cases grouped, we then
compared the average standardized charges and average length of stay
for cases with any of the infection diagnoses listed above with other
cases in the DRGs. Unlike in the past, we did not limit our analysis to
DRG 209 but examined all DRGs within MDC 8 that focus on surgical
procedures of the lower extremities or spine, including DRGs 209; 210,
211, and 212 (Hip and Femur Procedures Except Major Joint); 214 and 215
(Back and Neck Procedures); and 221 and 222 (Knee Procedures).
For the most part, we again found that these cases represented only
a very small proportion of the total cases in the DRGs in question. In
DRG 209, for example, cases with one of the above diagnosis codes as
the principal diagnosis continued to constitute less than 1 percent of
all cases in the DRG. Moreover, although the average standardized
charges for the deep infection cases ($24,834) were approximately 21
percent higher than the charges for the remaining cases in the DRG
($19,297), the differences are well within one standard deviation of
the average charge. Given the small volume of cases, we again conclude
that changes in DRG 209 are not justified.
The only DRGs that we examined in which cases with a principal
diagnosis of deep infection represented more than 1 percent of total
cases in our sample were DRGs 221 and 222. As illustrated in the chart
below, there are significant differences in both average charges and
average length of stay between infection cases in these DRGs and other
cases in the DRGs.
------------------------------------------------------------------------
Average
Number of Average length of
Type of case cases * charges (in stay (in
dollars) days)
------------------------------------------------------------------------
DRG 221 (All cases).............. 451 16,529 7.2
DRG 221 with infection........... 152 23,174 11.4
DRG 221 w/out infection.......... 299 13,151 5.1
DRG 222 (All cases).............. 340 9,149 3.9
DRG 222 with infection........... 37 14,452 7.0
DRG 222 w/out infection.......... 303 8,502 3.5
------------------------------------------------------------------------
* Based on the 10-percent random sample of the FY 1996 MedPAR file.
Thus, more than one-third of cases in DRG 221 had a principal
diagnosis of deep infection, the average length of stay for these cases
was more than twice as long as for the remaining cases, and average
charges were approximately 76 percent higher. Similarly, for the 12
percent of total DRG 222 cases with infection as the principal
diagnosis, the average length of stay was double that for other cases,
with average charges approximately 70 percent higher. Given
[[Page 29909]]
the proportional volume of cases involved, and the significant
differences in both average charges and length of stay for infection
cases in these DRGs, we concluded that DRG refinements are appropriate.
Based on this analysis, we are proposing to replace the two
existing DRGs for knee procedures with three new DRGs. Again, for ease
of reference and classification, current DRGs 221 and 222 would be made
invalid and we would establish new DRGs 501 through 503 to contain all
the cases that are currently grouped in DRGs 221 and 222. Discharges
would be assigned to each of the 3 proposed DRGs as follows:
DRG 501 Knee Procedures With Principal Diagnosis of Infection With CC
DRG 502 Knee Procedures With Principal Diagnosis of Infection Without
CC
DRG 501 and 502 would include any of the operating room procedures
now assigned to DRGs 221 and 222, when the principal diagnosis is any
of the following:
711.06 Pyogenic arthritis lower leg
730.06 Acute osteomyelitis lower leg
730.16 Chronic osteomyelitis lower leg
730.26 Unspecified osteomyelitis lower leg
996.66 Infection and inflammatory reaction due to internal joint
prosthesis
996.67 Infection and inflammatory reaction due to other internal
orthopedic device
DRG 503 Knee Procedures Without Principal Diagnosis of Infection
DRG 503 would include any of the operating room procedures now
assigned to DRGs 221 and 222 when the principal diagnosis is not listed
above under DRGs 501 and 502.
5. MDC 11 (Diseases and Disorders of the Kidney and Urinary Tract)
Among the ICD-9-CM coding changes that took effect October 1, 1995
was the addition of new procedure code 59.72 (injection of implant into
urethra or bladder neck). Although this procedure is not routinely
performed in an operating room, the code was previously included within
codes classified as operating room procedures. Thus, as is our
practice, we assigned this procedure code to the surgical DRGs to which
the procedure had formerly been assigned as a non-OR procedure that
affects DRG assignment. Therefore, procedure code 59.72 was assigned to
DRGs 308 and 309 (Minor Bladder Procedures) and DRG 356 (Female
Reproductive System Reconstructive Procedures).
In the June 2, 1995 proposed rule (60 FR 29209), we stated that we
would reevaluate the DRG classification of this code when data on its
use became available for analysis in 2 years, that is, in preparation
for the FY 1998 rulemaking process. We indicated that possible changes
would include moving the procedure code to a different surgical DRG or
classifying the code as a non-OR procedure that did not affect DRG
assignment.
In the FY 1996 MedPAR file, there were several cases with procedure
code 59.72 assigned to DRGs 308 and 309. The chart below compares
average charges and length of stay for cases in these DRGs with and
without the injection procedure.
------------------------------------------------------------------------
Avg. charge Avg. length
Type of case Number of (in of stay
cases * dollars) (in days)
------------------------------------------------------------------------
DRG 308 with procedure 59.72..... 5 6,978 4.2
DRG 308 w/out procedure 59.72.... 910 13,254 6.5
DRG 309 with procedure 59.72..... 7 5,879 1.4
DRG 309 w/out procedure 59.72.... 311 7,888 2.7
------------------------------------------------------------------------
* Based on the 10-percent random sample of the FY 1996 MedPAR file.
As the table illustrates, cases in which injection of implant into
the urethra or bladder neck is the only relevant procedure for DRG
assignment purposes constitute a very small minority of the cases in
DRGs 308 and 309. However, these cases have lower average charges and
length of stay than other cases in the DRGs. Thus, we are proposing to
reclassify the procedure code as a non-OR procedure that does not
affect DRG assignment.
Under this proposal, cases currently assigned to DRGs 308 and 309
because of the performance of an implant injection would be reassigned
to medical DRGs in MDC 11. We believe that most of the cases involved
would be assigned to either DRGs 320, 321, and 322 (Kidney and Urinary
Tract Infections) or DRGs 331 and 332 (Other Kidney and Urinary Tract
Diagnoses). Both of these sets of DRGs have average charges closely in
line with the charges for cases in which procedure 59.72 now determines
DRG assignment.
We note that this change would also affect DRG 356 in MDC 13
(Diseases and Disorders of the Female Reproductive System). Within the
10 percent sample used for this analysis, only 2 of the 2,689 cases in
DRG 356 were assigned based on the presence of procedure code 59.72,
and as in DRGS 308 and 309, both the average charges and length of stay
were lower than for other cases.
6. Surgical Hierarchies
Some inpatient stays entail multiple surgical procedures, each one
of which, occurring by itself, could result in assignment of the case
to a different DRG within the MDC to which the principal diagnosis is
assigned. It is, therefore, necessary to have a decision rule by which
these cases are assigned to a single DRG. The surgical hierarchy, an
ordering of surgical classes from most to least resource intensive,
performs that function. Its application ensures that cases involving
multiple surgical procedures are assigned to the DRG associated with
the most resource-intensive surgical class.
Because the relative resource intensity of surgical classes can
shift as a function of DRG reclassification and recalibration, we
reviewed the surgical hierarchy of each MDC, as we have for previous
reclassifications, to determine if the ordering of classes coincided
with the intensity of resource utilization, as measured by the same
billing data used to compute the DRG relative weights.
A surgical class can be composed of one or more DRGs. For example,
in MDC 5, the surgical class ``heart transplant'' consists of a single
DRG (DRG 103) and the class ``coronary bypass'' consists of two DRGs
(DRGs 106 and 107). Consequently, in many cases, the surgical hierarchy
has an impact on more than one DRG. The methodology for determining the
most resource-intensive surgical class, therefore, involves weighting
each DRG for frequency to determine the average resources for each
surgical class. For example, assume surgical class A includes DRGs 1
and 2 and surgical class B includes DRGs 3, 4, and 5, and that the
average charge of DRG 1 is higher than that of DRG 3, but the average
charges of DRGs 4 and 5 are higher than the average charge of DRG 2. To
determine whether surgical class A should be higher or lower than
[[Page 29910]]
surgical class B in the surgical hierarchy, we would weight the average
charge of each DRG by frequency (that is, by the number of cases in the
DRG) to determine average resource consumption for the surgical class.
The surgical classes would then be ordered from the class with the
highest average resource utilization to that with the lowest, with the
exception of ``other OR procedures'' as discussed below.
This methodology may occasionally result in a case involving
multiple procedures being assigned to the lower-weighted DRG (in the
highest, most resource-intensive surgical class) of the available
alternatives. However, given that the logic underlying the surgical
hierarchy provides that the GROUPER searches for the procedure in the
most resource-intensive surgical class, which may sometimes occur in
cases involving multiple procedures, this result is unavoidable.
We note that, notwithstanding the foregoing discussion, there are a
few instances when a surgical class with a lower average relative
weight is ordered above a surgical class with a higher average relative
weight. For example, the ``other OR procedures'' surgical class is
uniformly ordered last in the surgical hierarchy of each MDC in which
it occurs, regardless of the fact that the relative weight for the DRG
or DRGs in that surgical class may be higher than that for other
surgical classes in the MDC. The ``other OR procedures'' class is a
group of procedures that are least likely to be related to the
diagnoses in the MDC but are occasionally performed on patients with
these diagnoses. Therefore, these procedures should only be considered
if no other procedure more closely related to the diagnoses in the MDC
has been performed.
A second example occurs when the difference between the average
weights for two surgical classes is very small. We have found that
small differences generally do not warrant reordering of the hierarchy
since, by virtue of the hierarchy change, the relative weights are
likely to shift such that the higher-ordered surgical class has a lower
average weight than the class ordered below it.
Based on the preliminary recalibration of the DRGs, we are
proposing to modify the surgical hierarchy as set forth below. As we
stated in the September 1, 1989 final rule (54 FR 36457), we are unable
to test the effects of the proposed revisions to the surgical hierarchy
and to reflect these changes in the proposed relative weights due to
the unavailability of revised GROUPER software at the time this
proposed rule is prepared. Rather, we simulate most major
classification changes to approximate the placement of cases under the
proposed reclassification and then determine the average charge for
each DRG. These average charges then serve as our best estimate of
relative resource use for each surgical class. We test the proposed
surgical hierarchy changes after the revised GROUPER is received and
reflect the final changes in the DRG relative weights in the final
rule. Further, as discussed below in section II.C of this preamble, we
anticipate that the final recalibrated weights will be somewhat
different from those proposed, since they will be based on more
complete data. Consequently, further revision of the hierarchy, using
the above principles, may be necessary in the final rule.
We propose to revise the surgical hierarchy for the Pre-MDC DRGs,
MDC 9 (Diseases and Disorders of the Skin, Subcutaneous Tissue and
Breast), MDC 10 (Endocrine, Nutritional and Metabolic Diseases and
Disorders), and MDC 12 (Diseases and Disorders of the Male Reproductive
System) as follows:
In the Pre-MDC DRGs, we would reorder Bone Marrow
Transplant (DRG 481) above Liver Transplant (DRG 480).
In MDC 9, we would reorder Perianal and Pilonidal
Procedures (DRG 267) above Breast Procedures (DRGs 257-262).
In MDC 10, we would reorder OR Procedures for Obesity
(DRG 288) above Skin Graft and Wound Debridement (DRG 287).
In MDC 12, we would reorder Circumcision (DRGs 342 and
343) above Transurethral Prostatectomy (DRGs 336 and 337).
7. Refinement of Complications and Comorbidities List
There is a standard list of diagnoses that are considered
complications or comorbidities (CCs). We developed this list using
physician panels to include those diagnoses that, when present as a
secondary condition, would be considered a substantial complication or
comorbidity.
In previous years, we have made changes to the standard list of
CCs, either by adding new CCs or deleting CCs already on the list. At
this time, we do not propose to delete any of the diagnosis codes on
the CC list.
In the September 1, 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); and the August 30, 1996
final rule for the FY 1997 revisions (61 FR 46171).
We are proposing a limited revision of the CC Exclusions List to
take into account the changes that will be made
[[Page 29911]]
in the ICD-9-CM diagnosis coding system effective October 1, 1997, as
well as the proposed CC changes described above. (See section II.B.9,
below, for a discussion of ICD-9-CM changes.) These proposed changes
are being made in accordance with the principles established when we
created the CC Exclusions List in 1987.
The changes discussed above have been added to Table 6E, Additions
to the CC Exclusions List, in section V. of the Addendum to this
proposed rule.
Tables 6E and 6F in section V. of the Addendum to this proposed
rule contain the proposed revisions to the CC Exclusions List that
would be effective for discharges occurring on or after October 1,
1997. Each table shows the principal diagnoses with proposed changes to
the excluded CCs. Each of these principal diagnoses is shown with an
asterisk and the additions or deletions to the CC Exclusions List are
provided in an indented column immediately following the affected
principal diagnosis.
CCs that are added to the list are in Table 6E--Additions to the CC
Exclusions List. Beginning with discharges on or after October 1, 1997,
the indented diagnoses will not be recognized by the GROUPER as valid
CCs for the asterisked principal diagnosis.
CCs that are deleted from the list are in Table 6F--Deletions from
the CC Exclusions List. Beginning with discharges on or after October
1, 1997 the indented diagnoses will be recognized by the GROUPER as
valid CCs for the asterisked principal diagnosis.
Copies of the original CC Exclusions List applicable to FY 1988 can
be obtained from the National Technical Information Service (NTIS) of
the Department of Commerce. It is available in hard copy for $92.00
plus $6.00 shipping and handling and on microfiche for $20.50, plus
$4.00 for shipping and handling. A request for the FY 1988 CC
Exclusions List (which should include the identification accession
number, (PB) 88-133970) should be made to the following address:
National Technical Information Service; United States Department of
Commerce; 5285 Port Royal Road; Springfield, Virginia 22161; or by
calling (703) 487-4650.
Users should be aware of the fact that all revisions to the CC
Exclusions List (FYs 1989, 1990, 1991, 1992, 1993, 1994, 1995, 1996,
and 1997) and those in Tables 6E and 6F of this document must be
incorporated into the list purchased from NTIS in order to obtain the
CC Exclusions List applicable for discharges occurring on or after
October 1, 1997.
Alternatively, the complete documentation of the GROUPER logic,
including the current CC Exclusions List, is available from 3M/Health
Information Systems (HIS), which, under contract with HCFA, is
responsible for updating and maintaining the GROUPER program. The
current DRG Definitions Manual, Version 14.0, is available for $195.00,
which includes $15.00 for shipping and handling. Version 15.0 of this
manual, which will include the final FY 1998 DRG changes, will be
available in October 1997 for $195.00. These manuals may be obtained by
writing 3M/HIS at the following address: 100 Barnes Road; Wallingford,
Connecticut 06492; or by calling (203) 949-0303. Please specify the
revision or revisions requested.
8. Review of Procedure Codes in DRGs 468, 476, and 477
Each year, we review cases assigned to DRG 468 (Extensive OR
Procedure Unrelated to Principal Diagnosis), DRG 476 (Prostatic OR
Procedure Unrelated to Principal Diagnosis), and DRG 477 (Nonextensive
OR Procedure Unrelated to Principal Diagnosis) in order to determine
whether it would be appropriate to change the procedures assigned among
these DRGs.
DRGs 468, 476, and 477 are reserved for those cases in which none
of the OR procedures performed is related to the principal diagnosis.
These DRGs are intended to capture atypical cases, that is, those cases
not occurring with sufficient frequency to represent a distinct,
recognizable clinical group. DRG 476 is assigned to those discharges in
which one or more of the following prostatic procedures are performed
and are unrelated to the principal diagnosis:
60.0 Incision of prostate
60.12 Open biopsy of prostate
60.15 Biopsy of periprostatic tissue
60.18 Other diagnostic procedures on prostate and periprostatic
tissue
60.21 Transurethral prostatectomy
60.29 Other transurethral prostatectomy
60.61 Local excision of lesion of prostate
60.69 Prostatectomy NEC
60.81 Incision of periprostatic tissue
60.82 Excision of periprostatic tissue
60.93 Repair of prostate
60.94 Control of (postoperative) hemorrhage of prostate
60.95 Transurethral balloon dilation of the prostatic urethra
60.99 Other operations on prostate
All remaining OR procedures are assigned to DRGs 468 and 477, with
DRG 477 assigned to those discharges in which the only procedures
performed are nonextensive procedures that are unrelated to the
principal diagnosis. The original list of the ICD-9-CM procedure codes
for the procedures we consider nonextensive procedures if performed
with an unrelated principal diagnosis was published in Table 6C in
section IV of the Addendum to the September 30, 1988 final rule (53 FR
38591). As part of the final rules published on September 4, 1990,
August 30, 1991, September 1, 1992, September 1, 1993, September 1,
1994, September 1, 1995, and August 30, 1996, we moved several other
procedures from DRG 468 to 477. (See 55 FR 36135, 56 FR 43212, 57 FR
23625, 58 FR 46279, 59 FR 45336, 60 FR 45783, and 61 FR 46173,
respectively.)
a. Adding Procedure Codes to MDCs. We annually conduct a review of
procedures producing DRG 468 or 477 assignments on the basis of volume
of cases in these DRGs with each procedure. Our medical consultants
then identify those procedures occurring in conjunction with certain
principal diagnoses with sufficient frequency to justify adding them to
one of the surgical DRGs for the MDC in which the diagnosis falls.
Based on this year's review, we are proposing to move procedure code
54.92 (Removal of foreign body from peritoneal cavity) to MDC 11 and
assign it to DRG 315 (Other Kidney and Urinary Tract OR Procedures). We
note that, under the current DRGs, when procedure code 54.92 is coded
in addition to a principal diagnosis code of 868.14 (injury with open
wound into retroperitoneum), the case is assigned to DRG 468.
b. Reassignment of Procedures Among DRGs 468, 476, and 477. We also
reviewed the list of procedures that produce assignments to DRGs 468,
476, and 477 to ascertain if any of those procedures should be moved
from one of these DRGs to another based on average charges and length
of stay. Generally, we move only those procedures for which we have an
adequate number of discharges to analyze the data. Based on our review
this year, we are proposing to move one procedure from DRG 468 to DRG
477.
In reviewing the list of OR procedures that produce DRG 468
assignments, we analyzed the average charge and length of stay data for
cases assigned to that DRG to identify those procedures that are more
similar to the discharges that currently group to either DRG 476 or
477. We identified two procedures--other surgical occlusion of
abdominal arteries (procedure code 38.86) and other arthrotomy of knee
(procedure code 80.16)--that are significantly less resource intensive
than the other procedures assigned to DRG 468.
[[Page 29912]]
Therefore, we are proposing to move procedure codes 38.86 and 80.16 to
the list of procedures that result in assignment to DRG 477.
In reviewing the list of procedures assigned to DRG 477, we did not
identify any procedures that should be assigned to either DRG 468 or
476.
All of these proposed changes would be effective with discharges
occurring on or after October 1, 1997.
9. Changes to the ICD-9-CM Coding System
As discussed above in section II.B.1 of this preamble, the ICD-9-CM
is a coding system that is used for the reporting of diagnoses and
procedures performed on a patient. In September 1985, the ICD-9-CM
Coordination and Maintenance Committee was formed. This is a Federal
interdepartmental committee charged with the mission of maintaining and
updating the ICD-9-CM. That mission includes approving coding changes,
and developing errata, addenda, and other modifications to the ICD-9-CM
to reflect newly developed procedures and technologies and newly
identified diseases. The Committee is also responsible for promoting
the use of Federal and non-Federal educational programs and other
communication techniques with a view toward standardizing coding
applications and upgrading the quality of the classification system.
The Committee is co-chaired by the National Center for Health
Statistics (NCHS) and HCFA. The NCHS has lead responsibility for the
ICD-9-CM diagnosis codes included in Volume 1--Diseases: Tabular List
and Volume 2--Diseases: Alphabetic Index, while HCFA has lead
responsibility for the ICD-9-CM procedure codes included in Volume 3--
Procedures: Tabular List and Alphabetic Index.
The Committee encourages participation in the above process by
health-related organizations. In this regard, the Committee holds
public meetings for discussion of educational issues and proposed
coding changes. These meetings provide an opportunity for
representatives of recognized organizations in the coding fields, such
as the American Health Information Management Association (AHIMA)
(formerly American Medical Record Association (AMRA)), the American
Hospital Association (AHA), and various physician specialty groups as
well as physicians, medical record administrators, health information
management professionals, and other members of the public to contribute
ideas on coding matters. After considering the opinions expressed at
the public meetings and in writing, the Committee formulates
recommendations, which then must be approved by the agencies.
The Committee presented proposals for coding changes at public
meetings held on June 6 and December 5 and 6, 1996, and finalized the
coding changes after consideration of comments received at the meetings
and in writing within 60 days following the December 1996 meeting. The
initial meeting for consideration of coding issues for implementation
in FY 1999 will be held on June 6, 1997. Copies of the minutes of the
June 1996 meeting may be obtained by writing to one of the co-
chairpersons representing NCHS and HCFA. The minutes of the December
1996 meeting can be obtained from the HCFA Home Page @ http://
www.hcfa.gov.pubaffr.htm. Paper copies of these minutes will no longer
be available and the mailing list will be 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@nch11a.em.cdc.gov.
Questions and comments concerning the procedure codes should be
addressed to: Patricia E. Brooks, Co-Chairperson; ICD-9-CM Coordination
and Maintenance Committee; HCFA, Office of Hospital Policy; Division of
Prospective Payment System; C5-06-27; 7500 Security Boulevard;
Baltimore, Maryland 21244-1850. Comments may be sent by E-mail to:
pbrooks@hcfa.gov.
The ICD-9-CM code changes that have been approved will become
effective October 1, 1997. The new ICD-9-CM codes are listed, along
with their proposed DRG classifications, in Tables 6A and 6B (New
Diagnosis Codes and New Procedure Codes, respectively) in section V. of
the Addendum to this proposed rule. As we stated above, the code
numbers and their titles were presented for public comment in the ICD-
9-CM Coordination and Maintenance Committee meetings. Both oral and
written comments were considered before the codes were approved.
Therefore, we are soliciting comments only on the proposed DRG
classification.
Further, the Committee has approved the expansion of certain ICD-9-
CM codes to require an additional digit for valid code assignment.
Diagnosis codes that have been replaced by expanded codes, other codes,
or have been deleted are in Table 6C (Invalid Diagnosis Codes). These
invalid diagnosis codes will not be recognized by the GROUPER beginning
with discharges occurring on or after October 1, 1997. The
corresponding new or expanded diagnosis codes are included in Table 6A.
Revisions to diagnosis code titles are in Table 6D (Revised Diagnosis
Code Titles), which also include the proposed DRG assignments for these
revised codes. For FY 1998, there are no procedure codes that have been
replaced or deleted nor are there any revisions to procedure code
titles.
10. Other Issues--MDC 22 (Burns)
Under the current DRG system, burn cases generally are assigned to
one of six DRGs in MDC 22 (Burns). These DRGs-- DRGs 456 through 460
and 472--have been in place without change since 1986. Recently, we
have received several letters from representatives of facilities that
specialize in treating burn cases asserting that the existing DRGs do
not adequately capture the variation in resource use associated with
different types of burn cases. Among these correspondents' concerns are
the following:
In general, burn centers are disadvantaged because these
facilities tend to treat the most complicated and costly burn cases,
which are not always adequately defined and compensated under the
existing burn DRGs. At the same time, less complicated cases (with
lower costs and shorter lengths of stay) in the same DRGs can be
treated by hospitals that do not specialize in the treatment of burn
cases. As a result, some burn centers are experiencing a net loss of
income on cases in each of the burn DRGs. In some cases, this has led
to coding decisions that result in burn patients being assigned to non-
burn DRGs because these DRGs result in higher payments to hospitals.
DRG 456 (Burns, Transferred to Another Acute Care
Facility) either should be revised to include only cases transferred to
hospitals with a burn center or should be eliminated. This DRG
originally was designed to encourage transfers of burn patients to
hospitals with burn centers. Although it provides appropriate payment
in these situations, problems arise when burn centers treat patients
with extensive burns and then transfer them to hospitals closer to the
patients' homes for the final stages of acute care. Burn centers might
be severely penalized financially for such transfers, even though the
transfers may be both cost-effective and in the best interests of the
patient.
DRG 472 (Extensive Burns with OR Procedure) does not
capture fully the universe of critically ill, high cost
[[Page 29913]]
patients with extensive burn injuries. Currently, a patient must have a
burn of at least 50 percent of the total body surface area (or a third
degree burn covering at least 10 percent of the body) to be assigned to
DRG 472, which is by far the highest-weighted burn DRG. However, some
patients not assigned to this DRG experience equally high rates of
mortality and morbidity, with concomitant high resource use and long
lengths of stay. To address this problem, a new critical care burn DRG
should be created that would define patients by age, burn size, and
presence of co-morbidities, such as the presence of smoke inhalation,
liver or renal failure, and others.
To begin to examine these assertions, we have conducted a
preliminary analysis of cases assigned to the burn DRGs. Although the
overall volume of cases assigned to the burn DRGs is relatively small
(a combined total of about 5,000 Medicare cases in FY 1996), there is
clearly a large degree of heterogeneity in both charges and lengths of
stay for burn cases. For example, although approximately 75 percent of
cases in DRG 456 show lengths of stay below the mean of 7.3 days, a
small but significant group of cases have lengths of stay of 21 days or
more, resulting in DRG 456 having the largest length of stay
coefficient of variation of all DRGs (The coefficient of variation is a
statistical measure used to evaluate relative dispersions among all
values in a set of data.) Other DRGs in MDC 22 also have above-average
coefficients of variation. Although indications of statistical
heterogeneity are not uncommon in small volume DRGs, we believe that a
more in-depth analysis of the burn DRGs is appropriate.
Therefore, as part of our FY 1999 rulemaking agenda, we intend to
conduct a comprehensive review of MDC 22 to determine whether changes
in these DRGs can increase their ability to explain the variation in
resource use among burn cases. We welcome public comments on this
issue, particularly specific suggestions on the most appropriate ways
to categorize related diagnosis and procedure codes to produce DRG
groupings that would reflect more homogeneous resource use. We note
that any suggestions involving other types of payment adjustments for
hospitals designated as burn centers would require legislative action.
We intend to discuss our findings and, if appropriate, propose
modifications to MDC 22, in the FY 1999 proposed rule.
C. Recalibration of DRG Weights
We are proposing to use the same basic methodology for the FY 1998
recalibration as we did for FY 1997. (See the August 30, 1996 final
rule (61 FR 46176).) That is, we would recalibrate the weights based on
charge data for Medicare discharges. However, we would use the most
current charge information available, the FY 1996 MedPAR file, rather
than the FY 1995 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 1996 MedPAR data, based on bills received by HCFA through December
1996, from all hospitals subject to the prospective payment system and
short-term acute care hospitals in waiver States. The FY 1996 MedPAR
file includes data for approximately 11.1 million Medicare discharges.
The methodology used to calculate the proposed DRG relative weights
from the FY 1996 MedPAR file is as follows:
To the extent possible, all the claims were regrouped
using the proposed DRG classification revisions discussed above in
section II.B of this preamble. As noted in section II.B.6, due to the
unavailability of revised GROUPER software, we simulate most major
classification changes to approximate the placement of cases under the
proposed reclassification. However, there are some changes that cannot
be modeled.
Charges were standardized to remove the effects of
differences in area wage levels, indirect medical education costs,
disproportionate share payments, and, for hospitals in Alaska and
Hawaii, the applicable cost-of-living adjustment.
The average standardized charge per DRG was calculated by
summing the standardized charges for all cases in the DRG and dividing
that amount by the number of cases classified in the DRG.
We then eliminated statistical outliers, using the same
criteria as was used in computing the current weights. That is, all
cases that are outside of 3.0 standard deviations from the mean of the
log distribution of both the charges per case and the charges per day
for each DRG.
The average charge for each DRG was then recomputed
(excluding the statistical outliers) and divided by the national
average standardized charge per case to determine the relative weight.
A transfer case is counted as a fraction of a case based on the ratio
of its length of stay to the geometric mean length of stay of the cases
assigned to the DRG. That is, a 5-day length of stay transfer case
assigned to a DRG with a geometric mean length of stay of 10 days is
counted as 0.5 of a total case.
We established the relative weight for heart and heart-
lung, liver, and lung transplants (DRGs 103, 480, and 495) in a manner
consistent with the methodology for all other DRGs except that the
transplant cases that were used to establish the weights were limited
to those Medicare-approved heart, heart-lung, liver, and lung
transplant centers that have cases in the FY 1995 MedPAR file.
(Medicare coverage for heart, heart-lung, liver, and lung transplants
is limited to those facilities that have received approval from HCFA as
transplant centers.)
Acquisition costs for kidney, heart, heart-lung, liver,
and lung transplants continue to be paid on a reasonable cost basis.
Unlike other excluded costs, the acquisition costs are concentrated in
specific DRGs (DRG 302 (Kidney Transplant); DRG 103 (Heart Transplant
for heart and heart-lung transplants); DRG 480 (Liver Transplant); and
DRG 495 (Lung Transplant)). Because these costs are paid separately
from the prospective payment rate, it is necessary to make an
adjustment to prevent the relative weights for these DRGs from
including the effect of the acquisition costs. Therefore, we subtracted
the acquisition charges from the total charges on each transplant bill
that showed acquisition charges before computing the average charge for
the DRG and before eliminating statistical outliers.
When we recalibrated the DRG weights for previous years, we set a
threshold of 10 cases as the minimum number of cases required to
compute a reasonable weight. We propose to use that same case threshold
in recalibrating the DRG weights for FY 1998. Using the FY 1996 MedPAR
data set, there are 36 DRGs that contain fewer than 10 cases. We
computed the weights for the 36 low-volume DRGs by adjusting the FY
1997 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
[[Page 29914]]
nor decreases total payments under the prospective payment system.
Section 1886(d)(4)(C)(iii) of the Act requires that beginning with
FY 1991, reclassification and recalibration changes be made in a manner
that assures that the aggregate payments are neither greater than nor
less than the aggregate payments that would have been made without the
changes. Although normalization is intended to achieve this effect,
equating the average case weight after recalibration to the average
case weight before recalibration does not necessarily achieve budget
neutrality with respect to aggregate payments to hospitals because
payment to hospitals is affected by factors other than average case
weight. Therefore, as we have done in past years and as discussed in
section II.A.4.b of the Addendum to this proposed rule, we are
proposing to make a budget neutrality adjustment to assure that the
requirement of section 1886(d)(4)(C)(iii) of the Act is met.
III. Proposed Changes to the Hospital Wage Index
A. Background
Section 1886(d)(3)(E) of the Act requires that, as part of the
methodology for determining prospective payments to hospitals, the
Secretary must adjust the standardized amounts ``for area differences
in hospital wage levels by a factor (established by the Secretary)
reflecting the relative hospital wage level in the geographic area of
the hospital compared to the national average hospital wage level.'' In
accordance with the broad discretion conferred 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.
Section 1886(d)(3)(E) of the Act also requires that the wage index
be updated annually beginning October 1, 1993. Furthermore, this
section provides that the Secretary base the update on a survey of
wages and wage-related costs of short-term, acute care hospitals. The
survey should measure, to the extent feasible, the earnings and paid
hours of employment by occupational category, and must exclude the
wages and wage-related costs incurred in furnishing skilled nursing
services. We also adjust the wage index, as discussed below in section
III.B.3, to take into account the geographic reclassification of
hospitals in accordance with sections 1886(d)(8)(B) and 1886(d)(10) of
the Act.
B. FY 1998 Wage Index Update
The proposed FY 1998 wage index in section V. of the Addendum
(effective for hospital discharges occurring on or after October 1,
1997 and before October 1, 1998) is based on the data collected from
the Medicare cost reports submitted by hospitals for cost reporting
periods beginning in FY 1994 (the FY 1997 wage index was based on FY
1993 wage data). We propose to use the same categories of data that
were used in the FY 1997 wage index. Therefore, the proposed FY 1998
wage index reflects the following:
Total salaries and hours from short-term, acute care
hospitals.
Home office costs and hours.
Fringe benefits associated with hospital and home
office salaries.
Direct patient care contract labor costs and hours.
The exclusion of salaries and hours for nonhospital
type services such as skilled nursing facility services, home health
services, or other subprovider components that are not subject to
the prospective payment system.
We are proposing to calculate a separate Puerto Rico-specific wage
index to be applied to the Puerto Rico standardized amount. This wage
index will be calculated in the same manner as the national wage index
described below, but will be based solely on Puerto Rico's data. For
further explanation, see sections II.B.5 and III.A.6 of the Addendum to
this proposed rule.
Also, in response to a comment in the August 30, 1996 final rule,
we considered using data from Worksheet A-8-2 for the purpose of
excluding physician Part A salaries from the FY 1998 wage index
calculation (61 FR 46177). We stated that we would explore the
technical feasibility of using the data from that worksheet. However,
primarily because the intermediaries had already begun reviewing the FY
1994 cost report data and finalizing the Worksheet S-3 data, we did not
believe it would be appropriate to revise their instructions and
require them to make a change to their procedure. Therefore, we will
wait for the data from cost reporting periods beginning on or after
October 1, 1994, for which we revised the Medicare cost report to
provide for the separate reporting of physician salaries. As we have
stated previously, we will review and evaluate these salary cost data
when considering appropriate changes to the FY 1999 wage index.
1. Verification of Wage Data From the Medicare Cost Report
The data for the proposed FY 1998 wage index were obtained from
Worksheet S-3, Part II of the Medicare cost report. The data file used
to construct the proposed wage index includes FY 1994 data submitted to
the Health Care Provider Cost Report Information System (HCRIS) as of
the end of January 1997. As in past years, we performed an intensive
review of the wage data, mostly through the use of edits designed to
identify aberrant data.
Of the 5,197 hospitals in the database, 2,652 hospitals had data
elements that failed an initial edit. From mid-February 1997 through
early March 1997, intermediaries contacted hospitals to revise or
verify data elements that resulted in the edit failures. In addition,
intermediaries reviewed the database to ensure that no hospitals had
been inadvertently excluded from the database. As a result of that
review, data for two hospitals were added to the database.
Next, to check any revisions since the first edit, as well as to
apply additional edits based on the distribution of the data, we
subjected all of the data to edits a second time. As of March 14, 1997,
70 hospitals still had unresolved data elements. These unresolved data
elements are included in the calculation of the proposed FY 1998 wage
index pending their resolution before calculation of the final FY 1998
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
[[Page 29915]]
than June 16, 1997. We expect that all unresolved data elements will be
resolved by that date, and that the revised data will be reflected in
the final rule.
2. Computation of the Wage Index
The method used to compute the proposed wage index is as follows:
Step 1--As noted above, we are proposing to base the FY 1998 wage
index on wage data reported on the FY 1994 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, Part II of
the Medicare cost report for the hospital's cost reporting period
beginning on or after October 1, 1993 and before October 1, 1994. In
addition, we included data from a few hospitals that had cost reporting
periods beginning in September 1993 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 particular labor market areas might be
affected due to the omission of these hospitals. However, we generally
describe these wage data as FY 1994 data.
Step 2--For each hospital, we subtracted the excluded salaries
(that is, direct salaries attributable to skilled nursing facility
services, home health services, and other subprovider components not
subject to the prospective payment system) from gross hospital salaries
to determine net hospital salaries. To determine total salaries plus
fringe benefits, we added direct patient care contract labor costs,
hospital fringe benefits, and any home office salaries and fringe
benefits reported by the hospital, to the net hospital salaries.
Step 3--For each hospital, we adjusted the total salaries plus
fringe benefits resulting from Step 2 to a common period to determine
total adjusted salaries. To make the wage inflation adjustment, we used
the percentage change in average hourly earnings estimated for each 30-
day increment from October 14, 1993 through April 15, 1995, for
hospital industry workers from Standard Industry Classification 806,
Bureau of Labor Statistics Employment and Earnings Bulletin. The annual
inflation rates used were 3.6 percent for FY 1993, 2.7 percent for FY
1994, and 3.3 percent for FY 1995. The inflation factors used to
inflate the hospital's data were based on the midpoint of the cost
reporting period as indicated below.
Midpoint of Cost Reporting Period
------------------------------------------------------------------------
After Before Adjustment factor
------------------------------------------------------------------------
10/14/93............... 11/15/93 1.038679
11/14/93............... 12/15/93 1.036376
12/14/93............... 01/15/94 1.034077
01/14/94............... 02/15/94 1.031784
02/14/94............... 03/15/94 1.029496
03/14/94............... 04/15/94 1.027213
04/14/94............... 05/15/94 1.024935
05/14/94............... 06/15/94 1.022662
06/14/94............... 07/15/94 1.020394
07/14/94............... 08/15/94 1.018131
08/14/94............... 09/15/94 1.015873
09/14/94............... 10/15/94 1.013620
10/14/94............... 11/15/94 1.010881
11/14/94............... 12/15/94 1.008150
12/14/94............... 01/15/95 1.005426
01/14/95............... 02/15/95 1.002709
02/14/95............... 03/15/95 1.000000
03/14/95............... 04/15/95 0.997298
------------------------------------------------------------------------
For example, the midpoint of a cost reporting period beginning
January 1, 1994 and ending December 31, 1994 is June 30, 1994. An
inflation adjustment factor of 1.020394 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 1994 and covers a
period of less than 360 days or greater than 370 days, we annualized
the data to reflect a 1-year cost report. Annualization is accomplished
by dividing the data by the number of days in the cost report and then
multiplying the results by 365.
Step 4--For each hospital, we subtracted the reported excluded
hours from the gross hospital hours to determine net hospital hours. We
increased the net hours by the addition of any direct patient care
contract labor hours and home office hours to determine total hours.
Step 5--As part of our editing process, we deleted data for 17
hospitals for which we lacked sufficient documentation to verify data
that failed edits because the hospitals are no longer participating in
the Medicare program or are in bankruptcy status. We retained the data
for other hospitals that are no longer participating in the Medicare
program because these hospitals reflected the relative wage levels in
their labor market areas during their FY 1994 cost reporting period.
Step 6--Each hospital was assigned to its appropriate urban or
rural labor market area prior to any reclassifications under sections
1886(d)(8)(B) or 1886(d)(10) of the Act. Within each urban or rural
labor market area, we added the total adjusted salaries plus fringe
benefits obtained in Step 3 for all hospitals in that area to determine
the total adjusted salaries plus fringe benefits for the labor market
area.
Step 7--We divided the total adjusted salaries plus fringe benefits
obtained in Step 6 by the sum of the total hours (from Step 4) for all
hospitals in each labor market area to determine an average hourly wage
for the area.
Step 8--We added the total adjusted salaries plus fringe benefits
obtained in Step 3 for all hospitals in the Nation and then divided the
sum by the national sum of total hours from Step 4 to arrive at a
national average hourly wage. Using the data as described above, the
national average hourly wage is $20.0804.
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. We added the total adjusted salaries
plus fringe benefits (as calculated in Step 3) 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
$9.1956 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.
3. Revisions to the Wage Index Based on Hospital Redesignation
Under section 1886(d)(8)(B) of the Act, hospitals in certain rural
counties adjacent to one or more MSAs are considered to be located in
one of the adjacent MSAs if certain standards are met. Under section
1886(d)(10) of the Act, the Medicare Geographic Classification Review
Board (MGCRB) considers applications by hospitals for geographic
reclassification for purposes of payment under the prospective payment
system.
The methodology for determining the wage index values for
redesignated hospitals is applied jointly to the hospitals located in
those rural counties that were deemed urban under section 1886(d)(8)(B)
of the Act and those hospitals that were reclassified as a result of
the MGCRB decisions under section 1886(d)(10) of the Act. Section
1886(d)(8)(C) of the Act provides that the application of the wage
index to redesignated hospitals is dependent on the hypothetical impact
that the wage data from these hospitals would have on the wage index
value for the area to
[[Page 29916]]
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 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, provided the urban area's wage index value prior to
reclassification was greater than the statewide rural wage index value.
Reclassification of hospitals may not result in the
reduction of the wage index value for any urban area whose wage index
value is below the statewide rural wage index value. This provision
also applies to any urban area that encompasses an entire State.
We note that, except for those rural areas where redesignation
would reduce the rural wage index value, and those urban areas whose
wage index values are already below the statewide rural wage index
value and would be reduced by redesignations, 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
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 1998 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 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 rural hospital is redesignated is lower than the wage index
value for the rural areas of the State in which the rural hospital is
located, the redesignated rural 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, prior to the
redesignation of hospitals, based on the FY 1994 wage data. In
addition, Table 3C in the Addendum to this proposed rule includes the
adjusted (inflated) average hourly wage for each hospital based on the
FY 1994 data. The MGCRB will use the average hourly wage published in
the final rule to evaluate a hospital's application for
reclassification, unless that average hourly wage is later revised in
accordance with the wage data correction policy described in
Sec. 412.63(s)(2). In such cases, the MGCRB will use the most recent
revised data used for purposes of the hospital wage index. Hospitals
that choose to apply before publication of the final rule can use the
proposed wage data in applying to the MGCRB for wage index
reclassifications that would be effective for FY 1999. We note that in
adjudicating these wage index reclassification requests during FY 1998,
the MGCRB will use the average hourly wages for each hospital and labor
market area that are reflected in the final FY 1998 wage index.
At the time this proposed wage index was constructed, the MGCRB had
completed its review. The proposed FY 1998 wage index values
incorporate all 364 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 1998. The final number of
reclassifications may be different because some MGCRB decisions are
still under review by the Administrator and because some hospitals may
withdraw their requests for reclassification.
Any changes to the wage index that result from withdrawals of
requests for reclassification, wage index corrections, appeals, and the
Administrator's review process will be incorporated into the wage index
values published in the final rule. The changes may affect not only the
wage index value for specific geographic areas, but also whether
redesignated hospitals receive the wage index value for the area to
which they are redesignated, or a wage index 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 1998 must be received by the MGCRB by July 17, 1997. A
hospital that requests to withdraw its application may not later
request that the MGCRB decision be reinstated.
C. Requests for Wage Data Corrections
To allow hospitals more time to evaluate the wage data used to
construct the proposed FY 1998 hospital wage index, we have made
available to the public a data file containing the FY 1994 hospital
wage data. In a memorandum dated February 28, 1997, we instructed all
Medicare intermediaries to inform the prospective payment hospitals
they serve that the wage data file would be available approximately
mid-March 1997. The intermediaries were also instructed to advise
hospitals of the alternative availability of these data through the
Internet at HCFA's home page (http://www.hcfa.gov), their
representative hospital organizations, or directly from HCFA (using
order forms provided by the intermediary). Additional details on
ordering this data file are discussed in
[[Page 29917]]
section IX.A. of this preamble, ``Requests for Data from the Public.''
In addition, as discussed in section III.B.3 of this preamble,
Table 3C in the Addendum to this proposed rule contains each hospital's
adjusted average hourly wage used to construct the proposed wage index
values. A hospital can verify its average hourly wage as reflected on
its cost report (after taking into account any adjustments made by the
intermediary) by dividing the adjusted average hourly wage in Table 3C
by the applicable wage inflation adjustment factors as set forth above
in Step 3 of the computation of the wage index. An updated Table 3C
(along with applicable wage inflation adjustment factors) will be
included in the final rule.
We believe hospitals have had ample time to ensure the accuracy of
their FY 1994 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 or Table 3C, a
hospital believes that its FY 1994 wage data have been incorrectly
reported, the hospital must submit corrections along with complete,
detailed supporting documentation to its intermediary by May 15, 1997.
To be reflected in the final wage index, any wage data corrections must
be reviewed and verified by the intermediary and transmitted to HCFA
(through HCRIS) on or before June 16, 1997. These deadlines, which
correspond to the deadlines we used last year for developing the FY
1997 wage index, are necessary to allow sufficient time to review and
process the data so that the final wage index calculation can be
completed for development of the final prospective payment rates to be
published by August 29, 1997. We cannot guarantee that corrections
transmitted to HCFA after June 16, 1997, will be reflected in the final
wage index.
After reviewing requested changes submitted by hospitals,
intermediaries will transmit any revised cost reports to HCRIS and
forward a copy of the revised Worksheet S-3, Part II to the hospitals.
If requested changes are not accepted, fiscal intermediaries will
notify hospitals in writing of reasons why the changes were not
accepted. This procedure will ensure that hospitals have every
opportunity to verify the data that will be used to construct their
wage index values. We believe that fiscal intermediaries are generally
in the best position to make evaluations regarding the appropriateness
of a particular cost and whether it should be included in the wage
index data. However, if a hospital disagrees with the intermediary's
resolution of a requested change, the hospital may contact HCFA in an
effort to resolve the dispute. We note that the June 16 deadline also
applies to these requested changes, and we will not consider requests
to resolve such disputes that are not received by June 16.
We have created the process described above to resolve all
substantive wage data correction disputes before we finalize the wage
data for the FY 1998 payment rates. Accordingly, hospitals that do not
meet the procedural deadlines set forth above will not be afforded a
later opportunity to submit wage corrections or to dispute the
intermediary's decision with respect to requested changes.
We intend to make another file available in mid-August that will
contain the wage data that will be used to construct the wage index
values in the final rule. As with the file made available in March
1997, HCFA will make the August wage data file available to hospital
associations and the public. This August file, however, is being made
available only for the limited purpose of identifying any potential
errors made by HCFA or the intermediary in the entry of the final wage
data that result from the process described above, not for the
initiation of new wage data correction requests. Hospitals are
encouraged to review their hospital wage data promptly after the
release of the second file.
If, after reviewing the August 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 September 15, 1997. Requests
mailed to HCFA should be sent to: Health Care Financing Administration;
Office of Hospital Policy; Attention: Stephen Phillips, Technical
Advisor; Division of Prospective Payment System; C5-06-27; 7500
Security Boulevard; Baltimore, MD 21244-1850. Each request also must be
sent to the hospital's fiscal intermediary. The intermediary will
review requests upon receipt and contact HCFA immediately to discuss
its findings.
After mid-August, we will make changes to the hospital wage data
only in those very limited situations involving an error by the
intermediary or HCFA that the hospital could not have known about
before its review of the August wage data file. Specifically, after
that point, neither the intermediary nor HCFA will accept the following
types of requests in conjunction with this process:
Requests for wage data corrections that were submitted
too late to be included in the data transmitted to HCRIS on or
before June 16, 1997.
Requests for correction of errors that were not, but
could have been, identified during the hospital's review of the
March 1997 data.
Requests to revisit factual determinations or policy
interpretations made by the intermediary or HCFA during the wage
data correction process.
Verified corrections to the wage index received timely (that is, by
September 15, 1997) will be effective October 1, 1997.
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 wage data in mid-August, they will have the
opportunity to detect any data entry or tabulation errors made by the
intermediary or HCFA before the implementation of the FY 1998 wage
index on October 1, 1997. If hospitals avail themselves of this
opportunity, the wage index implemented on October 1 should be free of
such errors. Nevertheless, in the unlikely event that such errors
should occur, we retain the right to make midyear changes to the wage
index under very limited circumstances.
Specifically, in accordance with Sec. 412.63(s)(2), we may make
midyear corrections to the wage index only in those limited
circumstances where a hospital can show: (1) That the intermediary or
HCFA made an error in tabulating its data; and (2) that the hospital
could not have known about the error, or did not have an opportunity to
correct the error, before the beginning of FY 1998 (that is, by the
September 15, 1997 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.
[[Page 29918]]
D. Modification of the Process and Timetable for Updating the Wage
Index
Although the wage data correction process described above has
proven successful in the past for ensuring that the wage data used each
year to calculate the wage indexes are generally reliable and accurate,
we are concerned that there have been an excessive number of wage data
revisions occurring after the release of the wage data in mid-March.
Last year, in developing the FY 1997 wage index, the wage data were
revised between the proposed and the final rules for more than 13
percent of the hospitals (approximately 700 of 5,200). Since hospitals
are expected to submit complete and accurate data, and the data are
reviewed and edited by the intermediaries and HCFA, we believe that we
should be making few revisions after the release of the March wage data
file. According to information received from the intermediaries, these
late revisions are partly due to the lack of responsiveness of
hospitals in providing sufficient information to the intermediaries
during the desk reviews (that is, during the intermediary's review of
the hospital's cost report).
Our analysis of last year's wage data also shows that, although the
volume of revisions was high, the effect of the changes on the wage
index was minimal. Of the 368 labor market areas affected, only 4 (1.1
percent) experienced a change of 5 percent or more in their wage index
value and 39 (10.6 percent) experienced a change of 1 percent or more.
Thus, the intensity of work that must be performed in order to
incorporate these revisions in the 1 month available between the mid-
June date for revision requests and the mid-July date by which we must
begin calculation of the final wage index is not warranted in light of
the minimal changes to the actual wage index values.
Another problem with the current process is that it results in
corrections to the final wage index after the September 1 final rule
publication and before the October 1 effective date of the wage index.
Immediately following the development of the final wage index, a second
wage data file is made available in mid-August so that hospitals may
again verify the accuracy of their wage data. If a hospital detects an
error made by the intermediary or HCFA in the handling (entry or
transmission) of the wage data, the hospital may request a correction
(this year, by September 15). The corrections are published in the
Federal Register after the October 1 implementation date in a
correction notice to the final rule. We would prefer to eliminate the
need to republish certain wage index values after the final rule is in
effect.
Finally, hospitals base their geographic reclassification decisions
(whether or not to withdraw their applications) on the wage index
published in the proposed rule. Although the FY 1997 proposed and final
wage indexes were quite similar, we cannot ensure this will happen each
year if increasing numbers of hospitals delay the submittal to their
intermediaries of wage data supporting documentation until the May 15
deadline. We believe that a more informed reclassification decision
could be made if the proposed wage index more closely resembles the
final wage index. Therefore, we are proposing to revise the wage data
verification process beginning with the FY 1999 wage index.
1. Proposed Process and Timetable
The major change we are proposing to the current process would be
the requirement that wage data revisions be requested (and resolved)
earlier, before publication of the proposed rule. Subsequent
corrections would be allowed only for errors in handling the data (our
current timetable allows for such corrections after the final rule is
published). For example, the FY 1999 wage index will use FY 1995 cost
report data (that is, cost reports beginning in FY 1995) and become
effective October 1, 1998. Under the proposed timetable, hospitals
would be required to submit all requests for wage data revisions to
their intermediary by mid-December 1997. This would provide ample
opportunity for hospitals to evaluate the results of intermediaries'
desk reviews and prepare any requests for corrections. We note that the
desk reviews are performed on an ongoing basis as cost reports are
received from hospitals and, for the FY 1995 wage data, must be
completed prior to the mid-November 1997 deadline for submitting all FY
1995 wage data to HCRIS.
As under the current process, after reviewing requests for wage
data revisions submitted by hospitals, fiscal intermediaries will
transmit any revised cost report to HCRIS and forward a copy of the
revised Worksheet S-3, Part II to the hospital. If requested revisions
are not accepted, the fiscal intermediaries will notify the hospital in
writing of reasons why the changes were not accepted. We believe that
fiscal intermediaries are generally in the best position to make
evaluations regarding the appropriateness of a particular cost and
whether it should be included in the wage index data. However, if a
hospital disagrees with the intermediary's resolution of a requested
change, the hospital may contact HCFA in an effort to resolve the
dispute. All policy issues must be resolved by mid-January.
The proposed timetable for developing the annual update to the wage
index is as follows (an asterisk indicates no change from prior years):
Mid-November *
All desk reviews for hospital wage data are completed and revised
data transmitted by intermediaries to HCRIS.
Mid-December
Deadline for hospitals to request wage data revisions and provide
adequate documentation to support the request.
Mid-January
Deadline for intermediaries to submit to HCRIS all revisions
resulting from hospitals' requests for adjustments (as of mid-December)
(and verification of data submitted to HCRIS (as of mid-November)).
Early April
Edited wage data are available for release to the public.
May 1 *
Proposed rule published with 60-day comment period and 45-day
withdrawal deadline for geographic reclassification.
June 16, 1997
Deadline for hospitals to notify HCFA and intermediary that wage
data are incorrect due to mishandling of data (that is, error in data
entry or transmission) by intermediary or HCFA.
June 30, 1997
Deadline for intermediaries to transmit all revisions to HCRIS.
September 1 *
Publication of the final rule.
October 1 *
Effective date of updated wage index.
2. Cost Reporting Timetable
This proposed change will not significantly alter the time
hospitals have to ensure the accuracy of their data. In developing the
wage index for a given fiscal year, we use the most recent, reviewed
wage data, that is, wage data from cost reports that began in the
fiscal year 4 years earlier. For example, for the FY 1999 wage index,
we will use data from cost reporting periods beginning in FY 1995.
Hospitals must submit cost reports to their intermediaries within 150
days of the end of their cost reporting periods. Once the cost report
is received, the intermediary has 12 months to review and settle it.
As part of the settlement process, we require intermediaries to
conduct a desk
[[Page 29919]]
review of the wage data. The desk review program for hospital wage data
targets potentially aberrant data and checks the completeness and
accuracy of the data, including verifying that reported costs are in
conformance with our policy, before it is used in calculating the wage
index. The intermediary checks the wage data and supporting
documentation submitted by the hospital and contacts the hospital if
additional information is needed to verify the accuracy of the data.
When it is necessary for the intermediary to adjust a hospital's wage
data, the intermediary notifies the hospital in writing of the change
to the cost report and hospitals then have the opportunity to request
adjustments. This would continue to be the case.
Since intermediaries must settle cost reports within 12 months of
their receipt, most of the cost reports are settled by the time we
compile the data to calculate the wage index. We note, however, that
the annual update of the wage index is not tied directly to the cost
report settlement process since extensions or reopenings of settled
cost reports may be granted.
The following is an illustration of the process for settling a
typical cost report beginning in FY 1995. Of course, hospitals' cost
reporting periods may begin at any time during the year.
January 1, 1995
Cost reporting period begins.
December 31, 1995
Cost reporting period ends.
May 31, 1996
Cost report must be submitted by the hospital to the intermediary.
July 31, 1996
Cost report must be transmitted by the intermediary to HCRIS.
May 31, 1997
Cost report must be settled by the intermediary. (Desk review of
hospital wage data is performed on an ongoing basis by the intermediary
before the cost report is settled.)
July 31, 1997
Settled cost report must be transmitted by the intermediary to
HCRIS.
3. Impact of the Proposed Revised Timetable for Finalizing Wage Data
The most significant change from our current process is that we
would no longer release a preliminary wage data file prior to
hospitals' final opportunity to request corrections. We would instead
release a single data file in early April for the limited purpose of
identifying errors made by the intermediaries or HCFA in handling the
data. We no longer believe that the benefit of releasing the
preliminary data file outweighs the disadvantages in terms of increased
workload for the intermediaries. Under the current process,
intermediaries are required to verify the inclusion and accuracy of all
hospitals' wage data twice during the wage index development.
Verification is done in December and in July before the wage data
public use files are released in mid-March and mid-August.
Therefore, hospitals would no longer have until mid-May to request
wage data revisions. Instead, hospitals would have to request revisions
and provide supporting documentation by mid-December of the previous
year, and all policy issues would have to be resolved by mid-January.
We believe this proposed timetable for finalizing the wage data used in
the hospital wage index gives hospitals ample opportunity to ensure the
accuracy of the data and at the same time addresses the concerns we
have discussed (the number of revisions, the necessity of making
numerous corrections after the final rule, and the differences between
the proposed and final wage indexes). Moreover, we do not believe the
timetable change would impose any increased burden. Hospitals are
required to certify the completeness and the accuracy of the wage data
when they submit their cost reports, and the intermediaries complete
desk reviews before we begin to develop the wage index for a given
year. Hospitals would still have an opportunity to request revisions to
the cost report data. Although those requests would have to be made
earlier, hospitals would continue to have ample time to request
appropriate revisions given the timetable for cost report submission
and review.
We believe the proposed timetable is a logical step in the
evolution of the process for compiling the wage data used to calculate
the hospital wage index. For a number of years, the hospital wage index
was based on a wage survey that was not updated every year. Applicable
policies permitted hospitals to request and receive mid-year
corrections to the data on the wage survey. Beginning with FY 1994
(beginning on October 1, 1993), we used wage data submitted by
hospitals on Worksheet S-3, Part II of the hospital cost report, and we
update the wage data every year. We revised our wage data process
accordingly--we stopped making mid-year corrections to the wage data,
and instead attempted to finalize the wage data by the final rule.
The proposed timetable would shorten the time for revisions
somewhat further, in order to finalize wage data as much as possible
before publication of the proposed rule. Because we have used cost
report data for 5 years now, hospitals should be well aware of the
importance of submitting accurate wage data on the worksheet S-3, Part
II. And as intermediaries and hospitals have become increasingly
familiar with the data collection and verification process, handling
the data has become more routine and streamlined. For instance, over
the past year, we have greatly improved the overall efficiency of our
communications with the intermediaries through greater reliance on
electronic transmission of wage data. In short, then, there should be
less need for revising wage data after desk reviews, and we believe it
is reasonable and appropriate to revise the timetable for requesting
and resolving wage data revisions.
We would continue to make midyear corrections to the wage index in
accordance with Sec. 412.63(s)(2), in those limited circumstances where
a hospital can show: (1) That the intermediary or HCFA made an error in
tabulating its data; and (2) that the hospital could not have known
about the error, or did not have an opportunity to correct the error,
before the beginning of the fiscal year. Although we do not anticipate
that such situations would arise, this regulatory authority would
remain unchanged.
E. Proposed Wage Index Workgroup
We are concerned that the rapid and dramatic changes occurring in
hospitals' operating environments, combined with the current time lag
in the data used to construct the wage index, is leading to a situation
where the wage index may be becoming less representative of hospitals'
current labor costs. Hospitals' increasing reliance on contract labor
for a broadening array of functions, hospital mergers and the
development of integrated delivery systems, and the probable expansion
of the prospective payment system to other sites of care are factors
that indicate a need for a concerted effort to ensure that the data
required for calculating the wage index are available and reliable.
Furthermore, despite the improvements that resulted from the work of
the special Medicare Technical Advisory Group (MTAG) several years ago,
technical questions about the treatment of certain types of labor costs
continue to arise.
For these reasons, we believe there is a need for an ongoing
workgroup to address wage index related issues periodically. We are
interested in receiving input from representatives of the hospital
industry (and other provider types interested in the collection of wage
data) regarding the
[[Page 29920]]
need for such a workgroup and their willingness to participate. We are
also seeking public input regarding the structure and scope of such a
workgroup. In particular, we welcome comments on whether the workgroup
should be formally established (for example, a special MTAG), encompass
other provider types, or operate on an ongoing basis. We will respond
to comments we receive on this issue in the final rule.
IV. Revising the Hospital Operating Market Baskets
A. General Discussion
We use a hospital input price index (that is, the hospital ``market
basket'') to develop the inflation component update factors for
operating costs. Although ``market basket'' technically describes the
mix of goods and services used to produce hospital care, this term is
also commonly used to denote the input price index (that is, cost
category weights and price proxies combined) derived from that market
basket. Accordingly, the term ``market basket'' as used in this
document refers to the hospital input price index.
The terms rebasing and revising, although often used
interchangeably, actually denote different activities. Rebasing moves
the base year for the structure of costs of an input price index (for
example, moving the base year cost structure from FY 1987 to FY 1992).
Revising means changing data sources, cost categories, or price proxies
used in the input price index for a given base year. In the August 30,
1996 final rule, effective for FY 1997, we both rebased and revised the
hospital operating market baskets (61 FR 46186).
B. Revising the Hospital Market Basket
We propose this year to use a revised hospital market basket in
developing the FY 1998 update factor for the operating prospective
payment rates. In the August 30, 1996 final rule, we discussed the
possibility of revising the market basket when additional data became
available (61 FR 46187). Consistent with that discussion, we propose to
use a revised market basket which would still have a base year of FY
1992, but would incorporate additional data, specifically the Asset and
Expenditure Survey, 1992 Census of Service Industries, by the Bureau of
the Census, Economics and Statistics Administration, U.S. Department of
Commerce, which did not become available until after the FY 1997 final
rule was published. (For further discussion of the differences between
the proposed revised market basket and the current market basket, see
Appendix C of this proposed rule.)
In the current market basket, data for four major expense
categories (wages and salaries, employee benefits, pharmaceuticals, and
a residual category) are from Medicare hospital cost reports for
periods beginning in FY 1992 (that is, periods beginning on or after
October 1, 1991 and before October 1, 1992). These cost reports, which
we refer to as PPS-9 cost reports (the 9th year of PPS), are reported
in the Health Care Provider Cost Report Information System (HCRIS). In
the proposed hospital market basket, we still use the cost report data,
and categories and weights are unchanged from the current market
basket. Within the residual category, the categories and weights for
nonmedical professional fees and professional liability insurance are
also unchanged. (For a detailed discussion of the determination of
weights, see the August 30, 1996 final rule (61 FR 46187)).
Table 1 shows a comparison of the current and the proposed revised
operating market basket cost categories, weights, and price proxies.
For the proposed market basket, weights for the ``Utilities'' and ``All
Other'' cost categories, as well as most subcategories, were derived
using the Asset and Expenditure Survey, published by the Bureau of the
Census, Economics and Statistics Administration, U.S. Department of
Commerce, in conjunction with the latest available (1987) Input-Output
Table, produced by the Bureau of Economic Analysis (BEA), U.S.
Department of Commerce. The 1987 input-output cost shares, aged to 1992
using historical price changes between 1987 and 1992 for each category,
were allocated to be consistent with the newly available 1992 asset and
expenditure data.
The resulting combined data were allocated to be consistent with
the 1992 hospital cost report data. Revised relative weights for the
base year were then calculated for various expenditure categories. This
work resulted in the identification of 22 separate cost categories in
the revised market basket. Four categories previously separate were
combined with existing categories. Specifically, Business Services, and
Computer and Data Processing Services were combined with All Other
Labor-Intensive Services. Transportation Services was combined with All
Other Nonlabor-Intensive Services, and the Fuel, Oil, Coal etc.
category was split between Fuels (nonhighway) and Miscellaneous
Products. We combined these categories so that the market basket would
conform more closely with the 1992 Asset and Expenditure Survey.
Detailed descriptions of each of the four categories and their
respective price proxies can be found in the August 30, 1996 final rule
(61 FR 46323). Changing the structure of the market basket using the
1992 Asset and Expenditure Survey allows for a more accurate reflection
of the cost structures faced by hospitals. When the Bureau of the
Census or the BEA improves methodologies for the collection and
categorization of data, it is likely the weights will also change.
Table 1.--Comparison of Current 1992-Based Prospective Payment Hospital Market Basket With Proposed Revised 1992-
Based Prospective Payment Hospital Market Basket
----------------------------------------------------------------------------------------------------------------
Proposed
Current revised
1992-based 1992-based
Expense categories Price proxy excluded excluded
market market
basket \1\ basket
----------------------------------------------------------------------------------------------------------------
1. Compensation............................... ...................................... 61.390 61.390
A. Wages and Salaries..................... HCFA Occupational Wage Index.......... 50.244 50.244
B. Employee Benefits...................... HCFA Occupational Benefits Index...... 11.146 11.146
2. Nonmedical Professional Fees............... ECI-Compensation for Professional, 2.127 2.127
Specialty, and Technical.
3. Utilities.................................. ...................................... 2.470 1.542
A. Electricity............................ PPI Commercial Electric Power......... 1.349 0.927
B. Fuels (Nonhighway)..................... PPI Commercial Natural Gas............ 1.015 0.369
C. Water and Sewerage..................... CPI-U Water and Sewerage Maintenance.. 0.106 0.246
[[Page 29921]]
4. Professional Liability Insurance........... HCFA Professional Liability Insurance 1.189 1.189
Premium Index.
5. All Other Expenses......................... ...................................... 32.825 33.752
A. All Other Products..................... ...................................... 24.033 24.825
(1) Pharmaceuticals................... PPI Ethical (Prescription) Drugs...... 4.162 4.162
(2) Food.............................. ...................................... 3.459 3.386
(a) Direct Purchase............... PPI Processed Foods and Feeds......... 2.363 2.314
(b) Contract Service.............. CPI Food Away From Home............... 1.096 1.072
(3) Chemicals......................... PPI Industrial Chemicals.............. 3.795 3.666
(4) Medical Instruments............... PPI Medical Instruments and Equipment. 3.128 3.080
(5) Photographic Supplies............. PPI Photographic Supplies............. 0.399 0.391
(6) Rubber and Plastics............... PPI Rubber and Plastic Products....... 4.868 4.750
(7) Paper Products.................... PPI Converted Paper and Paperboard 2.062 2.078
Products.
(8) Apparel........................... PPI Apparel........................... 0.875 0.869
(9) Machinery and Equipment........... PPI Machinery and Equipment........... 0.211 0.207
(10) Miscellaneous Products........... PPI Finished Goods.................... 1.074 2.236
B. All Other Services..................... ...................................... 8.792 8.927
(1) Postage........................... CPI-U Postage......................... 0.272 0.272
(2) Telephone Services................ CPI-U Telephone Services.............. 0.531 0.581
(3) All Other: Labor Intensive........ ECI Compensation for Private Service 7.457 7.277
Occupations.
(4) All Other: Nonlabor Intensive..... CPI-U All Items....................... 0.532 0.796
-------------------------
Total............................. ...................................... 100.000 100.000
----------------------------------------------------------------------------------------------------------------
Note: Due to rounding, weights may not sum to total.
\1\ Expense categories based on proposed 1992-based hospital market basket for comparison purposes.
In calculating payments to hospitals, the labor-related portion of
the standardized amounts is adjusted by the hospital wage index. As
discussed in the August 30, 1996 final rule (61 FR 46189), for purposes
of determining the labor-related portion of the standardized amounts,
we sum the percentages of the labor-related items (that is, wages and
salaries, employee benefits, professional fees, business services,
computer and data processing services, postage, and all other labor-
intensive services) in the operating hospital market basket. Effective
for FY 1997, this summation resulted in a labor-related portion of the
hospital market basket of 71.246 percent, and a nonlabor-related
portion of 28.754 percent. Thus, since October 1, 1996, we have
considered 71.2 percent of operating costs to be labor-related for
purposes of the prospective payment system (we rounded to the nearest
tenth).
In connection with the revisions to the hospital market basket, we
have reestimated the labor-related share of the standardized amounts.
Based on the relative weights described in Table 2, the labor-related
portion (wages and salaries, employee benefits, professional fees,
postage, and all other labor-intensive services) is 71.066 percent, and
the nonlabor-related portion is 28.934 percent. Accordingly, effective
with discharges occurring on or after October 1, 1997, we are proposing
to revise the labor-related and nonlabor-related shares of the large
urban and other areas' standardized amounts used to establish the
prospective payment rates to 71.1 and 28.9, respectively. The amounts
in Table 2 reflect the revised labor-related and nonlabor-related
portions. We note that the labor-related portions of the rates
published in Table 2 have remained approximately the same. The labor-
related portion has decreased from 71.246 percent to 71.066 percent.
Table 2.--Labor-Related Share of Proposed 1992-Based Prospective Payment
Hospital Market Basket
------------------------------------------------------------------------
Cost category Weight
------------------------------------------------------------------------
Wages and salaries........................................... 50.244
Employee benefits............................................ 11.146
Professional fees............................................ 2.127
Postal services.............................................. 0.272
All other labor intensive.................................... 7.277
----------
Total labor-related...................................... 71.066
==========
Total nonlabor-related................................... 28.934
------------------------------------------------------------------------
C. Selection of Price Proxies
Only four categories that are part of the current hospital market
basket do not appear in the proposed revised hospital market basket. Of
the 22 categories that are part of both the current and the proposed
revised market baskets, only the weights might differ. The wage and
price proxies selected for these cost categories are the same as those
selected last year. A description and discussion of each price proxy
are set forth in the August 30, 1996 final rule (61 FR 46324). The
price proxies are shown in Table 1, above. The makeup of the HCFA
Blended Occupational Wage Index and the HCFA Blended Occupational
Benefits Index used as proxies for Wages and Salaries and Employee
Benefits, respectively, remain the same as last year. (See 61 FR
27463.)
To examine the impact of the changes to the weights and the
reduction of the number of cost categories, we developed a comparison
for the period FY 1994 through FY 1999. Using historical data for FY
1994 through FY 1996, and forecasts for FY 1997 through FY 1999 for the
prospective payment market basket, we compared the percentage changes
for the current and the proposed revised market baskets.
[[Page 29922]]
Table 3.--Comparison of the Proposed Prospective Payment Hospital Market
Basket and the Current Prospective Payment Hospital Market Basket
Percent Change, FY 1994-1999
------------------------------------------------------------------------
Current Proposed
hospital hospital
Federal fiscal year market market Difference
basket basket
------------------------------------------------------------------------
Historical:
1994.................................. 2.6 2.6 0.0
1995.................................. 3.2 3.2 0.0
1996.................................. 2.5 2.4 -0.1
Forecasted:
1997.................................. 2.4 2.3 -0.1
1998.................................. 2.7 2.8 0.1
1999.................................. 3.0 2.9 -0.1
Historical Average:
1994-1996............................. 2.8 2.7 -0.1
Forecasted Average:
1997-1999............................. 2.7 2.7 0.0
------------------------------------------------------------------------
Note that the historical average rate of growth for 1994 through
1996 for the improved proposed revised prospective payment hospital
market basket is almost equal to that of the current market basket. The
0.1 percentage point difference is less than the +/-0.25 percent
threshold for corrections for forecast error. The forecasted average
rate of growth for 1997 through 1999 for the revised market basket is
equal to that of the current market basket.
D. Separate Market Basket for Hospitals and Hospital Units Excluded
From the Prospective Payment System
As in the prospective payment hospital market basket, weights for
the six main cost categories contained in the excluded hospital market
basket (that is, weights for wages and salaries, employee benefits,
professional fees, malpractice insurance, pharmaceuticals, and the
residual category) remain the same. Only the weights for ``Utilities''
and the categories within ``All Other'' have been revised. Table 4
below shows weights for the current and proposed excluded hospital
market basket.
Table 4.--Comparison of Current 1992-Based Excluded Hospital Market Basket With Proposed Revised 1992-Based
Excluded Hospital Market Basket
----------------------------------------------------------------------------------------------------------------
Proposed
Current revised
1992-based 1992-based
Expense categories Price proxy excluded excluded
market market
basket \1\ basket
----------------------------------------------------------------------------------------------------------------
1. Compensation............................... ...................................... 63.721 63.721
A. Wages and Salaries..................... HCFA Occupational Wage Index.......... 52.152 52.152
B. Employee Benefits...................... HCFA Occupational Benefits Index...... 11.569 11.569
2. Nonmedical Professional Fees............... ECI-Compensation for Professional, 2.098 2.098
Specialty, and Technical.
3. Utilities.................................. ...................................... 2.557 1.675
A. Electricity............................ WPI Commercial Electric Power......... 1.396 1.007
B. Fuels (Nonhighway)..................... WPI Commercial Natural Gas............ 1.051 0.401
C. Water and Sewerage..................... CPI-U Water and Sewerage Maintenance.. 0.110 0.267
4. Professional Liability Insurance........... HCFA Professional Liability Insurance 1.081 1.081
Premium Index.
5. All Other Expenses......................... ...................................... 30.541 31.425
A. All Other Products..................... ...................................... 23.640 24.227
(1) Pharmaceuticals................... PPI Ethical (Prescription) Drugs...... 3.070 3.070
(2) Food.............................. ...................................... 3.581 3.468
(a) Direct Purchase............... PPI Processed Foods and Feeds......... 2.446 2.370
(b) Contract Service.............. CPI Food Away From Home............... 1.135 1.098
(3) Chemicals......................... PPI Industrial Chemicals.............. 3.929 3.754
(4) Medical Instruments............... PPI Medical Instruments and Equipment. 3.238 3.154
(5) Photographic Supplies............. PPI Photographic Supplies............. 0.413 0.400
(6) Rubber and Plastics............... PPI Rubber and Plastic Products....... 5.039 4.865
(7) Paper Products.................... PPI Converted Paper and Paperboard 2.134 2.182
Products.
(8) Apparel........................... PPI Apparel........................... 0.906 0.890
(9) Machinery and Equipment........... PPI Machinery and Equipment........... 0.218 0.212
(10) Miscellaneous Products........... PPI Finished Goods.................... 1.112 2.232
B. All Other Services..................... ...................................... 6.901 7.198
(1) Postage........................... CPI-U Postage......................... 0.282 0.295
(2) Telephone Services................ CPI-U Telephone Services.............. 0.549 0.631
(3) All Other: Labor Intensive........ ECI Compensation for Private Service 5.519 5.439
Occupations.
(4) All Other: Nonlabor Intensive..... CPI-U All Items....................... 0.551 0.833
-------------------------
Total............................. ...................................... 100.000 100.000
----------------------------------------------------------------------------------------------------------------
Note: Due to rounding, weights may not sum to total.
\1\ Expense categories based on proposed 1992-based hospital market basket for comparison purposes.
[[Page 29923]]
V. Other Decisions and Changes to the Prospective Payment System
for Inpatient Operating Costs
A. Elimination of Day Outlier Payments (Secs. 412.80 and 412.82)
Section 1886(d)(5)(A) of the Act provides for payments in addition
to the basic prospective payments for ``outlier'' cases, that is, cases
involving extraordinarily high costs (cost outliers) or long lengths of
stay (day outliers). That section also provides that, beginning with FY
1995, payments for day outliers will be phased out over 3 years. We
have discussed this phase out and its implementation in detail in the
September 1, 1994, September 1, 1995, and August 30, 1996 final rules
(59 FR 45366, 60 FR 45854, and 61 FR 46228, respectively). Since
payment for day outliers will be eliminated effective with discharges
occurring in FY 1998, we are proposing to make conforming revisions to
the regulations at Secs. 412.80, 412.82, 412.84, and 412.86. At the
same time, we are making a technical change to the provision concerning
outlier payments for transfer cases to conform the regulations text to
policies that we have stated in previous prospective payment system
rules but did not codify. See the final rules published September 1,
1995 (60 FR 45804) and September 1, 1993 (58 FR 46306-07).
B. Rural Referral Centers (Sec. 412.96)
Under section 1886(d) of the Act, hospitals generally are paid by
the Medicare program for inpatient hospital services covered by
Medicare in accordance with the prospective payment system. Certain
hospitals, however, receive special treatment under that system.
Section 1886(d)(5)(C)(i) of the Act specifically provides for
exceptions and adjustments to prospective payment amounts, as the
Secretary deems appropriate, to take into account the special needs of
rural referral centers.
Section 412.96(d) of the regulations provides that, for discharges
occurring before October 1, 1994, rural referral centers received the
benefit of payment for inpatient operating costs per discharge based on
the other urban payment amount rather than the rural standardized
amount. As of October 1, 1994, the other urban and rural standardized
amounts are the same. However, rural referral centers continue to
receive special treatment under both the disproportionate share
hospital payment adjustment and the criteria for geographic
reclassification. One of the ways that a rural hospital may qualify as
a rural referral center is to meet two mandatory criteria (specifying a
minimum case-mix index and a minimum number of discharges) and at least
one of three optional criteria (relating to specialty composition of
medical staff, source of inpatients, or volume of referrals). These
criteria are described in detail in 42 CFR 412.96(c).
1. Case-Mix Index Criteria
Section 412.96(c)(1) sets forth the case-mix index criteria and
provides that, for cost reporting periods beginning on or after October
1, 1986, a hospital's case-mix index for discharges ``during the
Federal fiscal year that ended 1 year prior to the beginning of the
cost reporting period for which the hospital is seeking referral center
status'' must be at least equal to the national case-mix index value as
established by HCFA or the median case-mix value for urban hospitals in
the region in which the hospital is located (excluding hospitals
receiving indirect medical education payments), whichever is lower. It
has come to our attention that the language in Sec. 412.96(c)(1) does
not clearly address situations in which the Federal fiscal year does
not end exactly 1 year prior to the beginning of the cost reporting
period for which the hospitals are seeking referral center status. In
order to minimize any confusion, we propose to clarify which case-mix
index values are used to determine referral center status.
Our policy, which we have applied consistently since 1986, is that
the case-mix index used for an individual hospital in the determination
of whether it meets the case-mix index criterion is the case-mix index
for discharges during the most recent Federal fiscal year that ended at
least 1 year prior to the beginning of the cost reporting period for
which the hospital is seeking referral center status.
In this proposed rule, we would revise Sec. 412.96(c)(1) to clarify
the time period used to calculate the case-mix index. We emphasize that
this clarification represents no substantive change in policy.
2. Updated Case-Mix and Discharge Criteria
As noted above, a rural hospital can qualify as a rural referral
center if the hospital meets two mandatory criteria (case-mix index and
number of discharges) and at least one of three optional criteria
(medical staff, source of inpatients, or volume of referrals). With
respect to the two mandatory criteria, a hospital may be classified as
a rural referral center if its--
Case-mix index is at least equal to the lower of the
median case-mix index for urban hospitals in its census region,
excluding hospitals with approved teaching programs, or the median
case-mix index for all urban hospitals nationally; and
Number of discharges is at least 5,000 discharges per year
or, if fewer, the median number of discharges for urban hospitals in
the census region in which the hospital is located. (The number of
discharges criterion for an osteopathic hospital is at least 3,000
discharges per year.)
a. Case-Mix Index. Section 412.96(c)(1) provides that HCFA will
establish updated national and regional case-mix index values in each
year's annual notice of prospective payment rates for purposes of
determining rural referral center status. In determining the proposed
national and regional case-mix index values, we follow the same
methodology we used in the November 24, 1986 final rule, as set forth
in regulations at Sec. 412.96(c)(1)(ii). Therefore, the proposed
national case-mix index value includes all urban hospitals nationwide,
and the proposed regional values are the median values of urban
hospitals within each census region, excluding those with approved
teaching programs (that is, those hospitals receiving indirect medical
education payments as provided in Sec. 412.105).
These values are based on discharges occurring during FY 1996
(October 1, 1995 through September 30, 1996) and include bills posted
to HCFA's records through December 1996. Therefore, in addition to
meeting other criteria, we are proposing that to qualify for initial
rural referral center status or to meet the triennial review standards
for cost reporting periods beginning on or after October 1, 1997, a
hospital's case-mix index value for FY 1996 would have to be at least--
1.3525; or
Equal to the median case-mix index value for urban
hospitals (excluding hospitals with approved teaching programs as
identified in Sec. 412.105) calculated by HCFA for the census region in
which the hospital is located.
The median case-mix values by region are set forth in the table
below:
------------------------------------------------------------------------
Case-
mix
Region index
value
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)........................ 1.2324
2. Middle Atlantic (PA, NJ, NY)................................ 1.2424
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)......... 1.3671
4. East North Central (IL, IN, MI, OH, WI)..................... 1.2625
5. East South Central (AL, KY, MS, TN)......................... 1.3076
[[Page 29924]]
6. West North Central (IA, KS, MN, MO, NE, ND, SD)............. 1.2089
7. West South Central (AR, LA, OK, TX)......................... 1.3270
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)................... 1.3449
9. Pacific (AK, CA, HI, OR, WA)................................ 1.3429
------------------------------------------------------------------------
The above numbers will be revised in the final rule to the extent
required to reflect the updated MedPAR file, which will contain data
from additional bills received for discharges through September 30,
1996.
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 1996 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.
b. Discharges. Section 412.96(c)(2)(i) provides that HCFA will set
forth the national and regional numbers of discharges in each year's
annual notice of prospective payment rates for purposes of determining
referral center status. As specified in section 1886(d)(5)(C)(ii) of
the Act, the national standard is set at 5,000 discharges. However, we
are proposing to update the regional standards. The proposed regional
standards are based on discharges for urban hospitals' cost reporting
periods that began during FY 1995 (that is, October 1, 1994 through
September 30, 1995). That is the latest year for which we have complete
discharge data available.
Therefore, in addition to meeting other criteria, we are proposing
that to qualify for initial rural referral center status or to meet the
triennial review standards for cost reporting periods beginning on or
after October 1, 1997, the number of discharges a hospital must have
for its cost reporting period that began during FY 1996 would have to
be at least--
5,000; or
Equal to the median number of discharges for urban
hospitals in the census region in which the hospital is located, as
indicated in the table below.
------------------------------------------------------------------------
Number of
Region discharges
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)..................... 6725
2. Middle Atlantic (PA, NJ, NY)............................. 8511
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)...... 6991
4. East North Central (IL, IN, MI, OH, WI).................. 6607
5. East South Central (AL, KY, MS, TN)...................... 5805
6. West North Central (IA, KS, MN, MO, NE, ND, SD).......... 4625
7. West South Central (AR, LA, OK, TX)...................... 5085
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)................ 8167
9. Pacific (AK, CA, HI, OR, WA)............................. 5945
------------------------------------------------------------------------
We reiterate that, to qualify for rural referral center status for
cost reporting periods beginning on or after October 1, 1997, an
osteopathic hospital's number of discharges for its cost reporting
period that began during FY 1996 would have to be at least 3,000.
3. Retention of Referral Center Status
Section 412.96(f) states that each hospital receiving the referral
center adjustment is reviewed every 3 years to determine if the
hospital continues to meet the criteria for referral center status. To
retain status as a referral center, a hospital must meet the criteria
for classification as a referral center specified in Sec. 412.96 (b)(1)
or (b)(2) or (c) for 2 of the last 3 years, or for the current year. A
hospital may meet any one of the three sets of criteria for individual
years during the 3-year period or the current year. For example, a
hospital may meet the two mandatory requirements in Sec. 412.96(c)(1)
(case-mix index) and (c)(2) (number of discharges) and the optional
criterion in paragraph (c)(3) (medical staff) during the first year.
During the second or third year, the hospital may meet the criteria
under Sec. 412.96(b)(1) (rural location and appropriate bed size).
A hospital must meet all of the criteria within any one of these
three sections of the regulations in order to meet the retention
requirement for a given year. That is, it will have to meet all of the
criteria of Sec. 412.96(b)(1) or Sec. 412.96(b)(2) or Sec. 412.96(c).
For example, if a hospital meets the case-mix index standards in
Sec. 412.96(c)(1) in years 1 and 3 and the number of discharge
standards in Sec. 412.96(c)(2) in years 2 and 3, it will not meet the
retention criteria. All of the standards would have to be met in the
same year.
In accordance with Sec. 412.96(f)(2), the review process is limited
to the hospital's compliance during the last 3 years. Thus, if a
hospital meets the criteria in effect for at least 2 of the last 3
years or if it meets the criteria in effect for the current year (that
is, the criteria for FY 1998 outlined above in this section of the
preamble), it will retain its status for another 3 years. We have
constructed the following chart and example to aid hospitals that
qualify as referral centers under the criteria in Sec. 412.96(c) in
projecting whether they will retain their status as a referral center.
Under Sec. 412.96(f), to qualify for a 3-year extension effective
with cost reporting periods beginning in FY 1998, a hospital must meet
the criteria in Sec. 412.96(c) for FY 1998 or it must meet the criteria
for 2 of the last 3 years as follows:
----------------------------------------------------------------------------------------------------------------
Use the discharges for
For the cost reporting period Use hospital's case-mix the hospital's cost Use numerical standards
beginning during FY index for FY reporting period as published in the
beginning during FY Federal Register on
----------------------------------------------------------------------------------------------------------------
1997............................. 1995.................... 1995.................... Aug. 30, 1996.
1996............................. 1994.................... 1994.................... Sept. 1, 1995.
1995............................. 1993.................... 1993.................... Sept. 1, 1994.
----------------------------------------------------------------------------------------------------------------
Example: A hospital with a cost reporting period beginning July
1 qualified as a referral center effective July 1, 1995. The
hospital has fewer than 275 beds. Its 3-year status as a referral
center is protected through June 30, 1998 (the end of its cost
reporting period beginning July 1, 1997). To determine if the
hospital should retain its status as a referral center for an
additional 3-year period, we will review its compliance with the
applicable criteria for its cost reporting periods beginning July 1,
1995, July 1, 1996, and July 1, 1997. The hospital must meet the
criteria in effect either for its cost reporting period beginning
July 1, 1998, or for two out of the three past periods. For example,
to be found to have met the criteria at Sec. 412.96(c) for its cost
reporting period beginning July 1,
[[Page 29925]]
1996, the hospital's case-mix index value during FY 1994 must have
equaled or exceeded the lower of the national or the appropriate
regional standard as published in the September 1, 1995 final rule
with comment period. The hospital's total number of discharges
during its cost reporting year beginning July 1, 1994, must have
equaled or exceeded 5,000 or the regional standard as published in
the September 1, 1995 final rule with comment period.
For those hospitals that seek to retain referral center status
by meeting the criteria of Sec. 412.96(b)(1) (i) and (ii) (that is,
rural location and at least 275 beds), we will look at the number of
beds shown for indirect medical education purposes (as defined at
Sec. 412.105(b)) on the hospital's cost report for the appropriate
year. We will consider only full cost reporting periods when
determining a hospital's status under Sec. 412.96(b)(1)(ii). This
definition varies from the number of beds criterion used to
determine a hospital's initial status as a referral center because
we believe it is important for a hospital to demonstrate that it has
maintained at least 275 beds throughout its entire cost reporting
period, not just for a particular portion of the year.
C. Determining the Total Number of Full-Time Equivalent Residents for
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
program receive an additional payment to reflect the higher indirect
operating costs associated with graduate medical education. The
regulations regarding the calculation of this additional payment, known
as the indirect medical education (IME) adjustment, are at
Sec. 412.105. The additional payment is calculated by multiplying a
hospital's DRG revenue (including outlier payments) by the applicable
IME adjustment factor. The adjustment factor is calculated by using a
hospital's ratio of residents-to-beds in the formula set forth at
section 1886(d)(5)(B)(ii) of the Act.
The criteria governing whether a program is considered approved are
at Sec. 412.105(g)(1)(i). These criteria are the same as those used to
identify approved programs for the direct graduate medical education
payment under Sec. 413.86(b). In the August 30, 1991 final rule (56 FR
43237), we added a criterion to Sec. 413.86(b), but inadvertently did
not add it to Sec. 412.105(g)(1)(i). This criterion added the Annual
Report and Reference Handbook of the American Board of Medical
Specialties (ABMS) as another publication to be used to identify
approved programs. To correct this inadvertent omission, we are
proposing a technical change to Sec. 412.105(g)(1) to parallel the
provisions of Sec. 413.86(b).
In addition, we are proposing to delete Sec. 412.105(g)(1)(iv),
which excludes from the IME resident count any anesthesiology residents
employed to replace anesthetists. This exclusion was originally
intended to prevent hospitals from hiring residents in lieu of
nonphysician anesthetists. Given that certain rural hospitals continue
to receive pass-through cost reimbursement for their anesthetist costs,
we no longer believe this provision is warranted. Nor are we aware of
any specific instances where it has been applied.
D. Direct Graduate Medical Education: Newly Participating Hospitals
(Sec. 413.86)
Under section 1886(h) of the Act and implementing regulations,
Medicare pays hospitals for the direct costs of graduate medical
education on the basis of per resident costs in a 1984 base year. Under
existing regulations at Sec. 413.86(e)(4), if a hospital did not have
residents in the 1984 base period but later participates in teaching
activities, the fiscal intermediaries calculate a per resident amount
based on a weighted average of all the hospitals in the same geographic
wage area. There must be at least three hospitals for this calculation.
If there are fewer than three hospitals, the regulations require the
fiscal intermediary to contact the HCFA Central Office for a
determination of the appropriate amount to use.
We are proposing to modify the regulations for determining base
year per resident amounts for hospitals that participated in residency
training after the 1984 base period. Under the proposed changes to
Sec. 413.86(e)(4)(i)(B), we would sequentially follow the criteria
listed below until we can base the weighted average calculation on a
minimum of 3 per resident amounts:
If there are fewer than three hospitals in the hospital's
geographic wage area, the intermediary will determine a weighted
average based on the per resident amounts for all hospitals in the
hospital's own wage area, plus hospitals in geographically contiguous
wage areas.
If there are still fewer than three hospitals in the
hospital's own wage area, plus hospitals in contiguous wage areas, the
weighted average will be based on the per resident amounts for all
hospitals in the State.
If there are fewer than three hospitals in the entire
State, the weighted average will be based on the per resident amounts
for all hospitals in that State plus hospitals in contiguous States.
If there are fewer than three hospitals in that State and
contiguous States, the weighted average per resident amount will be
based on the national average per resident amount.
E. Technical Change: Correction of Statutory Citation
The August 30, 1996 final rule (61 FR 46165) included an amendment
to Sec. 489.27 that reprinted the statutory reference governing the
distribution of an ``Important Message from Medicare.'' This reference,
``section 1886(a)(1)(M)'', was incorrect. We propose to correct this
reference to read ``section 1866(a)(1)(M)''.
VI. Changes to the Prospective Payment System for Capital-Related
Costs
A. Possible Adjustment to Capital Prospective Payment System Minimum
Payment Levels
Section 412.348(b) of the regulations provides that, during the
capital prospective payment system transition period, any hospital may
receive an additional payment under an exceptions process if its total
inpatient capital-related payments under its payment methodology (that
is, fully prospective or hold-harmless) are less than a minimum
percentage of its allowable Medicare inpatient capital-related costs.
The minimum payment levels are established by class of hospitals under
Sec. 412.348(c). The minimum payment levels for portions of cost
reporting periods occurring in FY 1997 are:
Sole community hospitals (located in either an urban or
rural area), 90 percent;
Urban hospitals with at least 100 beds and a
disproportionate share patient percentage of at least 20.2 percent and
urban hospitals with at least 100 beds that qualify for
disproportionate share payments under Sec. 412.106(c)(2), 80 percent;
and,
All other hospitals, 70 percent.
Under Sec. 412.348(d), the amount of the exceptions payment is
determined by comparing the cumulative payments made to the hospital
under the capital prospective payment system to the cumulative minimum
payment levels applicable to the hospital for each cost reporting
period subject to that system. Any amount by which the hospital's
cumulative payments for previous cost reporting periods exceed its
cumulative minimum payment is deducted from the additional payment that
would otherwise be payable for a cost reporting period.
Section 412.348(g) also provides for a separate special exceptions
process for hospitals undertaking major renovations or replacement of
aging facilities during the decade of the transition. For as long
[[Page 29926]]
as 10 years beyond the end of the transition period, certain hospitals
may be eligible to receive special exceptions payments at a 70 percent
minimum payment level. For hospitals that qualify for the special
exceptions provision before the end of the transition, the general and
special exceptions provisions will run concurrently during the later
years of the transition. However, since the minimum payment level for
the special exceptions provision is at the same level that applies to
all hospitals under the general provision (currently 70 percent), the
special exceptions provision will generate no additional payment to
hospitals until the end of the transition period.
Section 412.348(h) further provides that total estimated exceptions
payments under both the regular exceptions process and the special
exceptions process may not exceed 10 percent of the total estimated
capital prospective payments (exclusive of hold-harmless payments for
old capital) for the same fiscal year. In the FY 1997 final rule
implementing the prospective payment system for capital-related costs,
we stated that the minimum payment levels in subsequent transition
years would be revised, if necessary, to keep the projected percentage
of payments under the exceptions process at no more than 10 percent of
capital prospective payments.
In section III of the Addendum to this proposed rule, we discuss
the factors and adjustments used to develop the FY 1998 Federal and
hospital-specific rates. In particular, we discuss the FY 1998
exceptions payment reduction factor. This factor adjusts the annual
payment rates for the estimated amount of additional payments for
exceptions in FY 1998. In this proposed rule, we estimate that
exceptions will equal 7.24 percent of aggregate payments based on the
Federal rate and the hospital-specific rate. We will develop a new
estimate of the level of exceptions payments in FY 1998, and revise the
exceptions payment adjustment factor accordingly, on the basis of the
data that becomes available to us in time for developing the final rule
for FY 1998. While it is not necessary at this time to propose
reductions in the minimum payment levels, it is possible that it will
be necessary to implement adjustments to the minimum payment levels in
the final rule. Our current projections show that it will almost
certainly be necessary to adjust the minimum payment levels for FY
1999. We are therefore providing public notification that adjustments
to the minimum payment levels are possible in the final rule, and
almost certain for FY 1999.
When it does become necessary to adjust the minimum payment levels
in accordance with Sec. 412.348(h), our current intent is to adjust
each of the existing levels (that is, 90 percent for sole community
hospitals, 80 percent for large urban DSH hospitals, and 70 percent for
all other hospitals and special exceptions) by 5 percentage point
increments until estimated exceptions payments are within the 10
percent limit. For example, we would set minimum payment levels at 85
percent for sole community hospitals, 75 percent for large urban DSH
hospitals, and 65 percent for all other hospitals and special
exceptions, provided that aggregate exceptions payments at those
minimum payment levels were projected to be no more than 10 percent of
total rate-based payments. We believe that this policy appropriately
provides for all classes of hospitals to share in the reduction in
exceptions payments, while simultaneously preserving the special
protections provided by higher minimum payment levels for sole
community hospitals and large urban DSH hospitals relative to all other
hospitals. If aggregate exceptions payments at those minimum payment
levels still exceed 10 percent of total rate-based payments, we would
continue to reduce the minimum payment levels by 5 percentage point
increments each until the requirement of Sec. 412.348(h) was satisfied.
We are providing notification of our current thinking on this issue in
order to allow opportunity for public comment on the appropriate method
for adjusting the minimum payment levels.
We made a similar proposal on the possibility of adjusting minimum
payment levels in the FY 1997 proposed rule (61 FR 27481). In the FY
1997 final rule (61 FR 46219) we noted that some commenters objected to
our proposed method for handling necessary reductions to the minimum
payment levels. One commenter suggested that we develop a more
sophisticated methodology that would allow more refined adjustment of
the minimum payment levels. Another commenter suggested a 1- or 2-
percent reduction increment, rather than the proposed 5-percent
increment. We will take these comments into consideration when it
becomes necessary to adjust the minimum payment levels in accordance
with Sec. 412.348(h). We welcome other comments on this matter as well.
B. Special Exceptions Application Process
As discussed section VI.A. above, a separate special exceptions
provision extends protection to certain hospitals undertaking major
renovation or replacement of aging facilities during the decade of the
transition. The regulation establishing eligibility for this special
exceptions provision, and describing the criteria by which eligible
hospitals qualify for special exceptions payments (Sec. 412.348(g)),
was finalized on September 1, 1994 (59 FR 45385). At this time, we are
not proposing to make any policy changes to the special exceptions
provision. (We are (or may be), however, revising the minimum payment
level for this exceptions provision, along with the minimum payment
levels under the regular exceptions provision, as described in section
VI.A. above). However, we have received questions from hospitals and
intermediaries about the special exceptions process, and we would
therefore like to clarify a few aspects of that process.
Providers seeking special exceptions payments should submit
documentation to their fiscal intermediary to demonstrate that they
meet the eligibility and qualifying requirements in Sec. 412.348(g).
Documentation establishing that the hospital meets one of the
eligibility criteria, the project need requirement, the age of assets
test, and the project size requirement must be submitted to the
intermediary no later than the date on which the cost report is due for
the first cost reporting period in which the exceptions payment is
expected. (As noted in section VI.A. above, since the 70-percent
minimum payment level for the special exceptions provision is at the
same level that applies to all hospitals under the general provision,
the special exceptions provision will generate no additional payment to
hospitals until the end of the transition period.) The fiscal
intermediary will make an initial determination of whether the provider
has met these criteria for receiving special exceptions payments.
Further documentation demonstrating that the hospital continues to meet
one of the eligibility criteria, that it meets the excess capacity
test, as required, and that the hospital's regular payments fall short
of the minimum payment level (accounting for the cumulative payment
comparison and offsetting amounts, Sec. 412.348(g)(8)) will be required
for each successive cost reporting period in which the exception is
claimed.
To qualify, an eligible hospital must meet both project need and
project size
[[Page 29927]]
requirements. For hospitals in States with CON requirements, the
project need requirement is satisfied by obtaining CON approval. A copy
of the State CON approval should be submitted to the intermediary. For
other hospitals, the project need requirement is satisfied by meeting
an age of assets test. To meet the age of asset test, a hospital must
have an average age of buildings and fixed equipment at or above the
75th percentile nationally in the first year of capital prospective
payment. The hospital should submit to the intermediary copies of
Worksheets A-7 and G from the first cost reporting under the capital
prospective payment system, and a calculation of its average age of
assets for that cost reporting year. The average age of assets is
determined as the ratio of accumulated depreciation for buildings and
fixed equipment to current depreciation for buildings and fixed
equipment. (The data required for the age of assets computation are
found on HCFA 2552-92, Worksheet G, lines 14, 14.01, 16, 16.01, 18,
18.01, 20, and 20.01, and Worksheet A-7, Part III, Column 9, lines 1
and 3.)
At the time that the special exceptions process was finalized in
the September 1, 1994 final rule (59 FR 45385), data from the June 1994
update of the cost report file showed that the 75th percentile for
buildings and fixed equipment was 16.4 years. At that time, we stated
that we would make a final determination of the 75th percentile on the
basis of more complete cost report information for FY 1992. We believe
that the cost report information for FY 1992 is now sufficiently
complete and reliable to make the final determination of the 75th
percentile. As computed from the December 1996 update of the cost
report data, the 75th percentile nationally for buildings and fixed
equipment is 15.4 years.
We note that, in making this computation, we took account of the
fact that hospitals do not always report accumulated and current year
depreciation amounts consistently. For example, a hospital might report
accumulated depreciation amounts on Worksheet G on an accelerated
depreciation basis. In such a case, current year depreciation amounts
on Worksheet A-7 should be adjusted to reflect straight line
depreciation. This is because the program recognizes only straight line
depreciation for cost accounting and payment purposes. Obviously, the
numerator and denominator of the ratio used to establish average age of
assets must be consistent. In determining the 75th percentile of
average age of assets for FY 1992, we have employed only 4,611
hospitals. We eliminated hospitals that did not report both accumulated
and current year depreciation on a straight line basis in their FY 1992
cost reports. We also eliminated any hospital whose computed age of
assets was greater than 35.0 years. We took this step to eliminate
obvious outliers and to assure that hospitals are not disadvantaged in
meeting the 75th percentile requirement by the inclusion of hospitals
whose computed age of assets is relatively higher merely because the
Worksheet G data were not thoroughly audited. Eliminating these latter
hospitals is to the advantage of hospitals trying to qualify for an
exception, since it results in a lower threshold for meeting the
average age of assets test. Eliminating these latter hospitals from the
computation is the major reason why the 75th percentile has declined to
15.4 years from the 16.4 years that we previously estimated.
We note that, in the case of an individual hospital that reported
accumulated and current depreciation on a different basis, it would be
necessary to reconstruct accumulated depreciation for fixed assets that
were in use for patient care in FY 1992 for purposes of determining
whether that hospital met the average age of assets test. The following
information would be necessary for this purpose: the purchase prices
for each fixed asset in use in 1992, useful life of each asset, and the
number of years each asset had been in use prior to FY 1992.
Reconstructing FY 1992 accumulated depreciation for each asset would
involve dividing the purchase price by the useful life and multiplying
the result by the years in which the asset had been in service.
A hospital must also demonstrate that it meets a project size
requirement to qualify for a special exceptions payment. The project
size requirement is satisfied if the hospital completes, during the
capital PPS transition period, a project whose costs for replacement
and/or renovation of fixed assets (buildings and fixed equipment, but
not movable equipment) are at least $200 million, or 100 percent of its
operating costs during the first cost reporting period under the
prospective payment system. The hospital should, therefore, submit to
the intermediary auditable documentation establishing the costs for its
project to replace and/or renovate fixed assets. This documentation
also should establish that this project was completed during the
capital PPS transition period (that is, not before the start of its
first cost reporting period beginning on or before October 1, 1991, and
not later than the end of its last cost reporting period beginning
before October 1, 2001). Relevant documentation would include, but
would not be restricted to, the plans for the relevant construction
and/or renovation project, the total bills for construction and/or
renovation related to the project, and records showing that the new or
renovated facilities entered service for patient care during the
capital PPS transition period.
For hospitals in States without CON requirements, an urban hospital
must demonstrate either that it is in a MSA that does not have an
overall occupancy rate less than 80 percent, or that its capacity is no
more than 80 percent of its capacity (in terms of bed size) prior to
the completion of its qualifying project of construction or renovation
of fixed assets. (This test does not apply to rural hospitals.) An
urban hospital in a non-CON State must thus meet one of two tests in
order to satisfy the excess capacity requirement. We have been
contacted by hospitals and fiscal intermediaries about how to determine
if the excess capacity requirement has been met. Therefore, we would
like to clarify what is necessary to satisfy both the excess capacity
tests for urban hospitals.
For the bed size test, we use the same definition of bed size that
is used for indirect graduate medical education and DSH payments. Under
Sec. 412.105(b), the number of beds in a hospital is determined by
counting the number of available bed days during the cost reporting
period, not including beds or bassinets in the healthy newborn nursery,
custodial care beds, or beds in excluded distinct part hospital units,
and dividing that number by the number of days in the cost reporting
period. The number of beds is computed, using this formula, and entered
on Worksheet S-3 of the cost report. Section 2405.3 of the Medicare
Provider Reimbursement Manual provides additional information on bed
size. Bed size must be determined for the last cost reporting period
prior to completion of the qualifying project, and for each cost
reporting period, subsequent to the completion of that project, for
which a special exceptions payment is claimed. The ratio of bed size in
the latter period to bed size in the former period must be less than or
equal to 0.80. Hospitals electing to satisfy the excess capacity
requirement by meeting the bed size test must satisfy this requirement
for each year in which an exceptions payment might be claimed. In other
words, a hospital does not qualify for an exceptions payment during any
year in which its bed size ratio is greater than 0.80, even if its
ratio
[[Page 29928]]
was less than or equal to 0.80 in a previous year.
For the MSA occupancy test, overall average occupancy is determined
by dividing total patient days for all PPS hospitals in the MSA by
available beds days (as defined in prior paragraph) for all those
hospitals. Total patient days and available bed days are found on
Worksheet S-3 of the Medicare cost report. We would use the same
restrictions, as applicable, that were used in the definition of bed
size. HMO, organ acquisition, or observation bed days are not included.
Hospitals electing to meet the excess capacity requirement by
satisfying the MSA occupancy test must satisfy this requirement for
each year in which an exceptions payment might be claimed. In other
words, a hospital does not qualify for an exceptions payment during any
year in which overall average occupancy in its MSA is less than 80
percent, even if the occupancy in its MSA was greater than or equal to
80 percent in a previous year.
We welcome further questions and requests for clarification of
these requirements. As appropriate we will respond to the questions and
requests in future PPS rules.
VII. Proposed Changes for Hospitals and Units Excluded From the
Prospective Payment System
A. New Requirements for Certain Hospitals Excluded From the Prospective
Payment System (Sec. 412.22(e))
In the September 1, 1994 final rule (59 FR 45330), we established
several additional criteria for excluding long-term care hospitals that
occupy space in the same building or on the same campus as another
hospital from the PPS (Sec. 412.23(e)). Under these criteria, such
facilities (sometimes called ``hospitals within hospitals'') could
qualify for exclusion only if the two entities have separate governing
bodies, chief executive officers, medical staffs, and chief medical
officers. In addition, they were required to be capable of performing
certain basic hospital functions without assistance from the hospitals
with which they are co-located, or they had to receive at least 75
percent of their inpatients from sources other than the co-located
hospital. We further revised these regulations on September 1, 1995 (60
FR 45778), by adding a third option under which hospitals that did not
meet the criteria specified above could establish separate operation by
showing that no more than 15 percent of their inpatient operating costs
were attributable to the hospital with which they share space.
The regulations were necessary to prevent inappropriate Medicare
payments to entities that are effectively long-stay units of other
hospitals. At the same time, the regulations set forth criteria to
ensure that entities may qualify for exclusion from the PPS if an
exclusion is warranted. Exclusion of long-term care hospitals from the
PPS is appropriate when hospitals have few short-stay or low-cost cases
and might be systematically underpaid if the PPS were applied to them.
These reasons for exclusion do not apply if the entity that provides
the long-term care is part of a larger hospital, which does have short-
stay and low-cost cases and can be paid appropriately under the PPS.
ProPAC has recommended that HCFA monitor the growth in the number
of long term care hospitals within hospitals and evaluate whether the
current Medicare certification rules that apply to these facilities
should be changed (Recommendation 31). ProPAC noted that there is
concern that the hospital within a hospital model was devised as a way
for acute care hospitals to receive higher payments for their long-stay
cases. At the same time, the model may be an appropriate and efficient
alternative to acute inpatient care for cases that require additional
services, but at a more intensive level than those provided in other
post-acute settings. ProPAC recommended that HCFA conduct a
comprehensive study of the characteristics, patient mix, treatment
patterns, costs, and financial performance of hospitals within
hospitals.
We have been monitoring the development of the hospital within a
hospital model. We agree with ProPAC that our policy should
simultaneously strive to prevent inappropriate exclusions of units as
separate hospitals, while allowing an appropriate degree of flexibility
for facilities to respond to changing patient care needs. As a result
of our monitoring efforts, we are proposing two changes to the
hospital-within-a-hospital regulations. We propose to add a new
Sec. 412.22(f) to address hospitals that are unable to meet certain
exclusion criteria solely because of State law. In addition, we propose
to extend the application of these rules to other classes of facilities
that might seek exclusion from the PPS as hospitals within hospitals.
The first proposed change concerns the relationship between the
exclusion criteria and State laws. Following publication of the
original regulations governing long-term care hospitals within
hospitals, we received comments stating that it would not be equitable
to abruptly impose new criteria on long-term care hospitals that had
operated for many years under other organizational patterns. To
accommodate these hospitals, we allowed them an additional one-year
delay in the effective date of the ``hospital within a hospital''
regulations. Thus, a hospital that was excluded under prior rules was
not required to meet the new criteria until its first cost reporting
period beginning on or after October 1, 1995. (For other hospitals, the
rule was effective for the first cost reporting period beginning on or
after October 1, 1994.)
By delaying the effective date of these regulations for hospitals
within hospitals that had been excluded from the PPS before October 1,
1994, we intended to allow the hospitals adequate time to restructure
themselves to comply with the new criteria. However, it has since
become clear that some hospitals within hospitals operated by State
universities have not been able to make the necessary changes, because
the hospitals are required by State law to be subject to the ultimate
authority of the governing body of the same entity (the university)
that operates the hospital from which they obtain space. Thus, these
hospitals have not been able to comply with the hospital-within-a-
hospital criteria.
We continue to believe that it is important to exclude, as
hospitals, only facilities that actually operate as separate hospitals,
not as units of larger hospitals. At the same time, however, we are
concerned that certain hospitals might, as a matter of State law, be
unable to make the necessary organizational changes to meet our
criteria. We believe two considerations justify exclusion of these
facilities. First, the organizational arrangements under which they
operate were in place when the new regulation was adopted, and to the
extent the arrangements are required by State law, we believe they do
not reflect attempts by entities to establish nominal hospitals and, in
turn, seek inappropriate exclusions. Second, we believe it would be
inequitable to deny exclusions to hospitals solely because State
statutory requirements prevent them from having the same flexibility as
other institutions to reorganize themselves to meet our criteria.
Accordingly, we propose to add Sec. 412.22(f) to provide that if a
hospital cannot meet the criteria in Secs. 412.23(e)(3) (i) or (iii)
(proposed to be redesignated as Secs. 412.22(e) (1) and (3)) solely
because its governing body or medical staff is under the control of a
third entity that also controls the
[[Page 29929]]
hospital with which it shares a building or a campus or cannot meet the
criteria in Secs. 412.23(e)(3) (ii) or (iv) (proposed to be
redesignated as Secs. 412.22 (e)(2) and (e)(4)) solely because its
chief medical officer or chief executive officer is employed by, or
under contract with such a third entity, the hospital can nevertheless
qualify for an exclusion if that hospital meets the other applicable
criteria and:
Is owned and operated by a State university;
Has been continuously owned and operated by that
university since October 1, 1994;
Is required by State law to be subject to the ultimate
authority of the university's governing body; and
Was excluded from the prospective payment system as a
long-term care hospital for any cost reporting period beginning on or
after October 1, 1993, but before October 1, 1994.
We wish to emphasize that we intend to allow an exception to the
criteria in Sec. 412.23(e)(3) (i) through (iv) only if the hospital
cannot meet those criteria because of State law. We do not intend to
provide similar treatment for other State university or other hospitals
which are not subject to such statutory requirements but have chosen
not to undertake such a reorganization. We welcome comments and
suggestions on this issue and on whether the language of the proposed
rule effectively addresses the situation of hospitals disadvantaged by
State law.
We also propose to redesignate the specific criteria for hospitals
within hospitals now in Sec. 412.23 (e)(3) through (e)(5) under a new
Sec. 412.22 (e), (g), and (h). At the time of the adoption of the final
rule governing long-term care hospitals within hospitals, we did not
extend its application to other types of excluded facilities that might
seek to organize themselves on that model. Since the publication of the
final rule governing long-term care hospitals within hospitals, we have
received scattered inquiries from some providers and regional offices
about the appropriateness of other types of facilities organizing
themselves as hospitals within hospitals. It has become apparent that,
while rehabilitation and psychiatric facilities may be granted
exemptions from the PPS as units of larger hospitals, there may be
cases where such facilities may rather seek exclusion as hospitals
within hospitals in order to take advantage of certain payment rules
that favor hospitals. For example, new hospitals within hospitals
qualify for the new hospital exemption from the rate of increase
ceiling, which is not available to new units.
We believe that extension of the hospital-within-a-hospital rules
is appropriate to avoid recognizing nominal hospitals, while allowing
adequate flexibility for legitimate and efficient sharing of services.
We continue to believe it is important to exclude only separate long-
term care hospitals, not units, of larger hospitals. We believe that
the same principle should apply to cancer and children's facilities,
which the statute provides for excluding only as hospitals, not as
units. We also believe that it is important to exclude, as hospitals,
only separate rehabilitation and psychiatric hospitals that may share
space with another hospital. Rehabilitation and psychiatric facilities
that actually function as units of larger hospitals should seek
exclusion as units rather than as hospitals.
As stated earlier, we are proposing to extend the application of
the hospital-within-a-hospital rules to all types of facilities that
can be excluded from the PPS. We would also incorporate, within this
extended hospital-within-a-hospital rule, the provision that we have
proposed above for facilities owned and operated by a State university.
At the same time, we are considering whether it is appropriate for new
hospitals within hospitals to receive the exemption from the TEFRA
rate-of-increase ceiling during the first 2 years of operation. The
purpose of the new hospital exemption is to recognize that a hospital
might face a period of cost distortions as it begins operations and
tries to establish its presence in its market. We do not believe that
newly established hospitals within hospitals would necessarily face the
same degree of cost distortion during their initial periods of
operation. This is because such hospitals begin operation within other
hospitals that have established facilities and identifiable market
presence. While we are not formally proposing elimination of the new
hospital exemption for hospitals within hospitals at this time, we are
considering whether to adopt such a provision in this year's final
rule. We invite comment on whether elimination of the new hospital
exemption for hospitals within hospitals would be advisable.
Finally, we will continue monitoring the development of the
hospital within a hospital model. While we have not yet conducted the
kind of comprehensive study of these facilities that ProPAC has
recommended, we will consider whether doing so is worthwhile within the
limits our available resources.
B. Exclusion of New Rehabilitation Units and Expansion of Existing
Rehabilitation Units (Sec. 412.30(b)(4))
In the September 1, 1995 final rule (60 FR 45839), we made certain
changes to clarify the regulations applicable to the exclusion of new
rehabilitation units and the expansion of units already excluded. These
changes were intended only to clarify existing policy, not to change
it. However, in making these changes we inadvertently omitted a
paragraph that explicitly allowed newly participating hospitals to open
new rehabilitation units and also to allow the new rehabilitation units
to be excluded immediately from the PPS. In omitting this paragraph, we
had no intention of rescinding the policy. We are proposing to restore
this paragraph to the regulations, which this proposed rule would
redesignate at Sec. 412.30(b)(4), to correct this omission and to
reaffirm current policy. (For further information on this policy, see
the Federal Register published September 1, 1992 (57 FR 39746).)
C. Delicensing and Relicensing of Beds (Sec. 412.30)
We have received a number of questions about cases in which
hospitals remove some bed capacity from their State license and
Medicare certifications, then later increase the number of their
licensed and certified beds and seek to have the bed capacity ``added''
and considered part of a new, or newly expanded, PPS-exempt
rehabilitation unit. Assuming that simultaneous delicensure and
relicensure of beds would not be accepted as the addition of new bed
capacity, we also have been asked how long bed capacity would have to
be excluded from a hospital's licensure and certification to be
considered ``new'' for purposes of the PPS exclusion rules at
Sec. 412.30.
Section 412.30 establishes separate ways for new and converted
units to meet the exclusion criterion related to the type of patient
population treated. New units are allowed to qualify for initial
exclusion based in part on a certification regarding their intent to
treat a patient population of the kind described in Sec. 412.23(b)(2),
rather than on a showing that they have actually treated such a
population during the hospital's most recent cost reporting period.
Converted units may not be excluded based on a certification, but must
show that they actually met the Sec. 412.23(b) requirement during the
hospital's most recent 12-month cost reporting period. New units are
defined as those that are part of a hospital that
[[Page 29930]]
has not previously sought exclusion for any rehabilitation unit and
that comprise greater than 50 percent of the newly licensed and
certified bed capacity, while converted units are those that do not
qualify as new. Section 412.30 also provides for separate treatment of
new and converted bed capacity that is used to expand existing units.
Different rules apply to the addition of new (as opposed to
converted) bed capacity, and it would not be appropriate to recognize
an ``increase'' in the bed capacity that coincides with a decrease in
bed capacity in another area, resulting in no net increase in the
hospital's total licensed and certified bed capacity. Similarly, it
would not be appropriate to allow a hospital to circumvent those rules
simply by removing some bed capacity from its licensure and
certification on a temporary basis, and then increasing its bed size a
few days, weeks, or months later. Thus, when a hospital seeks to add a
new PPS-excluded rehabilitation unit, or to increase the size of an
existing unit by adding new bed capacity, the bed size of the hospital
in the past must be taken into account.
The current regulations do not specify how long a decrease in a
hospital's bed capacity must be effective before a subsequent increase
in the hospital's licensure and certification can be considered as
``new'' capacity. However, to ensure consistent and equitable treatment
of all hospitals with PPS-excluded rehabilitation units, we propose to
provide in the regulations (proposed Sec. 412.30(a)) that a decrease in
capacity must remain effective for at least a full 12-month cost
reporting period before an equal or lesser number of beds can be added
to the hospital's licensure and certification and considered ``new''.
This means that when a hospital seeks to establish a new unit, or to
enlarge an existing unit, under the criteria in Sec. 412.30, the
Regional Office will review its records on the facility to determine
whether any beds have been delicensed and decertified during the 12-
month cost reporting period before the period for which the new beds
are to be added. To the extent that bed capacity was removed from the
hospital's licensure and certification during that period, that amount
of bed capacity cannot be considered ``new'' under Sec. 412.30. For
example, if a hospital with a calendar year cost reporting period had
removed 15 beds from its licensure and certification in calendar year
1997 and, for calendar year 1998, sought to set up a new rehabilitation
unit that would include 20 beds that would be added to its licensure
and certification as of January 1, 1998, only 5 of those beds could be
considered ``new'' under section 412.30. The remaining beds would be
considered converted beds.
This guideline applies to changes in a hospital's total licensed
and certified bed capacity, regardless of whether specific beds or
physical areas within a hospital have previously been operational and
available to rehabilitation patients. Thus, if a hospital delicenses 25
beds on one floor in the third month of a cost reporting period and, 2
months later, increases its licensure and certification by adding a 25-
bed unit in a previously unoccupied area on another floor, that unit
could not be considered ``new'' under Sec. 412.30 even though it
occupies different space from the beds that represented the delicensed
capacity. This guideline applies only for purposes of PPS exclusion and
is not intended to limit a hospital's ability to add to its licensed
and certified bed capacity for the provision of services paid for under
the PPS.
VIII. ProPAC Recommendations
We have reviewed the March 1, 1997 report submitted by ProPAC to
Congress and have given its recommendations careful consideration in
conjunction with the proposals set forth in this document.
Recommendation 2, concerning the update for the prospective payment
system operating payment rates, is discussed in Appendix E of this
proposed rule. Recommendations 3 and 4, concerning the prospective
payment system capital payment rates, are discussed in section III. of
the Addendum of this proposed rule. Recommendation 13, concerning
updating the target amounts for PPS-excluded hospitals and distinct
part units, is discussed in section VII. of this proposed rule.
Recommendation 31, concerning long-term care hospitals within
hospitals, is discussed in section VI. of this proposed rule. The
remaining recommendations are discussed below.
A. Ensuring Quality of Care (Recommendation 1)
Recommendation: The Medicare program needs to be vigilant in
monitoring and improving the quality of care delivered to its
beneficiaries in both the fee-for-service and risk contracting options.
ProPAC supports a comprehensive approach to quality assurance that
includes both pattern analysis and systematic review of individual
cases.
Response: We concur with ProPAC's recommendation that ``continuous
quality improvement activities need to be accompanied by effective
methods to identify and monitor providers with questionable
performance.'' We are pursuing two complementary strategies in this
area: strengthening the mechanisms for soliciting, investigating, and
monitoring complaints; and establishing an ongoing pattern monitoring
system. We believe that there is ample evidence that returning to case
review of randomly selected cases would not be an effective way to
monitor providers with questionable performance.
Beneficiary Complaints
Peer Review Organizations (PROs) have had greater success
identifying quality of care concerns through the beneficiary complaint
process than through traditional case review. The number of such
complaints is relatively small but has proven in the past to be an
excellent source of problem identification. Complaints provide PROs
with the opportunity to identify and remedy instances of poor quality.
We are committed to improving the beneficiary complaint process. We
have formed the Beneficiary Protection and Documentation Issues Task
Force as a subgroup of the Medicare Technical Advisory Group. This task
force includes representatives from PROs, intermediaries, carriers,
provider groups, consumer organizations, the Office of the Inspector
General, and the Office of the General Counsel. The task force is
charged with reexamining the PRO beneficiary complaint process. Its
work plan includes the development of a proposed rule concerning the
beneficiary complaint process (expected to be published soon) that will
enable the PRO to be more responsive to beneficiary needs; and to
conduct studies that evaluate potential alternative approaches to
handling beneficiary complaints. The studies are being designed to test
a variety of new and innovative methods of investigating complaints
including exploring the possibility of working with other entities such
as licensing agencies, private accreditation bodies, State medical
societies, and consumer groups, in the resolution of beneficiary
complaints. The final report is due to the Medicare Technical Advisory
Group in January 1999.
A vital element of our strategy is to increase awareness among
beneficiaries of their rights as patients to file complaints, and the
ease with which they can submit their complaints. A number of efforts
are underway. HCFA plans to test a toll free hotline in four States
that will, for the first time, provide a single 1-800 number for all
[[Page 29931]]
beneficiary inquiries. Complaints about the quality of care will be
automatically routed to the appropriate HCFA agent (for example, the
PRO or the End Stage Renal Disease (ESRD) Network) for action. This
hotline will be advertised to ensure that Medicare beneficiaries are
aware of this service.
The conditions of participation for Medicare providers are being
revised to transition towards a patient outcome-based system, and to
stimulate improvements in processes, outcomes of care, and patient
satisfaction. Under the revised conditions, providers would be required
to prominently display a list of patient's rights, including the
patient's right to complain about the quality of the care provided.
In response to concerns expressed about the managed care appeals
process, we have recently published a final rule with comment period
that will require managed care plans contracting with Medicare to add
an expedited appeals procedure to their appeals process. This will
allow Medicare enrollees to obtain coverage decisions as well as to
have those decisions reconsidered within very short timeframes in
certain time-sensitive situations. We also are developing a separate
notice of proposed rulemaking that would shorten the timeframes for
standard appeals that are not time-sensitive and therefore not
expedited. Currently, Health Maintenance Organizations (HMOs) and
Competitive Medical Plans (CMPs) have 60 days to make decisions
regarding the necessity of beneficiary requests for services and 60
days to complete reconsiderations. These timeframes will be reduced
significantly.
In addition to improving the beneficiary complaint process, there
are efforts underway to ensure that these complaints are consolidated
and analyzed to improve our ability to identify and correct problems.
They currently arrive at a variety of points of contact, including HCFA
central office, 10 regional offices, PROs, ESRD Networks, fiscal
intermediaries, and carriers. We are developing a standard set of
definitions for use by HCFA and all of its agents in categorizing
inquiries, along with developing an integrated automated system to
continually track issues, provide timely and accurate responses, and
effectuate improvements.
The enhancements in the responsiveness of PROs to beneficiary
complaints, the pilots to improve our accessibility to beneficiaries,
the activities underway to improve beneficiary awareness of their right
to file a complaint, and the development of systems to categorize,
track, and analyze beneficiary inquiries will all improve our
effectiveness in identifying providers with questionable performance.
Pattern Monitoring
We recently implemented a national surveillance system for PROs to
use in identifying patterns, trends, and variations in the health and
health care of Medicare beneficiaries and in identifying sentinel
events or clusters that may indicate less-than-optimal care. We are
analyzing data from HCFA's National Claims History files to present
national and State-specific descriptive epidemiology of the Medicare
population, overall health care utilization, and selected markers of
potential quality issues. Updates will be provided on a quarterly
basis. PROs have the capacity to refine the analyses to the community
or hospital-specific level, in order to identify providers with
questionable performance and will use the surveillance information to
identify and act on opportunities to improve care.
We do not currently have encounter data for managed care plans, and
thus the national surveillance system does not focus on managed care
providers. There is a pilot program underway to test the development
and use of such data. In addition, there are efforts underway to ensure
that managed care plans with questionable performance are identified,
and actions taken to resolve concerns. All managed care plans will be
required to provide Health Plan Employer Data and Information System
(HEDIS) quality measures by the summer of 1997. In addition, we are
participating in the development of the Foundation for Accountability
(FACCT) measures and will be testing their use in at least five States.
To complement the collection of these quality of care measures from the
plans, we have developed a Medicare-specific consumer satisfaction
survey in collaboration with the Agency for Health Care Policy and
Research through its Consumer Assessment of Health Plan Study (CAHPS)
process. The survey will be plan-specific and administered on an annual
basis. It is designed to collect information on satisfaction with
quality of care, access, and utilization of care and will provide
another source of information about care provided by managed care
plans.
Other Sources
We also have other sources for identifying poor performers. PROs
are still obligated to review cases referred to them by carriers and
intermediaries, usually for quality concerns that may affect coverage
and payment. Hospitals are required to provide patients with a Notice
of Noncoverage if they believe that a beneficiary does not require
inpatient level of care. If the beneficiary disagrees with the
hospital's decision, he or she may ask the PRO to review the case. The
PRO may identify a quality concern in the process that would require
some type of intervention at the hospital or physician level.
B. Improving the Distribution of Medicare's Indirect Medical Education
(IME) Payments (Recommendation 5)
Recommendation: Medicare's IME payments should reflect the
historical relationship between hospital costs and teaching intensity.
Further, they should continue to be based on the hospital's volume of
Medicare patients. These payments should no longer change in proportion
to annual variations in the number of residents or beds. In addition,
the payment method should be flexible enough to allow and support
training in settings outside of the hospital.
Response: The President's FY 1998 budget includes several proposals
consistent with ProPAC's recommendations. As set forth in those
proposals, the total number of residents and the number of nonprimary
care residents would be capped on a hospital-specific basis; the
resident-to-bed ratios would be capped at the level of hospitals' cost
reporting periods ending on or before December 31, 1996; residents
would be counted based on a multi-year rolling average; and hospitals
could include residents training in nonhospital-based training sites in
their resident-to-bed ratios (as long as the hospital continues to pay
the residents' salaries).
We believe the incentives associated with the current IME
adjustment are contrary to the Administration's policy of decreasing
the number of residents trained in the United States, increasing the
relative number of residents trained in primary care, and encouraging
more training in nonhospital-based sites. Our proposals would end the
incentives to increase the number of residents, encourage more training
in primary care, decrease the financial penalty for reducing the number
of residents trained (thereby encouraging that reduction over time),
and provide funding for training in nonhospital-based sites.
C. Reducing the Level of Medicare's Indirect Medical Education Payments
(Recommendation 6)
Recommendation: The indirect medical education adjustment should be
[[Page 29932]]
reduced from its current level of 7.7 percent to 7.0 percent in fiscal
year 1998.
Response: We agree with ProPAC that the current level of payment
for the indirect costs of medical education is too high. The
President's FY 1998 budget would reduce the adjustment to 7.4 percent
in FY 1998, 7.0 percent in FY 1999, 6.8 percent in FY 2000, 6.6 percent
in FY 2001, and 5.5 percent in FY 2002 and thereafter. A gradual
reduction in IME adjustment over several years would allow teaching
hospitals time to adjust to lower payments, while accomplishing our
objective of reducing the adjustment to a more analytically justifiable
level, which we estimate to be in the 4-to-5 percent range.
D. Improving Medicare's Payments for Direct Graduate Medical Education
(GME) Costs (Recommendation 7)
Recommendation: Medicare's payments to hospitals for the direct
costs of GME programs should not change in proportion to annual
variations in the number of residents trained. The method for
determining the level and distribution of these payments should be as
neutral as possible concerning the number and speciality mix of
residents and the site of their training.
Response: We share many of ProPAC's concerns regarding the way
Medicare currently pays for direct medical education, and we are
hopeful that the graduate medical education demonstration in New York
State will provide insights into how Medicare can establish more
appropriate incentives. Under the demonstration, participating New York
hospitals will receive declining financial protections for residency
reductions. We believe that these financial protections, which will
phase out over 6 years, will provide incentives for participating
hospitals to realize appropriate reductions in their residency
programs, to increase the proportion of residents in primary care
training, and to provide more training opportunities in ambulatory
sites.
Although we do not support lump sum payments to hospitals for
direct graduate medical education, the President's FY 1998 budget
includes proposals that would address ProPAC concerns. For instance,
the budget provisions would base a hospital's direct graduate medical
education payment on a 3-year rolling average of full-time equivalent
(FTE) residents. This measure would reduce the adverse financial impact
on a hospital that reduces the size of its residency programs. The
proposals would further encourage training in primary care specialties
by providing payments to nonhospitals (federally qualified health
centers, rural health clinics, and health maintenance organizations)
for residents when the residents' salaries are not paid by hospitals.
E. Establishing a Broader-Based Financing Mechanism for Graduate
Medical Education and Teaching Hospitals (Recommendation 8)
Recommendation: Explicit payments for graduate medical education
and teaching hospital costs should not be limited to the Medicare
program. Mechanisms to broaden financial support for training
physicians in hospitals and other locations should be developed. The
payments should reflect the reasonable costs of training at each
facility and protect the access of beneficiaries and other populations
to the services they provide.
Response: We agree that all payers should contribute their fair
share toward physician training, particularly for the patient care
services that are provided in the course of this training. In addition,
we agree that academic medical centers play an important role as
training and research centers and are an integral part of our health
care system.
In response to ProPAC's observation that Medicare is the only payer
that explicitly supports graduate medical education, we note that some
Medicaid programs explicitly pay hospitals for the indirect and direct
costs of graduate medical education in a manner similar to Medicare. In
addition, some States (for example, New York, through the New York
Health Care Reform Act) provide explicit support for teaching hospitals
using private payers.
We note that although the President's health care reform bill in
1993 attempted to involve private insurers in directly supporting
medical education, we do not currently have a proposal to broaden
support for teaching hospitals beyond that currently provided by
Medicare. We have, however, proposed to broaden financial support for
teaching hospitals by changing the way Medicare funds medical education
through its managed care programs. Currently, Medicare payments to HMOs
are based on the average cost of providing services to Medicare
patients in the fee-for-service part of Medicare. These Medicare
payments to HMOs include payments for medical education. We have
proposed revising Medicare's payments to HMOs to exclude the portion
associated with medical education. Instead, we would pay these funds
directly to teaching hospitals and managed care plans with teaching
programs. Our proposal would thus benefit teaching hospitals, by
increasing their Medicare payments, as well as more appropriately
target Medicare funds designated for medical education.
F. Principles for Improving Medicare's Disproportionate Share (DSH)
Payment Adjustment (Recommendation 9)
Recommendation: Medicare's DSH payments should be aimed at
protecting access to hospital care for its beneficiaries. Payments
should be distributed based on each hospital's share of low-income
patient care and volume of Medicare cases. The low-income share measure
should reflect the costs of services provided to low-income groups in
both inpatient and outpatient settings. These groups include Medicare
patients eligible for SSI, patients sponsored by Medicaid and local
indigent care programs, and uninsured and underinsured patients as
represented by uncompensated care.
Response: The Medicare disproportionate share adjustment is linked
to hospital payments under the prospective payment system. In this way,
Medicare funds a share of the inpatient costs generated by hospitals
that are caring for a large number of indigent patients. The Medicare
disproportionate share adjustment was established by Congress effective
May 1, 1986, under section 1886(d)(5)(F) of the Act. It was intended to
be a mechanism through which hospitals that treated a high proportion
of indigent patients could be compensated for the higher Medicare costs
associated with treating that population. Medicaid also provides a
disproportionate share adjustment.
When the disproportionate share adjustment was enacted, eligible
hospitals were expected to be the exception, not the rule. However,
almost half of the hospitals under the prospective payment system
currently receive some level of Medicare disproportionate share
payments. In addition, as a result of recent court decisions concerning
HCFA's interpretation of Medicaid eligible days, not only will payments
increase to currently eligible disproportionate share hospitals, but we
expect that additional hospitals will qualify for disproportionate
share payments.
ProPAC believes that HCFA should continue to use a combination of
Medicare, Supplemental Security Income (SSI), and Medicaid data as
eligibility criteria and, in addition, uncompensated care data should
be collected on an individual hospital basis and included in the
calculation. We are
[[Page 29933]]
seeking to move away from the SSI and Medicaid measures that currently
exist within this adjustment formula due to the concerns outlined in
the May 31, 1996 proposed rule (61 FR 27473). None of the public
comments we received in response to these concerns suggested the
collection of uncompensated care data. In addition, such data would be
unverifiable, except through arduous auditing procedures, which would
be expensive and time-consuming for the fiscal intermediaries and the
hospitals.
The President's FY 1998 budget includes a provision to freeze
disproportionate share payment adjustments for 2 years while we develop
an alternative methodology for identifying and paying hospitals that
treat a disproportionate share of low-income patients. Our intention is
to move away from the current eligibility measures and to target
payments to those hospitals with the highest shares of low-income
patients.
G. Improving the Distribution of Disproportionate Share Payments
(Recommendation 10)
Recommendation: DSH payments should be concentrated among hospitals
with the highest shares of poor patients. Therefore, a minimum
threshold should be established for the low-income patient cost share.
Hospitals falling just above the threshold should receive only a
minimal per case payment, with the amount then increasing as low-income
share rises. The same general approach for distributing payments should
apply to all PPS hospitals.
Response: Congress set the current threshold payments for Medicare
disproportionate share hospitals in section 6003(c) of the Omnibus
Budget Reconciliation Act of 1989. This provision expanded both the
number of hospitals that could qualify for disproportionate share
payments as well as the level of those payments for some categories. We
note that large urban hospitals already receive payments based on this
graduated payment structure. ProPAC notes that 95 percent of the
hospitals receiving disproportionate share payments are designated as
large urban hospitals. A May 1990 Congressional Budget Office (CBO)
report to Congress, found that only large urban hospitals were
overburdened by the cost of caring for the indigent population.
We agree with ProPAC that the disproportionate share payments
should be concentrated on the hospitals in greatest need of assistance.
H. Collecting Data To Support Disproportionate Share Payment Reform
(Recommendation 11)
Recommendation: The Secretary should collect the data necessary to
implement a revised DSH payment mechanism. Due to recent and planned
changes in the Medicaid and SSI programs, the measure now used to
distribute DSH payments is becoming increasingly untenable. Although
several new data elements would be required, this need not
substantially increase the current hospital reporting burden. Periodic
audits of these data would also be necessary.
Response: Currently, hospitals are not required to distinguish
between bad debts and uncollectible accounts. When a patient does not
pay a bill, the hospital is required to proceed through a series of
steps in an attempt to collect the amount before it can be declared a
bad debt. If the hospital were also seeking to collect data on
uncompensated care, it would be required to further investigate whether
or not the patient had the ability to pay. This could be a very
burdensome task. ProPAC's solution to this problem is to include bad
debts and charity care as a lump sum. However, Medicare currently pays
hospitals for bad debts, and bad debts are removed from the exception
to the disproportionate share adjustment calculation under our
regulations at Sec. 412.106(c)(2). In addition, we believe that the
inclusion of bad debts in this calculation would encourage some
hospitals to relax their collection efforts, at Medicare's expense. In
any event, cost reporting forms would have to be changed and any data
collected would have to be audited extensively by the fiscal
intermediaries. Therefore, we question whether a data collection effort
is feasible.
Our preference would be to use data that are already available and
verifiable on a national basis for the Medicare disproportionate share
adjustment calculation. We are currently pursuing such data sources as
we fashion our legislative proposal.
I. Making Teaching and Disproportionate Share Payments to Facilities
That Treat Medicare Risk Plan Enrollees (Recommendation 12)
Recommendation: Facilities that receive explicit direct GME, IME,
or DSH payments for their Medicare fee-for-service patients should also
receive additional payments for their Medicare risk plan patients.
Mechanisms should be developed to distribute these payments in a way
that reflects the policy goals of the Medicare program.
Response: ProPAC is concerned that explicit support for teaching
and disproportionate share hospitals is eroding as managed care plans
enroll more Medicare patients. According to ProPAC, managed care plans
may be unwilling to pay the extra costs that these hospitals incur and
separate mechanisms need to be developed to allow teaching and
disproportionate share hospitals to remain competitive with other
hospitals.
We are concerned that Medicare's payment to managed care plans
includes compensation for direct and indirect graduate medical
education and a disproportionate share adjustment that may not be
reflected in the payments managed care plans are making to teaching and
disproportionate share hospitals. The President's FY 1998 budget
includes a proposal to remove funding included in Medicare's payment to
managed care plans for teaching and disproportionate share activities
and to pay these funds directly to teaching and disproportionate share
hospitals based on their Medicare risk plan discharges.
J. Modifying the Tax Equity and Fiscal Responsibility Act (TEFRA)
Payment System (Recommendation 14)
Recommendation: Congress should consider modifying the TEFRA
payment system to correct for the payment disparity between new and old
providers.
Response: HCFA has developed legislative proposals to modify the
TEFRA payment system. Our proposals include rebasing the target rates
for excluded hospitals and units using an average of each facility's
two most recent cost reporting periods. This measure would realign
payment rates with costs for both old and new providers. In conjunction
with rebasing, the new target rates would be capped at 150 percent of a
national mean rate for each type of facility in order to prevent newer
high cost hospitals from receiving excessive target rates. Lower cost
hospitals would be protected by establishing a floor of 70 percent of
the national mean rate for each type of facility. Incentive payments
would be modified by providing that no such payment would be made where
a provider incurs costs that are less than or equal to 110 percent of
the target amount. Finally, the President's FY 1998 budget proposal
would revise the payment of capital costs to excluded hospitals and
units by reducing reimbursement for capital to 85 percent of reasonable
costs. TEFRA providers are the only hospitals that continue to be
reimbursed for capital on a dollar-for-
[[Page 29934]]
dollar basis; consequently, they have no incentive to control their
capital expenditures. This policy would make capital reimbursement
policy more consistent among all hospitals and provide a needed
incentive for cost control, particularly for newer excluded hospitals
and units that may have more resources for capital expenditures because
they are not as limited by the target rates on inpatient operating
costs.
K. Prospective Payment System for Hospital Outpatient Services
(Recommendation 15)
Recommendation: The Secretary should implement a prospective
payment system for hospital outpatient services as soon as possible.
Such a system should incorporate methods for controlling the volume of
services.
Response: We agree with the need to implement a prospective payment
system for outpatient services. Under the President's FY 1998 budget, a
prospective payment system for outpatient services would be implemented
on January 1, 1999.
While we await legislative authority, we will continue to develop
and refine the Medicare-specific factors of the ambulatory patient
group (APG) classification system that we recommend using. We plan to
analyze the payments that would be made across sites (for example in
ambulatory surgical centers (ASCs) or physician radiology practices) to
ensure that we have not created unwarranted incentives to perform
procedures in a given setting for financial reasons.
We are concerned as well about the potential for increases in the
volume of services provided, both in outpatient departments and in
other settings. We are examining approaches to volume measurement and
control, including the level of packaging for ancillary services and
the monitoring of patterns of care. For example, we could track whether
Medicare beneficiaries received more clinic visits per patient under
APGs than they did under reasonable cost-based payment. If so, we could
take corrective action in one of two ways: We could adjust for the over
utilization of outpatient services under a prospective payment system
by incorporating the adjustments into the total system, which may
impact on all hospitals; or we could target the specific hospitals
identified as over utilizing services and apply the corrective action
specifically to them.
L. Reducing Beneficiary Liability for Hospital Outpatient Services
(Recommendation 16)
Recommendation: Beneficiary liability for hospital outpatient
services should be reduced from 20 percent of charges to 20 percent of
the allowed payment, as it is for other services. Further, Congress
should correct the blended payment formula. This would help offset the
increase in Medicare outlays resulting from a reduction in beneficiary
liability.
Response: We agree that the issue of beneficiary coinsurance should
be addressed and that the blended payment formula should be corrected.
As part of the President's FY 1998 budget proposal, coinsurance for
outpatient services would be reduced to 20 percent by 2007 as part of
the implementation of a prospective payment system for these services.
M. Improving Dialysis Facility Data (Recommendation 17)
Recommendation: HCFA should regularly audit a representative sample
of dialysis facility cost reports to ensure that it has accurate data
to assess the adequacy of the composite rates. Further, it should
systematically track quality indicators for these providers.
Response: HCFA does not audit renal facilities on a regular basis
since audits do not result in recoupment of Medicare funds. This is
because renal facilities are paid the composite rate, which is a set
fee. Thus, there is no cost reimbursement. In recent years, Medicare
funds for audits have been reduced. To manage these limited resources,
HCFA has instructed contractors to audit those entities that generate
the most return on audit dollars spent. With renal audits, the only
payback is recoupment of unallowable bad debts, which are limited under
the current payment system. Generally, audit funds in the budget are
not used to review cost reports that have little or no effect on
Medicare providers' payments.
We are also concerned about the quality of the data regarding
dialysis facility costs in the Health Care Provider Cost Report
Information System (HCRIS). Procedures and edits are in place to review
data that do not appear reasonable. However, these procedures and edits
cannot guarantee that renal facilities report their costs in accordance
with Medicare reasonable cost principles. To accomplish this task,
fiscal intermediaries perform desk reviews of cost reports for the
purpose of finding errors or for identifying cost reports that should
be audited. Because of limited resources, only in rare instances would
a fiscal intermediary audit a renal facility's cost report. HCRIS edits
are designed to ensure that data are within acceptable ranges or to
identify facilities with missing data. The best way to ensure that cost
reports are completed correctly is through education of individuals who
are responsible for completing renal cost reports. The National Renal
Administrator Association has been helpful in accomplishing this task
and in improving the quality of the renal cost reporting data in HCRIS.
To address ProPAC's concern, we will review the current procedures
and edits in HCRIS for renal facilities to address cost reporting data
elements that appear out of line. We also will revise instructions to
clarify problem areas in renal facility cost reporting. In addition, if
and when our contractors' funding levels permit, we will conduct a
limited set of audits on independent renal facilities. However, based
on our prior experience, we do not believe it is necessary to audit
hospital-based renal facilities, since these audits resulted in only
minor changes to reported costs. Since independent facilities furnish
about 75 percent of all dialysis treatments, we believe audit activity
should focus on those facilities. As in prior years, we would provide
ProPAC with the results of any audits and the percentage adjustment
between reported and audited costs.
To improve the quality of care renal patients are receiving, we are
in the process of developing revised ESRD conditions for coverage. The
proposed regulations are patient-centered and outcome-oriented. The
proposed conditions for coverage will focus on facilities achieving an
optimal level of health and well-being for all dialysis patients. When
published, these regulations should address ProPAC's recommendation
that HCFA monitor treatment patterns and patient outcomes. After
publication of a notice of proposed rulemaking, we plan to meet with
the renal community to develop complete clinical data sets to monitor
patient outcomes and medical conditions. These data will then be used
to evaluate the quality of dialysis services furnished by renal
facilities. In the short term, we are planning to require renal
facilities to report values for Kt/V (which indicates whether the
patient has too much urea in the blood after dialysis) or urea rate
reduction to assess the adequacy of patient dialysis treatments
furnished by facilities.
[[Page 29935]]
N. Update to the Composite Rate for Dialysis Services (Recommendation
18)
Recommendation: For FY 1998, the composite rate for dialysis
services should be increased by 2.8 percent to ensure that
beneficiaries receive quality care. This level reflects the projected
increase in the market basket index for dialysis services and the
Commission's judgment about the likely effects of scientific and
technological advances and productivity gains on facilities' costs.
Response: We share ProPAC's concerns about the relationship among
patient outcomes, adequacy of dialysis, and payment. As we acknowledged
in last year's response to a similar recommendation, we recognize that
an increase in the composite payment rate may be appropriate in the
future. However, we do not believe an across-the-board rate increase is
warranted. It may be appropriate to recommend payment increases based
on the number of treatments that a renal facility furnishes, since
dialysis facilities exhibit economies of scale. In proposing a future
increase, we would want to examine the need to adjust payment increases
for volume and the effects a new wage index would have on payments. The
results of the National Kidney Foundation Dialysis Outcomes Quality
Initiatives should provide us with information on the relationship
between patient outcomes and costs and thus provide us with a basis for
recommending an appropriate payment rate increase. However, our
position is that any payment increase should be linked to
implementation of the revised conditions for coverage for ESRD
facilities. Until these conditions are published in final, we will
continue to monitor facilities' costs and other factors to determine if
it is appropriate to recommend a payment rate increase. Moreover, any
dialysis rate increase must be considered within the context of the
Medicare budgetary concerns.
O. Prospective Payment System for Skilled Nursing Facilities (SNFs)
(Recommendation 19)
Recommendation: A case-mix adjusted prospective payment system for
skilled nursing facilities should be implemented as soon as possible.
Response: We concur with the recommendation to implement a
prospective payment system for SNFs as soon as possible. The
President's FY 1998 budget includes a provision for a prospective
payment system for SNFs to be implemented on July 1, 1998. This system
will include payment for all costs (routine, ancillary, and capital)
related to the services furnished to beneficiaries under Medicare Part
A. By including all costs of services in the payment rates, spending
growth per day of care can be contained. In addition, the provision
includes authority to adjust payments to providers where inappropriate
utilization (that is, excessive lengths of stay) of SNF services is
found. Finally, the proposed prospective payment system would include
case-mix adjustments using a resident classification system based on
resource utilization groups. These resource utilization groups are tied
to elements contained on the Minimum Data Set (MDS) 2.0 resident
assessment instrument for nursing homes.
P. Controlling Payments for Skilled Nursing Facility Ancillary Services
(Recommendation 20)
Recommendation: Until a prospective payment system is developed,
the Secretary should take steps to control SNF expenditures by limiting
payments for ancillary services.
Response: We agree that the rapid growth in payments for SNF
ancillary services must be curbed. As indicated in the previous
response, the President's FY 1998 budget includes a provision for an
SNF prospective payment system, to be implemented on July 1, 1998, that
will include payment for all the costs of services furnished to
Medicare beneficiaries in a single prospective rate. Under this system,
spending growth for ancillary and other services will be appropriately
contained.
In addition, on March 28, 1997, we issued proposed revised salary
equivalency guidelines for physical and respiratory therapy and new
guidelines for occupational and speech therapy (62 FR 14851). We hope
to finalize these guidelines prior to implementation of a SNF
prospective payment system. The guidelines will have a significant
impact on cost containment per hour of service billed for therapies
provided in SNFs and other providers. However, it is unlikely that we
will be able to implement other limits on ancillary services in the
limited time available before implementation of the SNF prospective
payment system. The suggestion that prospective payment rates for
ancillary services could be adopted is obviated by the absence of any
implementing authority in the current statute. Cost limits could be
adopted but would take time to develop and implement. For example,
using the resource based relative value scale (RBRVS) to set payment
limits on ancillary services would require SNFs (as well as HCFA and
fiscal intermediary claims processing systems) to begin using the HCFA
Common Procedure Coding System (HCPCS) on Part A SNF bills in order to
match a service with the appropriate fee schedule amount. With the
planned implementation of the SNF prospective payment system in only a
year, it would not seem practical to invest resources in the
development and implementation of a RBRVS-based limit system that would
not have any impact on the volume of services provided.
Q. Consolidated Billing for Skilled Nursing Facility Services
(Recommendation 21)
Recommendation: The Secretary should require consolidated billing
for all services furnished to beneficiaries during a Part A-covered SNF
stay. Further, SNFs should use consistent, procedure-level codes for
these services.
Response: We concur with ProPAC's observations regarding the need
for and potential benefits of establishing such requirements, and we
note that the President's FY 1998 budget proposal includes provisions
that adopt this recommendation by requiring consolidated billing for
Medicare services provided to SNF residents beginning in FY 1998, as
well as the use of HCPCS codes on SNF bills.
We would like to comment in greater detail on ProPAC's suggestion
that the consolidated billing proposal should specifically define the
ancillary services to be included. We note that a similar comprehensive
Medicare billing requirement for hospitals (section 1862(a)(14) of the
Act), which has been in effect for well over a decade, defines the
hospital's billing responsibility in terms of a blanket inclusion of
all services that a hospital patient receives, with specific exemptions
for the services of certain types of medical practitioners (for
example, physicians, certified nurse-midwives, qualified psychologists,
and certified registered nurse anesthetists) that are not regarded as
falling within the scope of the hospital benefit. Existing law in the
material following section 1861(h)(7) of the Act, defines the scope of
the SNF benefit, in part, as excluding those types of services that
would not be coverable under the inpatient hospital benefit when
furnished to a hospital inpatient. Accordingly, our SNF consolidated
billing proposal would similarly provide for a blanket inclusion of all
services that the SNF's resident receives (with specific exceptions for
certain types of medical practitioner services), in order to maintain
consistency with the longstanding hospital provision.
[[Page 29936]]
R. Eliminating the Cost Limit Exemption for New Skilled Nursing
Facilities (Recommendation 22)
Recommendation: The exemption from Medicare's routine cost limits
for new providers should be eliminated. All SNFs should be subject to
these limits.
Response: We concur with the recommendation to eliminate the
exemption to the Medicare routine cost limits for new skilled nursing
facilities. The rapid rise in the number of SNF beds and significant
growth in payments both generally and specifically to SNFs with
exemptions have demonstrated the diminished value of the exemption to
the Medicare program and necessitated its elimination.
Under the SNF prospective payment system proposed in the
President's FY 1998 budget, exemptions, as an artifact of reasonable
cost-based payment, will be eliminated with the implementation of the
system on July 1, 1998. Even so, we are moving to eliminate the new
provider exemption through issuance of regulations in the near future.
The issue of how the new policy will be applied relative to providers
currently operating under the exemption is being addressed as part of
the development of this regulation.
S. Defining the Home Health Care Benefit (Recommendation 23)
Recommendation: Congress should more specifically define the scope
of Medicare's home health care benefit. The absence of clear coverage
constraints limits the program's ability to control home health
utilization.
Response: We agree with ProPAC's recommendation that clearer
eligibility and coverage guidelines would aid the program's ability to
control improper and abusive home health care utilization. The
President's FY 1998 budget contains provisions regarding the definition
of homebound and intermittent skilled nursing care, as well as the
statutory authority for HCFA to develop and apply normative standards.
T. Prospective Payment System for Home Health Care Agencies
(Recommendation 24)
Recommendation: A case-mix adjusted prospective payment system for
home health care agencies should be implemented as soon as possible.
Response: We concur with ProPAC's recommendations. We agree that
research to develop a robust case-mix measure is necessary and we have
taken all available actions to expedite such research. In August 1996,
a contract was awarded to develop a case-mix measurement for a home
health prospective payment system. Under the terms of this contract,
extensive information about the characteristics of patients and
resource utilization will be collected. Agencies participating in this
project will collect patient information using the Outcome and
Assessment Information Set (OASIS) for home health, supplemented by
additional items that may be predictive of resource utilization.
Information will also be collected about visit lengths and procedures
performed during all home health visits during an episode of care. We
hope to recruit 90 agencies from 8 States for this project. Recruitment
began in April 1997. We expect to have recommendations for a case-mix
measurement for home health services by January 1999.
U. Interim Home Health Payment Method (Recommendation 25)
Recommendation: Congress should implement an interim home health
payment method to control Medicare outlays until a fully prospective
payment system is in place.
Response: The President's FY 1998 budget proposal includes an
interim system, which would be effective on October 1, 1997. We are
prepared to begin implementation of this system as soon as we are
granted the necessary statutory authority.
V. Home Health Visit Coding (Recommendation 26)
Recommendation: Medicare should require consistent home health
visit coding. Such information is essential for monitoring and
evaluating the home health benefit and developing an effective case-mix
adjustment system.
Response: Currently, there is no standard definition of what
comprises a visit and there is variation in the type of service and
length of time for providing those services. We agree such information
is critical to developing an effective case-mix measure for a home
health prospective payment system. In the case-mix research we are
beginning, we will collect information on the length of time and
procedures performed during a visit. This information will feed into
the development of a prospective payment system and related coding
system. We cannot proceed with specific coding refinements until the
findings are available and a prospective payment system is designed. We
are researching aspects of that approach rather than imposing reporting
burdens on all home health agencies.
W. Home Health Copayments (Recommendation 27)
Recommendation: Modest beneficiary copayments, subject to an annual
limit, should be introduced for home health care services.
Response: We are concerned about the impact that higher beneficiary
out-of-pocket expenses would have on poorer Medicare beneficiaries who
are not covered by Medicaid and cannot afford supplemental insurance.
Poorer beneficiaries spend a greater proportion of their income on out-
of-pocket costs. Our proposed interim system of limits should help
control the growth in service use.
X. Controlling Long-Term Home Health Use (Recommendation 28)
Recommendation: The Secretary should analyze the growing number of
beneficiaries who are receiving home health care for prolonged periods.
Additional policies may be needed to address the spending associated
with these beneficiaries.
Response: This is one of the many areas that are under evaluation
in several payment-related research projects that are currently
underway. We agree with ProPAC that there may need to be special
provisions under the payment system we develop to address the needs of
this type of patient. As the findings from the research become
available, we are sure that this issue will be more clearly identified
and we will propose whatever changes appear to best address these
patient's needs.
Y. Prospective Payment System for Rehabilitation Hospitals and
Distinct-Part Units (Recommendation 29)
Recommendation: A case-mix adjusted prospective payment system for
rehabilitation hospitals and distinct-part units should be implemented
as soon as possible.
Response: We have sponsored research on possible patient
classification systems for rehabilitation care. In particular, a study
by the RAND Corporation evaluated the prospects for a prospective
payment system based on the rehabilitation coding system known as
Functional Independence Measure (FIM) and the patient classification
system known as Function-Related Groups (FRGs). The final report on
this research will soon be complete. However, the preliminary results
indicate much work would be necessary before a prospective payment
system based on FRGs could be implemented. There are at least two
important implementation issues: The reliability of the patient status
measures and the
[[Page 29937]]
recognition of patient complications and comorbidities. In addition,
implementation of a case-mix payment system for rehabilitation
hospitals and units would require significant program resources and
impose data reporting and collection requirements on providers. As a
result, fewer resources would be available for research into developing
an integrated payment approach for payment of rehabilitation care
across all settings (excluded hospitals, SNFs, HHAs, comprehensive
outpatient rehabilitation facilities, etc.) Thus, we prefer to focus
our efforts on developing a coordinated payment system for post acute
care that relies on a core assessment tool.
Z. Prospective Payment System for Long-Term Care Hospitals
(Recommendation 30)
Recommendation: A case-mix adjusted prospective payment system for
long-term care hospitals should be developed and implemented as soon as
possible.
Response: We continually examine data and analyze proposals to
simplify payment mechanisms and ensure that Medicare payments reflect
efficient and high quality health care. We will be interested in
evaluating the results of independent studies on case-mix measurement
for long-stay hospital patients. At the same time, it is evident that
many long-term care hospitals furnish extensive rehabilitation care
that overlaps with care furnished in rehabilitation hospitals. Thus, a
prospective payment system for post-acute care providers which includes
SNFs and rehabilitation hospitals and units could conceivably be used
for patients in long-term care hospitals. As a result, we have concerns
that the development and implementation of a separate prospective
payment system for fewer than 200 Medicare-certified, long-term care
hospitals may not be an efficient use of program resources and may
result in overlapping complexity and manipulation of payment.
AA. Elimination of the New Provider Exemption Period (Recommendation
32)
Recommendation: The initial exemption period for new PPS-excluded
providers should be eliminated. Medicare payments for new providers
should be based on an average target amount for facilities serving
comparable types of patients.
Response: New hospitals that are excluded from the prospective
payment system are exempt from the rate-of-increase ceiling during
their first 2 years of operation. The purpose of this exemption is to
recognize certain cost distortions that may be present as a hospital
begins operation and tries to establish its presence in the market.
However, the growth of new excluded hospitals increasingly includes a
large number of hospitals that are reconfigurations of existing
structures. These new hospitals do not require the same length of time
to establish market presence and increase patient load. As a result,
there is evidence that the new hospital exemption does not always serve
its original purpose and might create incentives to increase its costs
in the exempt years when it is not subject to cost limitation. The
President's budget proposal would limit payment during the exempt years
to reasonable costs not to exceed 150 percent of the national mean cost
per case for each type of excluded hospital. This modification should
eliminate the incentive to increase costs in the first years of a new
excluded hospital's operation.
BB. Coordinating Post-Acute Care Provider Payment Methods
(Recommendation 33)
Recommendation: The Commission urges the Congress and the Secretary
to consider the overlap in services and beneficiaries across post-acute
care providers as they modify Medicare payment policies. Changes to one
provider's payment method could shift utilization to other sites and
thus fail to curb overall spending. To this end, ProPAC commends HCFA's
efforts to identify elements common to the various facility-specific
patient classification systems to use in comparing beneficiaries across
settings.
Response: We concur with the recommendation to coordinate payment
methods for post-acute providers. Our long-term strategy for Medicare
post-acute services centers on the development of a fully integrated
payment and delivery system for post-acute care that is as neutral as
possible regarding physicians' and patients' decisions about the use of
particular services. This system should provide payments sufficient to
ensure that beneficiaries receive quality care in the appropriate
settings and that transfers between settings occur when medically
necessary and not to generate higher or duplicate revenues for
comparable services. In addition, we believe that care should be
beneficiary-specific, relying on a standardized assessment of each
patient's care needs while offering them choices in the care that they
will receive. This system must have long-term financial integrity
through controlling both payment per service and the volume of services
offered.
Essential to achieving this long-term goal is the near-term
coordination of the separate payment methods for post-acute providers.
Through the development and implementation of prospective payment
systems that complement each other, Medicare can impose greater
coordination in the financing and delivery of post-acute services. This
will minimize quality and payment problems associated with site/service
substitution and allow for an easier transition to a fully integrated
system in the future. The key to the function of these prospective
payment systems, as well as any future integrated system for post-acute
services, is the adoption of principles for identifying patient
resource needs that have common elements from system to system so that
ultimately there can be a broader classification system and more
standardized methods for grouping patients and payments. Basic to this
process is the development of a core screening and assessment tool. An
assessment methodology is critical to addressing systematic issues
related to quality, payment, and utilization.
The President's FY 1998 budget contains proposed language giving
the Secretary authority to implement an integrated payment system for
Medicare post-acute services after FY 2001. This language also provides
authority to collect the data necessary to develop and implement such a
system prior to that date. We are in the early stages of designing the
post-acute core screening and assessment tool that will provide much of
the necessary data.
CC. Linking Payments for an Episode of Care (Recommendation 34)
Recommendation: The Secretary should begin a demonstration project
that links payments for the acute and post-acute portions of an episode
of care. It should be designed to test whether this approach can reduce
expenditures and improve continuity of care.
Response: As discussed in our previous response to recommendation
33, our long-term strategy for Medicare post-acute services centers on
the development of a fully integrated payment and delivery system.
Within the framework of this strategy and the basic concepts we have
outlined, there are a variety of different options for structuring a
payment and delivery system for Medicare post-acute services. These
include various case management approaches, integrated delivery/payment
systems, and more traditional resource based prospective payment
models. Certainly a system that links payment for the acute and post-
acute
[[Page 29938]]
portions of an episode would fall within the scope of this framework.
Conceptually, the idea of linking (or ``bundling'') payment for the
acute and post-acute portions of an episode makes sense and has great
potential for effective cost containment under the Medicare model. As a
practical matter, this approach is extremely complex, involving a range
of difficult technical and policy issues related to rate setting,
patient classification, quality, outcomes, accountability, and payment
arrangements (that is, which entity should receive the payment). HCFA
has funded several studies in this area. These studies have discussed
the complexity of this approach and concluded by citing the need for
additional research before going forward with a demonstration. In
addition, two other provisions in the President's FY 1998 budget
proposal give HCFA the authority to try this approach in certain
circumstances. The Centers of Excellence proposal expands the set of
conditions for which we could pay a single flat rate for all diagnostic
and physician services to include other heart procedures, knee surgery
and hip replacement. This might allow us to experiment with including
some postacute services in the bundled package of services. We are also
seeking legislative authority that would allow us to selectively
contract with providers for a package of services for a specific
condition, which would be another opportunity to experiment with
arrangements including postacute care.
DD. Improving the Risk Adjustment Method (Recommendation 35)
Recommendation: A combination of techniques should be used to
adjust Medicare's capitation payments so that they better reflect
enrollees' likely use of services. The Secretary should adopt risk
adjusters based on diagnosis, health status, or both as well as an
outlier policy for costly cases. Partial capitation arrangements should
be tested. Plans should provide data to Medicare to support improved
risk adjustment. The new risk adjustment system should be phased in.
Response: ProPAC recommends using risk adjustment methods that
would explain more of the variances in health care spending. Currently,
we are testing risk adjusters as part of the Medicare Choices
demonstration. The Administration is developing a new payments
methodology that incorporates more refined health status adjusters. A
proposal could be ready for Congressional consideration as early as
1999, with implementation beginning as early as 2001. HCFA would want
to apply risk adjusters as soon as technically feasible.
Also, ProPAC has suggested, as a part of risk adjustment, a partial
capitation method of payment, using an outlier approach to capitation
payment. We are trying to establish an outlier demonstration in the
Seattle area. One of the problems we have encountered is finding a
sufficient number of plans able to supply encounter data. We wanted at
least three plans included in the demonstration. To date, two of the
three plans have not demonstrated an ability to produce the data
required. The President's budget proposal includes a partial risk
method that we prefer to the outlier approach recommended by ProPAC.
Under the President's budget proposal, the partial risk method would
replace cost based payments. This method would allow organizations to
share with HCFA in either savings or losses if the payment mechanism
requires amounts to be paid either below or above the risk capitation
rate.
EE. Excluding Teaching and Disproportionate Share Payments From the
Capitation Rates (Recommendation 36)
Recommendation: The fee-for-service spending estimates Medicare
uses to calculate capitation rates should exclude special payments to
hospitals with graduate medical education (GME) programs and to those
serving a disproportionate share of low-income patients.
Response: We agree with ProPAC's recommendation to remove GME and
DSH components from the capitation rates. The President's budget
proposal removes these components from the capitation payments over a
2-year period. The funds removed from the capitation rates will be paid
directly to teaching and DSH hospitals when they care for managed care
enrollees. Managed care plans with approved teaching programs would
also be eligible for direct payment for graduate medical education
expenses.
FF. Increasing Capitation Rates to Reflect Use of Services Covered by
Other Government Programs (Recommendation 37)
Recommendation: Medicare should increase the capitation rates to
include estimated spending for covered services that program
beneficiaries receive in facilities operated by the Departments of
Veterans Affairs and Defense.
Response: Under the Administration's proposal to revise the payment
methodology, the current link between local fee-for-service payments
and managed care payments rates is not retained. By 2002, 30 percent of
the county rate will be based on national average payment levels. In
addition, rates will be updated based on the national average per
capita rate of growth in the Medicare program. In view of the reduced
weight of local fee-for-service payment levels and the anticipated
transition to a new methodology, we believe the need to further examine
the impact of spending for services provided to Medicare beneficiaries
in Veterans Affairs and Defense facilities is significantly reduced.
Additionally, when we undertook such an examination a few years ago, we
had problems with the data submitted and could not establish an
appropriate adjustment to the capitation payments.
GG. Reducing the Variation in Payment Rates (Recommendation 38)
Recommendation: The variation in capitation rates across counties
should be narrowed. The lowest rates should be raised to a minimum
amount, without increasing aggregate program spending. Medicare should
evaluate the adequacy and appropriateness of its payment rates, however
they are determined.
Response: The Administration supports narrowing the variation in
capitation rates across counties and creating a minimum payment amount.
The FY 1998 budget proposal to revise the payment methodology includes
both of these elements. By 2002, the difference between the highest and
the lowest county rates is reduced from the current difference of about
250 percent to about 100 percent. The Administration's proposal also
addresses the appropriateness of the rates by making an adjustment for
favorable selection into managed care plans, beginning in 2000. This
adjustment is consistent with the judgement of the General Accounting
Office, the Physician Payment Review Commission, as well as ProPAC,
that managed care plans are currently significantly overpaid because of
favorable selection. Also, as noted above, the Administration is
developing a new payment methodology that incorporates more refined
health status adjusters. A proposal could be ready for Congressional
consideration as early as 1999, with phase-in beginning as early as
2001.
HH. Updating Capitation Rates (Recommendation 39)
Recommendation: Medicare should use a national update framework
rather than fee-for-service spending increases to determine the annual
changes in risk plan payment rates.
[[Page 29939]]
Response: Under the current methodology, rates are updated based on
local fee-for-service spending patterns. Under the Administration's
proposal to revise the payment methodology, rates would be updated
based on the national average per capita rate of growth in the Medicare
program, which incorporates changes at the national level in both price
and utilization of services. In developing the revised methodology
noted above, which we expect to have ready for Congressional
consideration as early as 1999, we will examine appropriate update
mechanisms.
II. Evaluating Alternative Methods for Determining Capitation Rates
(Recommendation 40)
Recommendation: The Medicare program should continue to evaluate
other methods for determining payment rates, including competitive
bidding and negotiation between the program and risk plans.
Response: We are in the process of developing several demonstration
projects for evaluation purposes. One project concentrates on
competitive bids, including the use of a third party enroller. In this
project, HMOs could be paid an amount based on bids they submit. In
addition, the Choices project will have participants receiving payments
that start with 95 percent of the Adjusted Average per Capita Cost
(AAPCC) (HCFA's normal payment method). Later in the project, these
payments will be modified using risk adjusters. This project will also
include contracting with organizations that may not qualify as HMOs.
Finally, we are trying to establish an outlier project in Seattle, as
mentioned above. However, we have not yet been able to acquire
sufficient data to begin this project.
JJ. Data to Improve Plan Payments (Recommendation 41)
Recommendation: The Secretary should require risk plans to provide
information on the costs of furnishing services to Medicare enrollees.
These data are necessary to determine the appropriateness of payment
rates and improve Medicare payment methods.
Response: We are in the process of revising the adjusted community
rate (ACR) proposal and process. Some of the concepts included in this
review include requiring the ACR to contain and use certain cost data
to establish the plan's charge structure. In addition, we are
considering incorporating into the approval process a comparison of ACR
data to other required financial reports.
KK. Evaluating Plan Quality of Care (Recommendation 42)
Recommendation: The Commission supports the Secretary's efforts to
evaluate Medicare risk plans through the use of the Health Plan
Employer Data and Information Set (HEDIS) and satisfaction surveys. The
Secretary should, in cooperation with the appropriate organizations,
continue to adapt and improve measurement tools to evaluate plan
performance.
Response: In addition to our use of HEDIS to evaluate Medicare risk
plans, we will survey all of the enrollees of HMO and CMP contractors
(both risk and cost) on their satisfaction with various aspects of
their plan. This effort is in cooperation with the Agency for Health
Care Policy and Research.
LL. Improving Information for Beneficiary Choice (Recommendation 43)
Recommendation: The Commission supports the Secretary's efforts to
improve beneficiary information about managed care options. All
beneficiaries should receive quality and satisfaction data for risk
plans and the fee-for-service option to help them decide about
enrolling in a risk plan. Cost and benefit definitions should be
standardized so that beneficiaries can better compare plans.
Additionally, the Secretary should periodically assess whether such
information could be improved.
Response: We are continually trying to improve the information
given to the Medicare beneficiary. We are in the process of developing
a comparison chart comparing benefits and charges among HMOs within a
specified service area. Later this year, HEDIS data and consumer survey
results will be released. In addition, HCFA is in the process of
releasing national marketing guidelines that require HMOs to produce
marketing materials that fully disclose, in a clear and understandable
manner, information to be used by the Medicare beneficiary.
The Administration's FY 1998 budget also includes proposals
addressing the provision of information to beneficiaries. It would
require the Secretary to develop and provide comparative information to
beneficiaries on all managed care plans and Medigap plans in their
area, and it would require Medigap and managed care plans to finance
the associated costs. It would also require the Secretary to establish
standardized packages for certain additional benefits offered by
Medicare managed care plans. For example, if the Secretary established
a standardized package for outpatient prescription drugs, plans could
only offer enrollees this benefit according to the benefit structure
established by the Secretary.
IX. 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 format or
cartridges; however, some files are available on diskette, and on the
Internet at HTTP://WWW.HCFA.GOV/STATS/PUBFILES.HTML. Data files are
listed below with the cost of each. Anyone wishing to purchase data
tapes, cartridges, or diskettes should submit a written request along
with a company check or money order (payable to HCFA-PUF) to cover the
cost, to the following address: Health Care Financing Administration,
Public Use Files, Accounting Division, P.O. Box 7520, Baltimore,
Maryland 21207-0520, (410) 786-3691. Files on the Internet may be
downloaded without charge.
1. Expanded Modified MEDPAR-Hospital (National)
The Medicare Provider Analysis and Review (MEDPAR) file contains
records for 100 percent of Medicare beneficiaries using hospital
inpatient services in the United States. (The file is a Federal fiscal
year file which means discharges occurring October 1 through September
30.) The records are stripped of most data elements that will permit
identification of beneficiaries. The hospital is identified by the 6-
position Medicare billing number. The file is available to persons
qualifying under the terms of the Notice of Proposed New Routine Uses
for an Existing System of Records published in the Federal Register on
December 24, 1984 (49 FR 49941), and amended by the July 2, 1985 notice
(50 FR 27361). The national file consists of approximately 11 million
records. Under the requirements of these notices, a data release
agreement must be signed by the purchaser before release of these data.
For all files requiring a signed data release agreement, please write
or call to obtain a blank agreement form before placing an order. Two
versions of this file are created each year. They support the
following:
Notice of Proposed Rulemaking (NPRM) published in the
Federal Register, usually available by the end of May. This file is
derived from the MedPAR file with a cutoff of 3 months
[[Page 29940]]
after the end of the fiscal year (December file).
Final Rule published in the Federal Register, usually
available by the first week of September. This file is derived from the
MedPAR file with a cutoff of 9 months after the end of the fiscal year
(June file).
Media: Tape/Cartridge
File Cost: $3,415.00 per fiscal year
Periods Available: FY 1988 through FY 1996
2. Expanded Modified MedPAR-Hospital (State)
The State MedPAR file contains records for 100 percent of Medicare
beneficiaries using hospital inpatient services in a particular State.
The records are stripped of most data elements that will permit
identification of beneficiaries. The hospital is identified by the 6-
position Medicare billing number. The file is available to persons
qualifying under the terms of the Notice of Proposed New Routine Uses
for an Existing System of Records published in the December 24, 1984
Federal Register notice, and amended by the July 2, 1985 notice. This
file is a subset of the Expanded Modified MedPAR-Hospital (National) as
described above. Under the requirements of these notices, a data
release must be signed by the purchaser before release of these data.
Two versions of this file are created each year. They support the
following:
NPRM published in the Federal Register, usually available
by the end of May. This file is derived from the MedPAR file with a
cutoff of 3 months after the end of the fiscal year (December file).
Final Rule published in the Federal Register, usually
available by the first week of September. This file is derived from the
MedPAR file with a cutoff of 9 months after the end of the fiscal year
(June file).
Media: Tape/Cartridge
File Cost: $1,050.00 per State per year
Periods Available: FY 1988 through FY 1996
3. HCFA Hospital Wage Index Data File
This file is composed of four separate diskettes. Included are: (1)
The hospital hours and salaries for FY 1994 used to create the proposed
FY 1998 prospective payment system wage index; (2) a history of all
wage indexes used since October 1, 1983; (3) a list of State and county
codes used by SSA and FIPS (Federal Information Processing Standards),
county name, and Metropolitan Statistical Area (MSA); and (4) a file of
hospitals that were reclassified for the purpose of the proposed FY
1998 wage index. Two versions of these files are created each year.
They support the following:
NPRM published in the Federal Register, usually by the end
of May.
Final Rule published in the Federal Register, usually by
the first week of September.
Media: Diskette/Internet
File Cost: $500.00
Periods Available: FY 1998 PPS Update
We note that the files also are available individually as indicated
below.
(1) HCFA Hospital Wage Index Survey Only (usually available by the
end of March for the NPRM and the middle of August for the final rule).
(2) Urban and Rural Wage Indices Only.
(3) PPS SSA/FIPS MSA State and County Crosswalk Only (usually
available by the end of March).
(4) Reclassified Hospitals by Provider Only.
Media: Diskette/Internet
File cost: $145.00 per file
4. PPS-IV to PPS-XIII 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, 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
PPS XIII...................................... 10/01/95 10/01/96
------------------------------------------------------------------------
(Note: The PPS XIII Minimum Data Set covering FY 1996 will not
be available until July 31, 1997.)
File Cost: $715.00 per year
5. PPS-IX to PPS-XIII 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
PPS XIII...................................... 10/01/95 10/01/96
------------------------------------------------------------------------
(Note: The PPS XIII Capital Data Set covering FY 1996 will not
be available until July 31, 1997.)
File Cost: $715.00 per year
6. Provider-Specific File
This file is a component of the PRICER program used in the fiscal
intermediary's system to compute DRG payments for individual bills. The
file contains records for all prospective payment system eligible
hospitals, including hospitals in waiver States, and data elements used
in the prospective payment system recalibration processes and related
activities. Beginning with December 1988, the individual records were
enlarged to include pass-through per diems and other elements.
Media: Tape/Cartridge
File Cost: $500.00 per file
Periods Available: FY 1987 through FY 1997 (December updates)
Media: Diskette/Internet
File Cost: $265.00
Periods Available: FY 1997 PPS Update
7. HCFA Medicare Case-Mix Index File
This file contains the Medicare case-mix index by provider number
as published in each year's update of the Medicare hospital inpatient
prospective payment system. The case-mix index is a measure of the
costliness of cases treated by a hospital relative to the cost of the
national average of all Medicare hospital cases, using DRG weights as a
measure of relative costliness of cases. Two versions of this file are
created each year. They support the following:
NPRM published in the Federal Register, usually by the end
of May.
Final rule published in the Federal Register, usually by
the first week of September.
Media: Diskette/Internet
[[Page 29941]]
Price: $145.00 per year
Periods Available: FY 1985 through FY 1996 (Internet--FY 1996)
8. Table 5 DRG File
This file contains a listing of DRGs, DRG narrative description,
relative weight, 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: a. NPRM, usually published by the end of May. b.
Final rule, usually published by the first week of September.
Media: Diskette/Internet
File Cost: $145.00
Periods Available: FY 1998 PPS Update
9. PPS Payment Impact File
This file contains data used to estimate payments under Medicare's
hospital inpatient prospective payment systems for operating and
capital-related costs. The data are taken from various sources,
including the Provider-Specific File, Minimum Data Sets, and prior
impact files. The data set is abstracted from an internal file used for
the impact analysis of the changes to the prospective payment systems
published in the Federal Register. This file is available for release 1
month after the proposed and final rules are published in the Federal
Register.
Media: Diskette/Internet
File Cost: $145.00
Periods Available: FY 1998 PPS Update
10. AOR/BOR Tables
This file contains data used to develop the DRG relative weights.
It contains mean, maximum, minimum, standard deviation, and coefficient
of variation statistics by DRG for length of stay and standardized
charges. The BOR tables are ``Before Outliers Removed'' and the AOR is
``After Outliers Removed.'' (Outliers refers to statistical outliers,
not payment outliers.) Two versions of this file are created each year.
They support the following:
NPRM published in the Federal Register, usually by the end
of May.
Final rule published in the Federal Register, usually by
the first week of September.
Media: Diskette/Internet
File Cost: $145.00
Periods Available: FY 1998 PPS Update
11. HCFA FY 1992 Capital-Related Tax File
This file contains data used to develop a proposed FY 1996 special
property tax adjustment to the capital prospective payment system for
capital-related costs. This proposed adjustment was not implemented.
The data set includes a preliminary hospital-specific add-on amount for
all PPS hospitals. The data set also contains the information used to
propose an adjustment to the Federal rate so that the tax add-on is
budget neutral. The proposed property tax adjustment provides special
treatment to qualified hospitals who pay capital-related property
taxes. The add-on was determined using base year tax costs per
discharge attributable to Medicare. The data are taken from the FY 1992
Medicare hospital cost report and a special request for validation by
the fiscal intermediaries.
Media: Diskette
File cost: $145.00
Period available: FY 1992
For further information concerning these data tapes, contact Mary
R. White at (410) 786-0168.
Commenters interested in obtaining or discussing any other data
used in constructing this rule should contact Stephen Phillips at (410)
786-4548.
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 1998 be published by
September 1, 1997, we will consider only those comments that deal
specifically with the matters discussed in this proposed rule. Subject
to the provisions of the Contract With America Advancement Act of 1996,
(Pub. L. 104-121), these changes would be applicable to discharges
occurring on or after October 1, 1997.
List of Subjects
42 CFR Part 412
Administrative practice and procedure, Health facilities, Medicare,
Puerto Rico, Reporting and recordkeeping requirements.
42 CFR Part 413
Health facilities, Kidney diseases, Medicare, Puerto Rico,
Reporting and recordkeeping requirements.
42 CFR Part 489
Health facilities, Medicare, Reporting and recordkeeping
requirements.
42 CFR chapter IV would be amended as set forth below:
A. Part 412 is amended as follows:
PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL
SERVICES
1. The authority citation for part 412 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
2. Section 412.22 is amended by adding new paragraphs (e), (f),
(g), and (h) to read as follows:
Sec. 412.22 Excluded hospitals and hospital units: General rules.
* * * * *
(e) Hospitals within hospitals. Except as provided in paragraph (f)
of this section, for cost reporting periods beginning on or after
October 1, 1994, a hospital that occupies space 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, must meet the
following criteria:
(1) Separate governing body. The hospital has a governing body that
is separate from the governing body of the hospital occupying space in
the same building or on the same campus. The hospital's governing body
is not under the control of the hospital occupying space in the same
building or on the same campus, or of any third entity that controls
both hospitals.
(2) Separate chief medical officer. The hospital has a single chief
medical officer who reports directly to the governing body and who is
responsible for all medical staff activities of the hospital. The chief
medical officer of the hospital is not employed by or under contract
with either the hospital occupying space in the same building or on the
same campus or any third entity that controls both hospitals.
(3) Separate medical staff. The hospital has a medical staff that
is separate from the medical staff of the hospital occupying space in
the same building or on the same campus. The hospital's medical staff
is directly accountable to the governing body for the quality of
medical care provided in the hospital, and adopts and enforces bylaws
governing medical staff activities, including criteria and procedures
for recommending to the governing body the privileges to be granted to
individual practitioners.
[[Page 29942]]
(4) Chief executive officer. The hospital has a single chief
executive officer through whom all administrative authority flows, and
who exercises control and surveillance over all administrative
activities of the hospital. The chief executive office is not employed
by, or under contract with, either the hospital occupying space in the
same building or on the same campus or any third entity that controls
both hospitals.
(5) Performance of basic hospital functions. The hospital meets one
of the following criteria:
(i) The hospital performs the basic functions specified in
Secs. 482.21 through 482.27, 482.30, and 482.42 of this chapter through
the use of employees or under contracts or other agreements with
entities other than the hospital occupying space in the same building
or on the same campus, or a third entity that controls both hospitals.
Food and dietetic services and housekeeping, maintenance, and other
services necessary to maintain a clean and safe physical environment
could be obtained under contracts or other agreements with the hospital
occupying space in the same building or on the same campus, or with a
third entity that controls both hospitals.
(ii) For the same period of at least 6 months used to determine
compliance with the length-of-stay criterion in Sec. 412.23(e)(2), the
cost of the services that the hospital obtained under contracts or
other agreements with the hospital occupying space in the same building
or on the same campus, or with a third entity that controls both
hospitals, is no more than 15 percent of the hospital's total inpatient
operating costs, as defined in Sec. 412.2(c). For purposes of this
paragraph (e)(5)(ii), however, the costs of preadmission services are
those specified under Sec. 413.40(c)(2) rather than those specified
under Sec. 412.2(b)(5).
(iii) For the same period of at least 6 months used to determine
compliance with the length-of-stay criterion in Sec. 412.23(e)(2), the
hospital has an inpatient population of whom at least 75 percent were
referred to the hospital from a source other than another hospital
occupying space in the same building or on the same campus.
(f) Special provision for certain hospitals. If a hospital cannot
meet the criteria in paragraph (e)(1) or (e)(3) of this section solely
because its governing body or medical staff is under the control of a
third entity that also controls the hospital with which it shares a
building or campus, or cannot meet the criteria in paragraph (e)(2) or
(e)(4) of this section solely because its chief medical officer or
chief executive officer is employed by or under contract with such a
third entity, the hospital can nevertheless qualify for an exclusion if
it meets other applicable criteria and--
(1) Is owned and operated by a State university, and has been
continuously owned and operated by that university since October 1,
1994;
(2) Is required by State law to be subject to the ultimate
authority of the university's governing body; and
(3) Was excluded from the prospective payment systems under this
section for any cost reporting period beginning on or after October 1,
1993, but before October 1, 1994.
(g) Effective date for certain hospitals. If a hospital has been
excluded from the prospective payment systems under this section for
any cost reporting period beginning on or after October 1, 1993, but
before October 1, 1994, the criteria in paragraph (e) of this section
do not apply to the hospital until the hospital's first cost reporting
period beginning on or after October 1, 1995.
(h) Definition of control. For purposes of this section, control
exists if an individual or an organization has the power, directly or
indirectly, significantly to influence or direct the actions or
policies of an organization or institution.
Sec. 412.23 [Amended]
3. Section 412.23 is amended by removing paragraphs (e)(3) through
(e)(5).
4. Section 412.30 is amended by redesignating paragraphs (a)
through (d) as paragraphs (b) through (e), respectively, and adding a
new paragraph (a). Redesignated paragraph (b) is further amended by
redesignating paragraph (b)(4) as paragraph (b)(5), and adding a new
paragraph (b)(4) to read as follows:
Sec. 412.30 Exclusion of new rehabilitation units and expansion of
units already excluded.
(a) Bed capacity in units. A decrease in bed capacity must remain
in effect for at least a full 12-month cost reporting period before an
equal or lesser number of beds can be added to the hospital's licensure
and certification and considered ``new'' under paragraph (b) of this
section. Thus, when a hospital seeks to establish a new unit under the
criteria under paragraph (b) of this section, or to enlarge an existing
unit under the criteria under paragraph (d) of this section, the
regional office will review its records on the facility to determine
whether any beds have been delicensed and decertified during the 12-
month cost reporting period before the period for which the hospital
seeks to add the beds. To the extent bed capacity was removed from the
hospital's licensure and certification during that period, that amount
of bed capacity may not be considered ``new'' under paragraph (b) of
this section.
(b) New units.
(5) * * *
* * * * *
(4) If a hospital that has not previously participated in the
Medicare program seeks exclusion of a rehabilitation unit, it may
designate certain beds as a new rehabilitation unit for the first full
12-month cost reporting period that occurs after it becomes a Medicare-
participating hospital. The written certification described in
paragraph (b)(2) of this section also is effective for any cost
reporting period of not less than 1 month and not more than 11 months
occurring between the date the hospital began participating in Medicare
and the start of the hospital's regular 12-month cost reporting period.
* * * * *
5. Section 412.80 is revised to read as follows:
Sec. 412.80 General provisions.
(a) Basic rule--(1) Discharges occurring on or after October 1,
1994 and before October 1, 1997. For discharges occurring on or after
October 1, 1994, and before October 1, 1997, except as provided in
paragraph (b) of this section concerning transferring hospitals, HCFA
provides for additional payment, beyond standard DRG payments, to a
hospital for covered inpatient hospital services furnished to a
Medicare beneficiary if either of the following conditions is met:
(i) The beneficiary's length of stay (including days at the SNF
level of care if a SNF bed is not available in the area) exceeds the
mean length-of-stay for the applicable DRG by the lesser of the
following:
(A) A fixed number of days, as specified by HCFA; or
(B) A fixed number of standard deviations, as specified by HCFA.
(ii) The beneficiary's length of stay does not exceed criteria
established under paragraph (a)(1)(i) of this section, but the
hospital's charges for covered services furnished to the beneficiary,
adjusted to operating costs and capital costs by applying cost-to-
charge ratios as described in Sec. 412.84(h), exceed the DRG payment
for the case plus a fixed dollar amount (adjusted for geographic
variation in costs) as specified by HCFA.
(2) Discharges occurring on or after October 1, 1997. For
discharges occurring on or after October 1, 1997,
[[Page 29943]]
except as provided in paragraph (b) of this section concerning
transfers, HCFA provides for additional payment, beyond standard DRG
payments, to a hospital for covered inpatient hospital services
furnished to a Medicare beneficiary if the hospital's charges for
covered services, adjusted to operating costs and capital costs by
applying cost-to-charge ratios as described in Sec. 412.84(h), exceed
the DRG payment for the case plus a fixed dollar amount (adjusted for
geographic variation in costs) as specified by HCFA.
(b) Outlier cases in transferring hospitals. HCFA provides cost
outlier payments to a transferring hospital that does not receive
payment under Sec. 412.2(b) for discharges specified in
Sec. 412.4(d)(2), if the hospital's charges for covered services
furnished to the beneficiary, adjusted to cost by applying a national
cost/charge ratio, exceed the DRG payment for the case plus a fixed
dollar amount (adjusted for geographic variation in costs) as specified
by HCFA, divided by the geometric mean length of stay for the DRG and
multiplied by the beneficiary's length of stay plus 1 day.
(c) Publication and revision of outlier criteria. HCFA will issue
threshold criteria for determining outlier payment in the annual notice
of the prospective payment rates published in accordance with
Sec. 412.8(b).
(d) Relation to hospitals that incur indirect costs for graduate
medical education programs and that serve as disproportionate share of
low-income patients. The outlier payment amounts are included in total
DRG revenue for purposes of determining payments to hospitals that
incur indirect costs for graduate medical education programs under
Sec. 412.105 and to hospitals that serve a disproportionate share of
low-income patients under Sec. 412.106.
Sec. 412.82 [Amended]
6. In Sec. 412.82(a), in the first sentence, the word ``If'' is
removed and the phrase ``For discharges occurring before October 1,
1997, if'' is added in its place.
Sec. 412.84 [Amended]
7. In Sec. 412.84 in the first sentence of paragraph (a), the
reference ``Sec. 412.80(a)(1)(ii)'' is revised to read
``Sec. 412.80(a)''.
Sec. 412.86 [Amended]
8. In the introductory text to Sec. 412.86, the word ``If'' is
removed and the phrase ``For discharges occurring before October 1,
1997, if'' is added in its place.
9. In Sec. 412.96, the introductory text of paragraph (c)(1) is
revised to read as follows:
Sec. 412.96 Special treatment: Referral centers.
* * * * *
(c) * * *
(1) Case mix index. HCFA sets forth national and regional case-mix
index values in each year's annual notice of prospective payment rates
published under Sec. 412.8(b). The methodology HCFA uses to calculate
these criteria is described in paragraph (g) of this section. The case-
mix index value to be used for an individual hospital in the
determination of whether it meets the case-mix index criteria is that
calculated by HCFA from the hospital's own billing records for Medicare
discharges as processed by the fiscal intermediary and submitted to
HCFA. The hospital's case-mix index for discharges (not including
discharges from units excluded from the prospective payment system
under subpart B of this part) during the most recent Federal fiscal
year that ended at least one year prior to the beginning of the cost
reporting period for which the hospital is seeking referral center
status must be at least equal to--
* * * * *
10. In Sec. 412.105, paragraph (g)(1)(i) is republished, paragraph
(g)(1)(i)(B) is revised, and paragraph (g)(1)(iv) is removed, to read
as follows:
Sec. 412.105 Special treatment: Hospitals that incur indirect costs
for graduate medical education programs.
* * * * *
(g) Determining the total number of full-time equivalent residents
for cost reporting periods beginning on or after July 1, 1991.
(1) For cost reporting periods beginning on or after July 1, 1991,
the count of full-time equivalent residents for the purpose of
determining the indirect medical education adjustment is determined as
follows:
(i) The residents must be enrolled in an approved teaching program.
An approved teaching program is one that meets one of the following
requirements:
* * * * *
(B) May count towards certification of the participant in a
specialty or subspecialty listed in the current edition of either of
the following publications:
(1) The Directory of Graduate Medical Education Programs published
by the American Medical Association.
(2) The Annual Report and Reference Handbook published by the
American Board of Medical Specialties.
* * * * *
B. Part 413 is amended as set forth below:
PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR
END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED
PAYMENT RATES FOR SKILLED NURSING FACILITIES
1. The authority citation for Part 413 continues to read as
follows:
Authority: Secs. 1102, 1861(v)(1)(A), and 1871 of the Social
Security Act (42 U.S.C. 1302, 1395x(v)(1)(A), and 1395hh).
2. In Sec. 413.86, paragraph (e)(4)(i)(B) is revised to read as
follows:
Sec. 413.86 Direct graduate medical education payments.
* * * * *
(e) Determining per resident amounts for the base period. * * *
(4) Exceptions.
(i) Base period for certain hospitals. * * *
(B) The mean value of per resident amounts of hospitals located in
the same geographic wage area, as that term is used in the prospective
payment system under part 412 of this chapter, for cost reporting
periods beginning in the same fiscal years. If there are fewer than
three amounts that can be used to calculate the mean value, the
calculation of the per resident amounts includes all hospitals in the
hospital's geographic wage area and in geographically contiguous wage
areas. If there are still fewer than three hospitals with per resident
amounts in the hospital's own wage area, plus contiguous wage areas,
this calculation will include all hospitals with per resident amounts
in the State. If there are fewer than three hospitals with per resident
amounts in the State, this calculation will include the per resident
amounts for all hospitals in the State plus hospitals in contiguous
States. If there are still fewer than three hospitals in that State
plus contiguous States, this calculation will be based on the national
average per resident amount.
* * * * *
C. Part 489 is amended as set forth below:
PART 489--PROVIDER AGREEMENTS AND SUPPLIER APPROVAL
1. The authority citation for Part 489 continues to read as
follows:
Authority: Secs. 1102, 1819, 1861, 1864(m), 1866, and 1871 of
the Social Security Act (42 U.S.C. 1302, 1395i-3, 1395x, 1395aa(m),
1395cc, and 1395hh).
[[Page 29944]]
Sec. 489.27 [Amended]
2. In Sec. 489.27, the reference ``section 1886(a)(1)(M) of the
Act'' is revised to read ``section 1866(a)(1)(M) of the Act''.
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance)
Dated: May 1, 1997.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
Dated: May 23, 1997.
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, 1997 and Update Factors and
Rate-of-Increase Percentages Effective With Cost Reporting Periods
Beginning on or After October 1, 1997
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, 1997, except for
sole community hospitals and hospitals located in Puerto Rico, each
hospital's payment per discharge under the prospective payment
system will be based on 100 percent of the Federal national rate.
Sole community hospitals are paid based on whichever of the
following rates yields the greatest aggregate payment: The Federal
national rate, the updated hospital-specific rate based on FY 1982
cost per discharge, or the updated hospital-specific rate based on
FY 1987 cost per discharge. For hospitals in Puerto Rico, the
payment per discharge is based on the sum of 75 percent of a Puerto
Rico rate and 25 percent of a national rate (section 1886(d)(9)(A)
of the Act).
As discussed below in section II, we are proposing to make
changes in the determination of the prospective payment rates for
Medicare inpatient operating costs. The changes, to be applied
prospectively, would affect the calculation of the Federal rates. In
section III, we discuss our proposed changes for determining the
prospective payment rates for Medicare inpatient capital-related
costs. Section IV sets forth our proposed changes for determining
the rate-of-increase limits for hospitals excluded from the
prospective payment system. The tables to which we refer in the
preamble to the proposed rule are presented at the end of this
addendum in section V.
II. Proposed Changes to Prospective Payment Rates for Inpatient
Operating Costs for FY 1998
The basic methodology for determining prospective payment rates
for inpatient operating costs is set forth at Sec. 412.63 for
hospitals located outside of Puerto Rico. The basic methodology for
determining the prospective payment rates for inpatient operating
costs for hospitals located in Puerto Rico is set forth at
Secs. 412.210 and 412.212. Below, we discuss the manner in which we
are changing some of the factors used for determining the
prospective payment rates. The Federal and Puerto Rico rate changes,
once issued as final, would be effective with discharges occurring
on or after October 1, 1997. 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 1998.
In summary, the proposed standardized amounts set forth in
Tables 1A and 1C of section V of this addendum reflect--
Updates of 2.8 percent for all areas (that is, the
market basket percentage increase);
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 1997
budget neutrality factor and applying a revised factor;
An adjustment to apply the revised outlier offset by
removing the FY 1997 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 that Medicare
target amounts be determined for each hospital located in Puerto
Rico for its cost reporting period beginning in FY 1987. The
September 1, 1987 final rule contains a detailed explanation of how
the target amounts were determined and how they are used in
computing the Puerto Rico rates (52 FR 33043, 33066).
The standardized amounts are based on per discharge averages of
adjusted hospital costs from a base period or, for Puerto Rico,
adjusted target amounts from a base period, updated and otherwise
adjusted in accordance with the provisions of section 1886(d) of the
Act. Sections 1886(d)(2) (B) and (C) of the Act required that the
base-year per discharge costs be updated for FY 1984 and then
standardized in order to remove from the cost data the effects of
certain sources of variation in cost among hospitals. These include
case mix, differences in area wage levels, cost of living
adjustments for Alaska and Hawaii, indirect medical education costs,
and payments to hospitals serving a disproportionate share of low-
income patients.
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, 1996, when the market
basket was last revised and rebased, we have considered 71.2 percent
of costs to be labor-related for purposes of the prospective payment
system. As discussed in section IV of the preamble, we are proposing
to include data not available when the market basket was last
rebased to adjust the market basket effective for FY 1998. Based on
the proposed revised market basket, we are revising the labor and
nonlabor proportions of the standardized amounts. Effective with
discharges occurring on or after October 1, 1997, we are proposing a
labor-related proportion of 71.1 percent and a nonlabor-related
proportion of 28.9 percent. (We are revising the Puerto Rico
standardized amounts by the average labor share in Puerto Rico of
71.3 percent. We are revising the discharged-weighted national
standardized amount to reflect the proportion of discharges in large
urban and other areas from the FY 1996 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 75 percent of the applicable Puerto Rico
standardized amount and 25 percent of a national standardized
payment amount.
Section 1886(d)(2)(D) of the Act defines ``urban 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
[[Page 29945]]
based on the large urban standardized amount. Payment for discharges
from hospitals located in other urban and rural areas will be based
on the other standardized amount.
Based on 1995 population estimates published by the Bureau of
the Census, 56 areas meet the criteria to be defined as large urban
areas for FY 1998. These areas are identified by an asterisk 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 and the other areas average standardized amounts for FY 1998
using the applicable percentage increases specified in section
1886(b)(3)(B)(i) of the Act. Section 1886(b)(3)(B)(i)(XIII) of the
Act specifies that, for hospitals in all areas, the update factor
for the standardized amounts for FY 1998 is equal to the market
basket percentage increase.
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
revised hospital market basket increase for FY 1998 is 2.8 percent.
Thus, for FY 1998, the proposed update to the average standardized
amounts equals 2.8 percent. (See section IV. of the preamble of this
proposed rule for a discussion of the adjustments to the market
basket.)
As in the past, we are adjusting the FY 1997 standardized
amounts to remove the effects of the FY 1997 geographic
reclassifications and outlier payments before applying the FY 1998
updates. That is, we are increasing the standardized amounts to
restore the reductions that were made for the effects of geographic
reclassification and outliers. After including offsets to the
standardized amounts for outliers and geographic reclassification,
we estimate that there will be an overall increase of 2.9 percent to
the large urban and other area standardized amounts.
Although the update factor for FY 1998 is set by law, we are
required by section 1886(e)(3)(B) of the Act to report to Congress
on our initial recommendation of update factors for FY 1998 for both
prospective payment hospitals and hospitals excluded from the
prospective payment system. For general information purposes, we
have included the report to Congress as Appendix D to this proposed
rule. Our proposed recommendation on the update factors (which is
required by sections 1886 (e)(4)(A) and (e)(5)(A) of the Act), as
well as our responses to ProPAC's recommendation concerning the
update factor, are set forth as Appendix E to this proposed rule.
4. Other Adjustments to the Average Standardized Amounts
a. Recalibration of DRG Weights and Updated Wage Index--Budget
Neutrality Adjustment. Section 1886(d)(4)(C)(iii) of the Act
specifies that beginning in FY 1991, the annual DRG reclassification
and recalibration of the relative weights must be made in a manner
that ensures that aggregate payments to hospitals are not affected.
As discussed in section II of the preamble, we normalized the
recalibrated DRG weights by an adjustment factor, so that the
average case weight after recalibration is equal to the average case
weight prior to recalibration.
Section 1886(d)(3)(E) of the Act specifies that the hospital
wage index must be updated on an annual basis beginning October 1,
1993. This provision also requires that any updates or adjustments
to the wage index must be made in a manner that ensures that
aggregate payments to hospitals are not affected by the change in
the wage index.
To comply with the requirement of section 1886(d)(4)(C)(iii) of
the Act that DRG reclassification and recalibration of the relative
weights be budget neutral, and the requirement in section
1886(d)(3)(E) of the Act that the updated wage index be budget
neutral, we used historical discharge data to simulate payments and
compared aggregate payments using the FY 1997 relative weights and
wage index to aggregate payments using the proposed FY 1998 relative
weights and wage index. The same methodology was used for the FY
1997 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 0.998400. We 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 0.999224. These budget
neutrality adjustment factors are applied to the standardized
amounts without removing the effects of the FY 1997 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 continue to apply the same FY
1998 adjustment factor to the hospital-specific rates that are
effective for cost reporting periods beginning on or after October
1, 1997, in order to ensure that we meet the statutory requirement
that aggregate payments neither increase nor decrease as a result of
the implementation of the FY 1998 DRG weights and updated wage
index. (See the discussion in the September 4, 1990 final rule (55
FR 36073).)
b. Reclassified Hospitals--Budget Neutrality Adjustment. Section
1886(d)(8)(B) of the Act provides that certain rural hospitals are
deemed urban effective with discharges occurring on or after October
1, 1988. In addition, section 1886(d)(10) of the Act provides for
the reclassification of hospitals based on determinations by the
Medicare Geographic Classification Review Board (MGCRB). Under
section 1886(d)(10) of the Act, a hospital may be reclassified for
purposes of the standardized amount or the wage index, or both.
Under section 1886(d)(8)(D) of the Act, the Secretary is
required to adjust the standardized amounts so as to ensure that
total aggregate payments under the prospective payment system after
implementation of the provisions of sections 1886(d)(8) (B) and (C)
and 1886(d)(10) of the Act are equal to the aggregate prospective
payments that would have been made absent these provisions. To
calculate this budget neutrality factor, we used historical
discharge data to simulate payments, and compared total prospective
payments (including IME and DSH payments) prior to any
reclassifications to total prospective payments after
reclassifications. We are applying an adjustment factor of 0.995127
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 1997 budget neutrality
adjustment factor. We note that the proposed FY 1998 adjustment
reflects wage index and standardized amount reclassifications
approved by the MGCRB or the Administrator as of February 27, 1997.
The effects of any additional reclassification changes resulting
from appeals and reviews of the MGCRB decisions for FY 1998 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 1998.
c. Outliers. Section 1886(d)(5)(A) of the Act provides for
payments in addition to the basic prospective payments for
``outlier'' cases, cases involving extraordinarily high costs (cost
outliers) or long lengths of stay (day outliers). Section
1886(d)(3)(B) of the Act requires the Secretary to adjust both the
large urban and other area national standardized amounts by the same
factor to account for the estimated proportion of total DRG payments
made to outlier cases. Similarly, section 1886(d)(9)(B)(iv) of the
Act requires the Secretary to adjust the large urban and other
standardized amounts applicable to hospitals in Puerto Rico to
account for the estimated proportion of total DRG payments made to
outlier cases. Furthermore, under section 1886(d)(5)(A)(iv) of the
Act, outlier payments for any year must be projected to be not less
than 5 percent nor more than 6 percent of total payments based on
DRG prospective payment rates.
Beginning with FY 1995, section 1886(d)(5)(A) of the Act
requires the Secretary to phase out payments for day outliers
(correspondingly, payments for cost outliers would increase). Under
the requirements of section 1886(d)(5)(A)(v), the proportion of day
outlier payments to total outlier payments is reduced from FY 1994
levels as follows: 75 percent of FY 1994 levels in FY 1995, 50
percent of FY 1994 levels in FY 1996, and 25 percent of FY 1994
levels in FY 1997. For discharges occurring after September 30,
1997, the Secretary will no longer pay for day outliers under the
provisions of section 1886(d)(5)(A)(i) of the Act.
i. Proposed FY 1998 Outlier Payment Thresholds. For FY 1997, the
day outlier threshold is the geometric mean length of stay for each
DRG plus the lesser of 24 days
[[Page 29946]]
or 3.0 standard deviations. The marginal cost factor for day
outliers (the percent of Medicare's average per diem payment paid
for each outlier day) is 33 percent for FY 1997. The fixed loss cost
outlier threshold is equal to the prospective payment for the DRG
plus $9,700 ($8,850 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 1997 standardized amounts of 0.948766
for the large urban and other areas rates and 0.9481 for the capital
Federal rate.
As noted above, section 1886(d)(5)(A)(v) of the Act provides
that payment will not be made for day outliers beginning with
discharges occurring in FY 1998.
We are proposing a fixed loss cost outlier threshold in FY 1998
equal to the prospective payment rate for the DRG plus $7,600
($6,950 for hospitals that have not yet entered the prospective
payment system for capital-related costs). In addition, we are
proposing to maintain the marginal cost factor for cost outliers at
80 percent.
In accordance with section 1886(d)(5)(A)(iv) of the Act, we
calculated proposed outlier thresholds so that outlier payments are
projected to equal 5.1 percent of total payments based on DRG
prospective payment rates. In accordance with section 1886(d)(3)(E),
we reduced the proposed FY 1998 standardized amounts by the same
percentage to account for the projected proportion of payments paid
to outliers.
As stated in the September 1, 1993 final rule (58 FR 46348), we
establish outlier thresholds that are applicable to both inpatient
operating costs and inpatient capital-related costs. When we modeled
the combined operating and capital outlier payments, we found that
using a common set of thresholds resulted in a higher percentage of
outlier payments for capital-related costs than for operating costs.
We project that the proposed thresholds for FY 1998 will result in
outlier payments equal to 5.1 percent of operating DRG payments and
5.5 percent of capital payments based on the Federal rate.
The proposed outlier adjustment factors applied to the
standardized amounts for FY 1998 are as follows:
------------------------------------------------------------------------
Operating
standardized
amounts
------------------------------------------------------------------------
National.................................................. 0.949117
Puerto Rico............................................... 0.961488
------------------------------------------------------------------------
(Note: The proposed outlier adjustment factors applied to the
capital Federal rate are found at section III.A.2. of the Addendum.)
We would apply the proposed outlier adjustment factors after
removing the effects of the FY 1997 outlier adjustment factors on
the standardized amounts.
ii. Other Changes Concerning Outliers. Table 8A in section V of
this addendum contains the updated Statewide average operating cost-
to-charge ratios for urban hospitals and for rural hospitals to be
used in calculating cost outlier payments for those hospitals for
which the intermediary is unable to compute a reasonable hospital-
specific cost-to-charge ratio. These Statewide average ratios would
replace the ratios published in the August 30, 1996 final rule (61
FR 46302), effective October 1, 1997. 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 0.230118 or greater than 1.30054 and
capital cost-to-charge ratios lower than 0.01289 or greater than
0.19057. This range represents 3.0 standard deviations (plus or
minus) from the mean of the log distribution of cost-to-charge
ratios for all hospitals. We note that the cost-to-charge ratios in
Tables 8A and 8B would be used for all cost reports settled during
FY 1998 (regardless of the actual cost reporting period) when
hospital-specific cost-to-charge ratios are either not available or
outside the three standard deviations range.
iii. FY 1996 and FY 1997 Outlier Payments. In the August 30,
1996 final rule (61 FR 46229), we stated that, based on available
data, we estimated that actual FY 1996 outlier payments would be
approximately 4.0 percent of actual total DRG payments. This was
computed by simulating payments using actual FY 1995 bill data
available at the time. That is, the estimate of actual outlier
payments did not reflect actual FY 1996 bills but instead reflected
the application of FY 1996 rates and policies to available FY 1995
bills. Our current estimate, using available FY 1996 bills, is that
actual outlier payments for FY 1996 were approximately 4.1 percent
of actual total DRG payments. We note that the MedPAR file for FY
1996 discharges continues to be updated.
We currently estimate that actual outlier payments for FY 1997
will be approximately 4.9 percent of actual total DRG payments
(slightly lower than the 5.1 percent we projected in setting outlier
policies for FY 1997). This estimate is based on simulations using
the December 1996 update of the provider-specific file and the
December 1996 update of the FY 1996 MedPAR file (discharge data for
FY 1996 bills). We used these data to calculate an estimate of the
actual outlier percentage for FY 1997 by applying FY 1997 rates and
policies to available FY 1996 bills.
In FY 1994, we began using a cost inflation factor rather than a
charge inflation factor to update billed charges for purposes of
estimating outlier payments. This refinement was made to improve our
estimation methodology. We believe that actual FY 1996 and FY 1997
outlier payments as a percentage of total DRG payments may be lower
than expected in part because actual hospital costs may be lower
than reflected in the methodology used to set outlier thresholds for
those years. Our most recent data on hospital costs show that rates
of increase are continuing to decline. Thus, the cost inflation
factor of 0.871 percent used to set FY 1996 outlier policy (based on
the best data then available) appears to have been overstated. For
FY 1997, we used a cost inflation factor of minus 1.906 percent (a
cost per case decrease of 1.906 percent). For FY 1998, based on more
recent data, we are proposing a cost inflation factor of minus 1.969
percent to set outlier thresholds. We will reevaluate this factor
when we develop the final rule for FY 1998. At that time, more
recent data should be available for analysis, specifically, cost
report data for cost reporting periods beginning in FY 1996.
Although we estimate that FY 1996 outlier payments will
approximate 4.1 percent of total DRG payments, we note that the
estimate of the market basket rate of increase used to set the FY
1996 rates was 3.5 percentage points, while the latest FY 1996
market basket rate of increase forecast is 2.7 percent. Thus, the
net effect is that hospitals received higher FY 1996 payments than
would have been established based on a more recent forecast of the
market basket rate of increase.
5. FY 1998 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 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.
The Puerto Rico standardized amounts reflect application of
Puerto Rico-specific wage index for FY 1998. Thus, before
application of the wage index, the proposed FY 1998 Puerto Rico
standardized amounts are lower than the FY 1997 standardized
amounts. However, after application of the wage index, the FY 1998
Puerto Rico rate is higher than for FY 1997. This is due to the
higher Puerto Rico wage index values that will be applied to these
standardized amounts in calculating the FY 1998 Puerto Rico rate.
Below, we use two wage areas to illustrate that the proposed FY 1998
Puerto Rico wage-adjusted standardized amounts are higher than the
FY 1997 Puerto Rico wage-adjusted standardized amounts.
[[Page 29947]]
Puerto Rico Standardized Amounts
----------------------------------------------------------------------------------------------------------------
FY 1997 Proposed FY 1998
Area ---------------------------------------------------------------
Labor Nonlabor Labor Nonlabor
----------------------------------------------------------------------------------------------------------------
Large Urban..................................... $2,488.70 $518.65 $1,346.08 $541.83
Other Areas..................................... 2,449.31 510.45 1,324.77 533.25
----------------------------------------------------------------------------------------------------------------
Puerto Rico Wage Adjusted Standardized Amount for the San Juan MSA and
Rural Puerto Rico
------------------------------------------------------------------------
Proposed FY
FY 1997 1998
------------------------------------------------------------------------
San Juan Wage Index..................... 0.4506 1.0273
Wage-Adjusted Standardized Amount....... $1,640.06 $1,924.66
Rural Wage Index........................ 0.4026 0.8732
Wage-Adjusted Standardized Amount....... $1,496.54 $1,690.04
------------------------------------------------------------------------
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 require
that an adjustment be made to the labor-related portion of the
prospective payment rates to account for area differences in
hospital wage levels. This adjustment is made by multiplying the
labor-related portion of the adjusted standardized amounts by the
appropriate wage index for the area in which the hospital is
located. In section III of the preamble, we discuss certain
revisions we are making to the wage index. These changes include the
calculation of a Puerto Rico-specific wage index that would be
applied to the Puerto Rico standardized amounts. The 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 1998, we propose to adjust the payments for hospitals in
Alaska and Hawaii by multiplying the nonlabor portion of the
standardized amounts by the appropriate adjustment factor contained
in the table below. If the Office of Personnel Management releases
revised cost-of-living adjustment factors before August 1, 1997, we
will publish them in the final rule and use them in determining FY
1998 payments.
Table of Cost-of-Living Adjustment Factors, Alaska and Hawaii Hospitals
------------------------------------------------------------------------
------------------------------------------------------------------------
Alaska--All areas............................................. 1.25
Hawaii:
County of Honolulu.......................................... 1.225
County of Hawaii............................................ 1.15
County of Kauai............................................. 1.225
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 V of this addendum
contains the relative weights that we propose to use for discharges
occurring in FY 1998. These factors have been recalibrated as
explained in section II. of the preamble.
D. Calculation of Prospective Payment Rates for FY 1998
General Formula for Calculation of Prospective Payment Rates for FY
1998
Prospective payment rate for all hospitals located outside
Puerto Rico except sole community hospitals = Federal rate.
Prospective payment rate for sole community hospitals =
Whichever of the following rates yields the greatest aggregate
payment: 100 percent of the Federal rate, 100 percent of the updated
FY 1982 hospital-specific rate, or 100 percent of the updated FY
1987 hospital-specific rate.
Prospective payment rate for Puerto Rico = 75 percent of the
Puerto Rico rate + 25 percent of a discharge-weighted average of the
national large urban standardized amount and the national other
standardized amount.
1. Federal Rate
For discharges occurring on or after October 1, 1997 and before
October 1, 1998, except for sole community hospitals and hospitals
in Puerto Rico, the hospital's payment is based exclusively on the
Federal national rate. Section 1866(d)(1)(A)(iii) of the Act
provides that the Federal rate is comprised of 100 percent of the
Federal national rate.
The payment amount is determined as follows:
Step 1--Select the appropriate national standardized amount
considering the type of hospital and designation of the hospital as
large urban or other (see Tables 1A, section V of this addendum).
Step 2--Multiply the labor-related portion of the standardized
amount by the applicable wage index for the geographic area in which
the hospital is located (see Tables 4A, 4B, and 4C of section V of
this addendum).
Step 3--For hospitals in Alaska and Hawaii, multiply the
nonlabor-related portion of the standardized amount by the
appropriate cost-of-living adjustment factor.
Step 4--Add the amount from Step 2 and the nonlabor-related
portion of the standardized amount (adjusted if appropriate under
Step 3).
Step 5--Multiply the final amount from Step 4 by the relative
weight corresponding to the appropriate DRG (see Table 5 of section
V of this addendum).
2. Hospital-Specific Rate (Applicable Only to Sole Community Hospitals)
Sections 1886(d)(5)(D)(i) and (b)(3)(C) of the Act provide that
sole community hospitals are paid based on whichever of the
following rates yields the greatest aggregate payment: the Federal
rate, the updated hospital-specific rate based on FY 1982 cost per
discharge, or the updated hospital-specific rate based on FY 1987
cost per discharge.
Hospital-specific rates have been determined for each of these
hospitals based on both the FY 1982 cost per discharge and the FY
1987 cost per discharge. For a more detailed discussion of the
calculation of the FY 1982 hospital-specific rate and the FY 1987
hospital-specific rate, we refer the reader to the September 1, 1983
interim final rule (48 FR 39772); the April 20, 1990 final rule with
comment (55 FR 15150); and the September 4, 1990 final rule (55 FR
35994).
a. Updating the FY 1982 and FY 1987 Hospital-Specific Rates for
FY 1998. We are
[[Page 29948]]
proposing to increase the hospital-specific rates by 2.8 percent
(the hospital market basket percentage increase) for sole community
hospitals located in all areas in FY 1998. Section 1886(b)(3)(C)(ii)
of the Act provides that the update factor applicable to the
hospital-specific rates for sole community hospitals equals the
update factor provided under section 1886(b)(3)(B)(ii) of the Act,
which, for FY 1998, is the market basket rate of increase.
b. Calculation of Hospital-Specific Rate. For sole community
hospitals, the applicable FY 1998 hospital-specific rate would be
calculated by multiplying a hospital's hospital-specific rate for
the preceding fiscal year by the applicable update factor (2.8
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,
0.998400) as discussed in section II.A.4.a of this Addendum. This
resulting rate would be used in determining under which rate a sole
community hospital is paid for its discharges beginning on or after
October 1, 1997, 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, 1997
and Before October 1, 1998
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 V 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 V of the addendum).
Step 3--Add the amount from Step 2 and the nonlabor-related
portion of the standardized amount.
Step 4--Multiply the result in Step 3 by 75 percent.
Step 5--Multiply the amount from Step 4 by the appropriate DRG
relative weight (see Table 5 of section V 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 V of the
addendum) by the appropriate national wage index (see Tables 4A and
4B of section V 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 25 percent.
Step 4--Multiply the amount from Step 3 by the appropriate DRG
relative weight (see Table 5 of section V of the addendum).
The sum of the Puerto Rico rate and the national rate computed
above equals the prospective payment for a given discharge for a
hospital located in Puerto Rico.
III. Proposed Changes to Payment Rates for Inpatient Capital-Related
Costs for FY 1998
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 1998. The rates
will be effective for discharges occurring on or after October 1,
1997.
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.
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.
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.
In accordance with section 1886(d)(9)(A) of the Act, under the
prospective payment system for inpatient operating costs, hospitals
located in Puerto Rico are paid for operating costs under a special
payment formula. These hospitals are paid a blended rate that is
comprised of 75 percent of the applicable standardized amount
specific to Puerto Rico hospitals and 25 percent of the applicable
national average standardized amount. Section 412.374 provides for
the use of this blended payment system for payments to Puerto Rico
hospitals under the prospective payment system for inpatient
capital-related costs. Accordingly, for capital-related costs we
compute a separate payment rate specific to Puerto Rico hospitals
using the same methodology used to compute the national Federal rate
for capital. Hospitals in Puerto Rico are paid based on 75 percent
of the Puerto Rico rate and 25 percent of the Federal rate.
A. Determination of Federal Inpatient Capital-Related Prospective
Payment Rate Update
For FY 1997, the Federal rate is $438.92. With the changes we
are proposing to the factors used to establish the Federal rate, the
proposed FY 1998 Federal rate is $438.43.
In the discussion that follows, we explain the factors that were
used to determine the proposed FY 1998 Federal rate. In particular,
we explain why the FY 1998 Federal rate has decreased 0.11 percent
compared to the FY 1997 Federal rate. Nevertheless, as explained in
section VII of Appendix A, capital payments per case are estimated
to increase 4.68 percent. Taking into account the effects of
increases in projected discharges, we also estimate that aggregate
capital payments will increase 7.19 percent.
The major factor contributing to the decrease in the proposed FY
1998 rate in comparison to the FY 1997 rate is the change in the
exceptions reduction factor. We have expected the number and amount
of exceptions payments generally to increase throughout the
transition period.
Total payments to hospitals under the prospective payment system
are relatively 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 1998 compared to
FY 1997. Specifically, we estimate that aggregate payments in FY
1998 will be 7.19 percent higher than they were in FY 1997. Changes
in aggregate payments
[[Page 29949]]
include changes in capital payments per discharge and changes in the
number of discharges. Under the prospective payment system for
capital-related costs, payments per discharge (or case) are
estimated to increase 4.68 percent in FY 1998 compared to FY 1997.
ProPAC recommends that the rate be adjusted to a more
appropriate level (Recommendation 3). ProPAC believes that the rate
is 15 to 17 percent too high and attributes this to overstatement of
the 1992 base payment rates and the method used to update the rates
prior to implementation of the update framework. ProPAC notes that
there are several approaches for adjusting the rate. For example,
they note that the base capital rates could be replaced by the
actual rates used in FY 1995, which reflected the budget neutrality
adjustment, updated to the current year using the update factor.
We agree with ProPAC that the capital rates are too high. The
President's FY 1998 budget includes a provision to reduce the base
Federal and hospital-specific rates by approximately the magnitude
suggested by ProPAC. This proposal incorporates ProPAC's suggestion
that the FY 1995 budget neutrality adjustment could be built
permanently into the rates. As we stated in the final rule for FY
1997 (61 FR 46216), we continue to believe that it is most
appropriate to make such adjustments to the capital rates in the
context of a comprehensive package of Medicare program changes. We
are, therefore, not proposing to implement this revision to the base
capital rates by regulation at this time.
1. Standard Federal Rate Update
a. Description of the Update Framework. Section 412.308(c)(1)
has provided that 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 1998 under that
framework is 1.1 percent. This proposal is based on a projected 1.3
percent increase in the CIPI, and on policy adjustment factors of
-0.2. We explain the basis for the FY 1998 CIPI projection in
section 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 1992 DRG reclassification and recalibration as
part of our FY 1994 update recommendation.) The operating adjustment
consists of a reduction for total observed case-mix change, an
increase for the portion of case-mix change that we determine is due
to real case-mix change rather than coding modifications, and an
adjustment for the effect of prior DRG reclassification and
recalibration changes. We have adopted this case-mix index
adjustment in the capital update framework as well.
For FY 1998, we are projecting a 1.0 percent increase in the
case-mix index. We estimate that real case-mix increase will equal
0.8 percent in FY 1998. Therefore, the proposed net adjustment for
case-mix change in FY 1998 is -0.2 percentage points.
We estimate that DRG reclassification and recalibration resulted
in a 0.0 percent change in the case mix when compared with the case-
mix index that would have resulted if we had not made the
reclassification and recalibration changes to the DRGs.
The current operating update framework contains an adjustment
for forecast error. The input price index forecast is based on
historical trends and relationships ascertainable at the time the
update factor is established for the upcoming year. In any given
year there may be unanticipated price fluctuations that may result
in differences between the actual increase in prices faced by
hospitals and the forecast used in calculating the update factors.
In setting a prospective payment rate under the proposed framework,
we make an adjustment for forecast error only if our estimate of the
capital input price index rate of increase for any year is off by
0.25 percentage points or more. There is a 2-year lag between the
forecast and the measurement of the forecast error. Thus, for
example, we would adjust for a forecast error made in FY 1996
through an adjustment to the FY 1998 update. Because we only
introduced this analytical framework in FY 1996, FY 1998 is the
first year in which a forecast error adjustment could be required.
We estimate that the FY 1996 CIPI was .20 percentage points higher
than our current data show, which means that we estimate a forecast
error of .20 percentage points for FY 1996. Therefore no adjustment
for forecast error will be made in FY 1998.
Under the capital prospective payment system framework, we also
make an adjustment for changes in intensity. We calculate this
adjustment using the same methodology and data as in the framework
for the operating prospective payment system. The intensity factor
for the operating update framework reflects how hospital services
are utilized to produce the final product, that is, the discharge.
This component accounts for changes in the use of quality-enhancing
services, changes in within-DRG severity, and expected modification
of practice patterns to remove cost-ineffective services.
We calculate case-mix constant intensity as the change in total
charges per admission, adjusted for price level changes (the CPI
hospital component), and changes in real case mix. The use of total
charges in the calculation of the proposed intensity factor makes it
a total intensity factor, that is, charges for capital services are
already built into the calculation of the factor. We have,
therefore, incorporated the intensity adjustment from the operating
update framework into the capital update framework. 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 1998, we have developed a Medicare-specific intensity
measure based on a 5-year average using FY 1991-1995. In determining
case-mix constant intensity, we found that observed case-mix
increase was 2.8 percent in FY 1991, 1.8 percent in FY 1992, 0.9
percent in FY 1993, 0.8 percent in FY 1994, 1.7 percent in FY 1995,
and 1.6 percent in FY 1996. For FY 1992, 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 rather a
fairly steady 1.0 to 1.5 percent per year. We use 1.4 percent as the
upper bound because the RAND study did not take into account that
hospitals may have induced doctors to document medical records more
completely in order to improve payment. Following that study, we
consider up to 1.4 percent of observed case-mix change as real for
FY 1991 through FY 1995. Based on this analysis, we believe that all
of the observed case-mix increase for FY 1993 and FY 1994 is real.
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
[[Page 29950]]
case-mix. Given estimates of real case-mix increase of 1.0 percent
for FY 1992, 0.9 percent for FY 1993, 0.8 percent for FY 1994, 1.0
percent for FY 1995, and 1.0 percent for FY 1996, we estimate that
case-mix constant intensity declined by an average 1.4 percent
during FYs 1992 through 1996, for a cumulative decrease of 7.0
percent. If we assume that real case-mix increase was 1.4 percent
for FY 1992, 0.9 percent for FY 1993, 0.8 percent for FY 1994, 1.4
percent for FY 1995, and 1.4 percent for FY 1996, we estimate that
case-mix constant intensity declined by an average 1.6 percent
during FYs 1992 through 1996, for a cumulative decrease of 7.5
percent. Since we estimate that intensity has declined during that
period, we are recommending a 0.0 percent intensity adjustment for
FY 1998.
b. Comparison of HCFA and ProPAC Update Recommendations. ProPAC
recommends (Recommendation 4) a zero update to the standard Federal
rate and we have recommended a 1.1 percent update. There are some
significant differences between the HCFA and ProPAC update
frameworks, which account for the difference in the respective
update recommendations. A major difference is the input price index
which each framework uses as a beginning point to estimate the
change in input prices since the previous year. The HCFA 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 ProPAC capital market basket does
not include interest expense; instead the ProPAC update framework
includes an 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. ProPAC'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 ProPAC's input price index, the percentage change in
HCFA's CIPI is 1.3 percent, and the percentage change in ProPAC's
market basket is 2.4 percent.
ProPAC and HCFA also differ in the adjustments they make to
their price indices. (See Table 1 for a comparison of HCFA and
ProPAC's update recommendations.) ProPAC makes an adjustment for
productivity, while HCFA has not adopted an adjustment for capital
productivity or efficiency. ProPAC 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. We discuss the differences
related to the intensity adjustment in section III of Appendix E of
this proposed rule in our discussion of the operating update
framework. For FY 1998 ProPAC recommends a -3.0 to a -1.0
productivity adjustment. We recommend a 0.0 intensity adjustment.
We recommend a -0.2 total case mix adjustment since we are
projecting a 1.0 percent increase in the case mix index and we
estimate that real case-mix increase will equal 0.8 percent in FY
1998. ProPAC recommends no case mix adjustment. We also discuss the
differences in these recommendations in section III of Appendix E.
The net result of these adjustments is that ProPAC's capital
update framework suggests a -0.2 to a 1.8 percent update. ProPAC has
recommended a zero update to the rate for FY 1998 because they
believe that a zero update applied to revised base rates would
permit hospitals to maintain quality of care while meeting
Medicare's responsibility to act as a prudent purchaser. We describe
the basis for our proposed 1.1 percent total update in the preceding
section.
The two update recommendations are quite close, with ProPAC
recommending no update and HCFA recommending a modest one. As stated
previously, the President's FY 1998 budget contains a provision to
reduce the rate by 15.7 percent in order to extend the expired
budget neutrality provision. We believe that legislation is the
appropriate mechanism for dealing with cutting the rate.
Table 1.--HCFA's FY 1998 Update Factor and ProPAC's Recommendation
------------------------------------------------------------------------
HCFA's
update ProPAC's
factor recommendation
------------------------------------------------------------------------
Capital Input Price Index............... 1.3 2.4
Policy Adjustment Factors:
Productivity........................ ........... -3.0 to -1.0
Intensity........................... 0.0 .................
Science and Technology.......... ........... 0.4
Intensity....................... ........... (\1\)
Real within DRG Change.......... ........... (\2\)
-------------------------------
Subtotal.................... 0.0 -2.6 to -0.6
Case-Mix Adjustment Factors:
Projected Case-Mix Change........... -1.0 .................
Real across DRG Change.............. 0.8 .................
Real within DRG Change.............. (\3\) 0.0
-------------------------------
Subtotal.................... -0.2 0.0
Effect of FY 1996 Reclassification and
Recalibration.......................... 0.0 .................
Forecast Error Correction............... 0.0 0.0
Total Update........................ 1.1 -0.2 to 1.8
------------------------------------------------------------------------
\1\ Included in ProPAC's productivity measure.
\2\ Included in ProPAC'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, 70 percent for cost reporting periods beginning in FY
1998 for hospitals paid under the fully prospective methodology).
Section 412.308(c)(2) provides that the standard Federal rate for
inpatient capital-related costs be reduced by an adjustment factor
equal to the estimated proportion of outlier payments under the
Federal rate to total inpatient capital-related payments under the
Federal rate. The outlier thresholds are set so that operating
outlier payments are projected to be 5.1 percent of total operating
DRG payments. The inpatient capital-related outlier reduction factor
reflects the inpatient capital-related outlier payments that would
be made if all hospitals were paid according to 100 percent of the
Federal rate. For purposes of calculating the outlier thresholds and
the outlier reduction factor, we model all hospitals as if they 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 August 30, 1996 final rule, we estimated that outlier
payments for capital in FY 1997 would equal 5.19 percent of
inpatient capital-related payments based on
[[Page 29951]]
the Federal rate. Accordingly, we applied an outlier adjustment
factor of 0.9481 to the Federal rate. Based on the thresholds as set
forth in section II.A.4.d of this Addendum, we estimate that outlier
payments for capital will equal 5.51 percent of inpatient capital-
related payments based on the Federal rate in FY 1998. We are,
therefore, proposing an outlier adjustment factor of 0.9449 to the
Federal rate. Thus, estimated capital outlier payments for FY 1998
represent a higher percentage of total capital standard payments
than in FY 1997.
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 1998 is 0.9966 (0.9449/
0.9481). Thus, the outlier adjustment decreases the FY 1998 Federal
rate by 0.34 percent (0.9966--1) compared with the FY 1997 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 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 1997, we calculated a GAF/DRG budget neutrality factor of
0.9987. For FY 1998, we are proposing a GAF/DRG budget neutrality
factor of 1.0001. 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 1997 to FY 1998 is 1.0001. The
proposed cumulative change in the rate due to this adjustment is
1.0013 (the product of the incremental factors for FY 1993, FY 1994,
FY 1995, FY 1996, FY 1997 and the proposed incremental factor for FY
1998: 0.9980 x 1.0053 x 0.9998 x 0.9994 x 0.9987 x 1.0001 = 1.0014).
This factor accounts for DRG reclassifications and recalibration
and for changes in the GAF. It also incorporates the effects on the
GAF of FY 1998 geographic reclassification decisions made by the
MGCRB compared to FY 1997 decisions. However, it does not account
for changes in payments due to changes in the disproportionate share
and indirect medical education adjustment factors or in the large
urban add-on.
4. Exceptions Payment Adjustment Factor
Section 412.308(c)(3) requires that the standard Federal rate
for inpatient capital-related costs be reduced by an adjustment
factor equal to the estimated proportion of additional payments for
exceptions under Sec. 412.348 relative to total payments under the
hospital-specific rate and Federal rate. We use the model originally
developed for determining the budget neutrality adjustment factor to
determine the exceptions payment adjustment factor. We describe that
model in Appendix B to this proposed rule.
For FY 1997, we estimated that exceptions payments would equal
6.42 percent of aggregate payments based on the Federal rate and the
hospital-specific rate. Therefore, we applied an exceptions
reduction factor of 0.9358 (1--0.0642) in determining the Federal
rate. For this proposed rule, we estimate that exceptions payments
for FY 1998 will equal 7.24 percent of aggregate payments based on
the Federal rate and the hospital-specific rate. We are, therefore,
proposing an exceptions payment reduction factor of 0.9276 to the
Federal rate for FY 1998.
The proposed exceptions reduction factor for FY 1998 is thus
0.88 percent lower than the factor for FY 1997. We have expected the
number and amount of exceptions payments generally to increase
throughout the transition period.
The exceptions reduction factors are not built permanently into
the rates; that is, the factors are not applied cumulatively in
determining the Federal rate. Therefore, the proposed net adjustment
to the FY 1998 Federal rate is 0.9276/0.9358, or 0.9912.
5. Standard Capital Federal Rate for FY 1998
For FY 1997, the capital Federal rate was $438.92. With the
changes we are proposing to the factors used to establish the
Federal rate, the FY 1998 Federal rate would be $438.43. The
proposed Federal rate for FY 1998 was calculated as follows:
The proposed FY 1998 update factor is 1.0110, that is,
the proposed update is 1.10 percent.
The proposed FY 1998 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 1.0001.
The proposed FY 1998 outlier adjustment factor is
0.9449.
The proposed FY 1998 exceptions payments adjustment
factor is 0.9276.
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 1998 affected the computation of the proposed FY
1998 Federal rate in comparison to the FY 1997 Federal rate. The
proposed FY 1998 update factor has the effect of increasing the
Federal rate by 1.10 percent compared to the rate in FY 1997, while
the proposed geographic and DRG budget neutrality factor has the
effect of increasing the Federal rate by 0.01 percent. The proposed
FY 1998 outlier adjustment factor has the effect of decreasing the
Federal rate by 0.34 percent compared to FY 1997. The proposed FY
1998 exceptions reduction factor has the effect of decreasing the
Federal rate by 0.88 percent compared to the exceptions reduction
for FY 1997. The combined effect of all the proposed changes is to
decrease the proposed Federal rate by 0.11 percent compared to the
Federal rate for FY 1997.
Comparison of Factors and Adjustments: FY 1997 Federal Rate and Proposed FY 1998 Federal Rate
----------------------------------------------------------------------------------------------------------------
FY 97 Proposed FY 98 Change Percent change
----------------------------------------------------------------------------------------------------------------
Update factor \1\............................... 1.0070 1.0110 1.0110 1.10
GAF/DRG Adjustment Factor \1\................... 0.9987 1.0001 1.0001 0.01
Outlier Adjustment Factor \2\................... 0.9481 0.9449 0.9966 -0.34
Exceptions Adjustment Factor \2\................ 0.9358 0.9276 0.9912 -0.88
Federal Rate.................................... $438.92 $438.43 0.9988 -0.11
----------------------------------------------------------------------------------------------------------------
\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 1997 to FY 1998 resulting from the application of the 1.0001 GAF/DRG
budget neutrality factor for FY 1998 is 1.0001.
\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 1998 outlier reduction factor is 0.9449/0.9481, or 0.9966.
[[Page 29952]]
6. Special Rate for Puerto Rico Hospitals
As explained at the beginning of this section, hospitals in
Puerto Rico are paid based on 75 percent of the Puerto Rico rate and
25 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. Since the GAF is based on the
wage index, we plan to revise the method of accounting for
geographical variation in Puerto Rico, to parallel the change that
is being proposed on the operating rate, where a Puerto Rico-
specific wage index is being calculated (section III.B.).
Specifically, we propose to use the new Puerto Rico wage index to
determine the GAF for the Puerto Rico part of the capital blended
rate and retain the use of the national wage index to determine the
GAF for the national part of the blended rate. Hospitals in Puerto
Rico would still be paid based on 75 percent of the Puerto Rico rate
and 25 percent of the Federal rate. This means that, in computing
the payment for a particular Puerto Rico hospital, the Puerto Rico
portion of the rate will be multiplied by the Puerto Rico-specific
GAF for the MSA in which the hospital is located, and the national
portion of the rate will be 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).
We have adjusted the Puerto Rico rate to account for the
application of Puerto Rico-specific GAFs. We did this in order to be
consistent with the method by which we originally determined the
national and Puerto Rico rates. This resulting standard Puerto Rico
rate does not translate into a reduction in payments to Puerto Rico
hospitals. The Puerto Rico-specific GAFs are higher than the
national GAFs because they use the Puerto Rico mean only rather than
the national mean. As a result, application of Puerto Rico-specific
GAFs means Puerto Rico hospitals receive more money.
For FY 1997, before application of the GAF, the special rate for
Puerto Rico hospitals was $337.63. With the changes we are proposing
to the factors used to determine the rate, the proposed FY 1998
special rate for Puerto Rico is $204.46. After application of the
GAF, the proposed FY 1998 capital rates for Puerto Rico hospitals
are higher than the FY 1997 rates.
The example below is based on the proposed FY 1998 San Juan-
Bayamon GAF and Puerto Rico capital rate in comparison to the final
FY 1997 San Juan-Bayamon GAF and Puerto Rico capital rate. (For
purposes of simplicity we have not included all elements involved in
computing a payment to a particular hospital. For a more complete
description of calculating the payment for a specific discharge see
Section C. below. In addition the Puerto Rico rate and GAF would be
used to compute 75 percent of a Puerto Rico hospital's payment. The
remaining 25 percent would be based on the national rate and GAF.)
San Juan-Bayamon MSA
------------------------------------------------------------------------
FY 1997 Proposed
final FY 1998
------------------------------------------------------------------------
Rate.............................................. $337.63 $204.46
GAF............................................... .5793 1.0186
Rate X GAF =...................................... $195.59 $208.26
------------------------------------------------------------------------
The example illustrates that based on the changes we are
proposing to the FY 1998 Puerto Rico GAF and capital rate, all other
factors being equal, a hospital in the San Juan-Bayamon MSA would
receive a larger payment with the proposed FY 1998 capital rate and
GAF compared with the final FY 1997 capital rate and GAF.
B. Determination of Hospital-Specific Rate Update
Section 412.328(e) of the regulations provides that the
hospital-specific rate for FY 1998 be determined by adjusting the FY
1997 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 1998, we are proposing that the hospital-
specific rate be updated by a factor of 1.0110.
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 1998, we
estimate that exceptions payments will be 7.24 percent of aggregate
payments based on the Federal rate and the hospital-specific rate.
We therefore propose that the updated hospital-specific rate be
reduced by a factor of 0.9276. The exceptions reduction factors are
not built permanently into the rates; that is, the factors are not
applied cumulatively in determining the hospital-specific rate.
Therefore, the proposed net adjustment to the FY 1998 hospital-
specific rate is 0.9276/0.9358, or 0.9912.
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 1997 and FY 1998
and the net adjustment for each factor. It also shows that the
proposed cumulative net adjustment from FY 1997 to FY 1998 is
1.0021, which represents a proposed increase of 0.21 percent to the
hospital-specific rate. For each hospital, the proposed FY 1998
hospital-specific rate is determined by multiplying the FY 1997
hospital-specific rate by the cumulative net adjustment of 1.0021.
Proposed FY 1998 Update and Adjustments to Hospital-Specific Rates
----------------------------------------------------------------------------------------------------------------
FY 97 Proposed FY 98 Net adjustment Percent change
----------------------------------------------------------------------------------------------------------------
Update Factor................................... 1.0070 1.0110 1.0110 1.10
Exceptions Payment Adjustment Factor............ 0.9358 0.9276 0.9912 -0.88
Cumulative Adjustments.......................... 0.9424 0.9444 1.0021 0.21
----------------------------------------------------------------------------------------------------------------
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 1997 to FY 1998 is 1.0110. In
contrast, the exceptions payment adjustment factor is not applied
cumulatively. Thus, for example, the incremental increase in the
exceptions reduction factor from FY 1997 to FY 1998 is 0.9276/
0.9358, or 0.9912.
C. Calculation of Inpatient Capital-Related Prospective Payments
for FY 1998
During the capital prospective payment system transition period,
a hospital is paid for the inpatient capital-related costs under one
of two alternative payment methodologies; the fully prospective
payment methodology or the hold-harmless methodology. The payment
methodology applicable to a particular hospital is determined when a
hospital comes under the prospective payment system for capital-
related costs by comparing its hospital-specific rate to the Federal
rate applicable to the hospital's first cost reporting period under
the prospective payment system.
The applicable Federal rate was determined by making adjustments
as follows:
For outliers by dividing the standard Federal rate by
the outlier reduction factor for that fiscal year; and,
For the payment adjustment factors applicable to the
hospital (that is, the hospital's GAF, the disproportionate share
adjustment factor, and the indirect medical
[[Page 29953]]
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 termed the adjusted Federal rate.
Payments under the hold-harmless methodology are determined
under one of two formulas. A hold-harmless hospital is paid the
higher of:
100 percent of the adjusted Federal rate for each
discharge; or
An old capital payment equal to 85 percent (100 percent
for sole community hospitals) of the hospital's allowable Medicare
inpatient old capital costs per discharge for the cost reporting
period plus a new capital payment based on a percentage of the
adjusted Federal rate for each discharge. The percentage of the
adjusted Federal rate equals the ratio of the hospital's allowable
Medicare new capital costs to its total Medicare inpatient capital-
related costs in the cost reporting period.
Once a hospital receives payment based on 100 percent of the
adjusted Federal rate in a cost reporting period beginning on or
after October 1, 1994 (or the first cost reporting period after
obligated capital that is recognized as old capital under
Sec. 412.302(c) is put in use for patient care, if later), the
hospital continues to receive capital prospective payment system
payments on that basis for the remainder of the transition period.
Payment for each discharge under the fully prospective
methodology is the sum of:
The hospital-specific rate multiplied by the DRG
relative weight for the discharge and by the applicable hospital-
specific transition blend percentage for the cost reporting period;
and
The adjusted Federal rate multiplied by the Federal
transition blend percentage.
The blend percentages for cost reporting periods beginning in FY
1998 are 70 percent of the adjusted Federal rate and 30 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 70 percent of the Federal rate for discharges
occurring in cost reporting periods beginning during FY 1998. Thus,
a fully prospective hospital will receive 70 percent of the capital-
related outlier payment calculated for the case for discharges
occurring in cost reporting periods beginning in FY 1998. 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 1998 are published in
section II.A.4.c of this Addendum. For FY 1998, 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 $7,600.
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 1998 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
In the following section we explain why we are not proposing to
revise the Capital Input Price Index (CIPI) as we are the operating
input price index to incorporate more recent data from Bureau of the
Census. (This change to the operating price index is described in
section IV. of the preamble.)
Like the prospective payment hospital operating input price
index, the Capital Input Price Index (CIPI) is a fixed-weight price
index. A fixed-weight price index measures how much it would cost at
a later date to purchase the same mix of goods and services
purchased in the base period. For the prospective payment hospital
operating and capital input price indices, the base period is
selected and cost category weights are determined using available
data on hospitals. Next, appropriate price proxy indices are chosen
for each cost category. Then a price proxy index level for each
expenditure category is multiplied by the comparable cost category
weight. The sum of these products (that is, weights multiplied by
price proxy index levels) for all cost categories yields the
composite index level of the market basket for a given year.
Repeating the step for other years produces a time series of
composite market basket index levels. Dividing an index level by a
later index level produces a rate of growth in the input price
index. Since the percent change is computed for the fixed mix of
total capital inputs with a 1992 base, the index is fixed-weight.
Like the operating input price index, the CIPI measures the
price changes associated with costs during a given year. In order to
do so, the CIPI must differ from the operating input price index in
one important aspect. The CIPI must reflect the vintage nature of
capital, which is the acquisition and use of capital over time.
Capital expenses in any given year are determined by the stock of
capital in that year (that is, capital that remains on hand from all
current and prior capital acquisitions). An index measuring capital
price changes needs to reflect this vintage nature of capital.
Therefore, the CIPI was developed to capture the vintage nature of
capital by using a weighted-average of past capital purchase prices
up to and including the current year.
Using Medicare cost reports, AHA data, and Securities Data
Corporation data, a vintage-weighted price index was developed to
measure price increases associated with capital expenses. We
periodically update the base year for the operating and capital
input prices to reflect the changing composition of inputs for
operating and capital expenses. Currently, both the operating input
price index and the CIPI are based on FY 1992. They were rebased in
FY 1997. The process for updating the CIPI was explained in the May
31, 1996 Federal Register (61 FR 27466) and the August 30, 1996
Federal Register (61 FR 46196). The following Federal Register
documents also describe development and
[[Page 29954]]
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)
2. Research on Reweighting the CIPI
After analyzing various data sources and methodologies for
determining capital weights for the HCFA PPS CIPI, we propose to
continue using the weights published in the August 30, 1996 Federal
Register. In developing the rebased CIPI for the FY 1997 proposed
and final rules, we stated that we had planned to use the 1992
Department of Commerce data for developing capital cost category
weights but the data was not available in time. The data has since
become available, and although we are planning to use it to revise
the operating market basket, we are not planning to do so for the
capital input price index.
The weights for the 1992 rebased CIPI were developed from the
1992 Medicare Cost Reports and the 1992 AHA Annual Survey. We
analyzed the newly available 1992 Census of Service Industries Asset
and Expenditures Survey from the Bureau of the Census, Department of
Commerce. There are three major reasons we are proposing to continue
using the current 1992 HCFA PPS CIPI without modifying the weights
using the 1992 Asset and Expenditures Survey.
First, HCFA's preference in determining index weights is to
continue to use the Medicare Cost Reports for the Medicare subset of
hospitals (PPS only). Beginning in 1992, detailed capital cost data
for PPS hospitals was available from the Medicare Cost Reports. This
data includes depreciation, interest, and other capital-related
expenses. We used the 1992 AHA Annual Survey as the source for
interest expenses because of its strength in measuring interest
compared to the Medicare Cost Reports. All of the other cost
category weights in the HCFA PPS CIPI were developed from the 1992
Medicare Cost Reports. Using these two data sources we were able to
produce weights for PPS hospitals only, as opposed to all nonfederal
hospitals as reported in the Asset and Expenditures Survey. Because
this detailed capital data will be available in Medicare Cost
Reports in future years, we believe the Medicare Cost Reports are
the most appropriate source for determining the weights in the HCFA
PPS CIPI.
The second major reason we are proposing to continue using the
current HCFA PPS CIPI is that the capital cost shares are similar to
those provided by the 1992 Asset and Expenditures Survey. The 1992
Asset and Expenditures Survey reports capital cost shares for
buildings, structures, and related facilities depreciation (fixed)
and machinery, equipment, and other depreciation (movable), as well
as total depreciation as a percentage of total hospital
``operating'' expenses (operating and capital expenses). Hospital
expenses in the 1992 Asset and Expenditures Survey are based on
information collected from a probability sample of both PPS and non-
PPS hospitals. The CIPI weights from the 1992 Medicare Cost Reports
and the 1992 AHA Annual Survey are based on a universal count of PPS
hospitals only. Despite these methodological differences, capital
cost shares as measured by these data sources are similar.
Specifically, the 1992 Medicare Cost Reports show building and fixed
equipment depreciation was 46.4 percent of total depreciation and
movable equipment depreciation was 53.6 percent. The distribution
for the 1992 Asset and Expenditures Survey was 44.4 percent for
buildings, structures, and related facilities depreciation and 55.6
percent for machinery, equipment, and other depreciation. These
differences are acceptable given the differences in universe and
methodologies of the two data sources. A simulation of the CIPI
using each set of weights showed a less than 0.1 percentage point
impact on the percent change of the CIPI for each year between 1980-
2007.
Another comparison between cost shares in the Medicare Cost
Reports and the Asset and Expenditures Survey produced minor
differences as well. The 1992 Asset and Expenditures Survey shows
depreciation as a percentage of total ``operating'' expenses
(operating and capital expenses) of 5.0 percent. A similar
calculation of PPS hospitals from the 1992 Medicare Cost Reports
shows depreciation as 5.3 percent of total ``operating'' expenses.
Given the differences in universe and methodologies between the
Asset and Expenditure Survey and the Medicare Cost Reports we
consider this 0.3 percentage point difference to be within the range
of reasonableness.
The last major reason for continuing to use the 1992 Medicare
Cost Reports in determining capital weights for the HCFA PPS CIPI is
that the detail needed for future rebasing of the index will be
available from this data source. The 1997 Asset and Expenditures
Survey, which is being renamed the Business Expenditures survey,
will not include data on fixed assets, interest expense, and capital
leases. Also, detail on capital expenditures and depreciation,
including the breakout of structures and movable equipment, will not
be part of the 1997 survey. The lack of this detailed capital data
would create an obstacle to rebasing in the future.
This survey data is appropriate for use in the operating PPS
index because it provides operating expense information not
available from the Medicare cost reports and which will be available
in the 1997 survey. The Bureau of Census now considers the principal
source of data on fixed assets and capital expenditures for health
industries to be the Annual Capital Expenditures Survey, which began
in 1993. The Annual Capital Expenditures Survey will not include the
detail needed for determining weights for the CIPI, such as
depreciation at the hospital level. However, we will continue to
consider and monitor the Annual Capital Expenditures Survey as a
possible data source for future rebasing.
For the three major reasons explained above we are proposing to
stay with the current HCFA PPS CIPI and to not modify the index
using the newly available 1992 Asset and Expenditures Survey.
3. Forecast of the CIPI for Federal Fiscal Year 1998
DRI forecasts a 1.3 percent increase in the CIPI for FY 1998.
This is the outcome of a projected 2.3 percent increase in vintage-
weighted depreciation prices (building and fixed equipment, and
movable equipment) and a 3.0 percent increase in other capital
expense prices in FY 1998, partially offset by a 1.6 percent decline
in vintage-weighted interest rates in FY 1998. The weighted average
of these three factors produces the 1.3 percent increase for the
CIPI as a whole.
IV. Proposed Changes to Payment Rates for Excluded Hospitals and
Hospital Units: Rate-of-Increase Percentages
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 Sec. 413.40 of the regulations.
Under these limits, an annual 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). 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.
Effective with cost reporting periods beginning on or after
October 1, 1991, a hospital that has Medicare inpatient operating
costs in excess of its ceiling is paid its ceiling plus 50 percent
of its costs in excess of the ceiling. Total payment may not exceed
110 percent of the ceiling. A hospital that has inpatient operating
costs less than its ceiling is paid its costs plus the lower of--
Fifty percent of the difference between the allowable
inpatient operating costs and the ceiling; or
Five percent of the ceiling.
Each hospital's target amount is adjusted annually, at the
beginning of its cost reporting period, by an applicable rate-of-
increase percentage. Section 1886(b)(3)(B) of the Act provides that
for cost reporting periods beginning on or after October 1, 1997 and
before October 1, 1998, the applicable rate-of-increase percentage
is the market basket percentage. In order to determine a hospital's
target amount for its cost reporting period beginning in FY 1998,
the hospital's target amount for its cost reporting period that
began in FY 1997 is increased by the market basket percentage
increase for FY 1998. The most recent forecast of the market basket
increase for FY 1998 for hospitals and hospital units excluded from
the prospective payment system is 2.8 percent.
[[Page 29955]]
V. Tables
This section contains the tables referred to throughout the
preamble to this proposed rule and in this Addendum. For purposes of
this proposed rule, and to avoid confusion, we have retained the
designations of Tables 1 through 5 that were first used in the
September 1, 1983 initial prospective payment final rule (48 FR 39844).
Tables 1A, 1C, 1D, 3C, 4A, 4B, 4C, 4D, 4E, 4F, 5, 6A, 6B, 6C, 6D, 6E,
6F, 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 1996 and Hospital Average Hourly Wage for Federal Fiscal
Year 1998 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 Captial Geographic Adjustment
Factor (GAF)
Table 5--List of Diagnosis Related Groups (DRGs), Relative Weighting
Factors, Geometric and Arithmetic Mean Length of Stay.
Table 6A--New Diagnosis Codes
Table 6B--New Procedure Codes
Table 6C--Invalid Diagnosis Codes
Table 6D--Revised Diagnosis Code Titles
Table 6E--Additions to the CC Exclusions List
Table 6F--Deletions to the CC Exclusions List
Table 7A--Medicare Prospective Payment System; Selected Percentile
Lengths of Stay (FY 96 MEDPAR Update 12/96 GROUPER V14.0)
Table 7B--Medicare Prospective Payment System; Selected Percentile
Lengths of Stay (FY 96 MEDPAR Update 12/96 GROUPER V15.0)
Table 8A--Statewide Average Operating Cost-to-Charge Ratios [for Urban
and Rural Hospitals] (Case Weighted) April 1997
Table 8B--Statewide Average Capital Cost-to-Charge Ratios for Urban and
Rural Hospitals (Case Weighted) April 1997
Table 1A.--National Adjusted Operating Standardized Amounts, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
Large urban areas Other areas
----------------------------------------------------------------------------------------------------------------
Labor-related Nonlabor-related Labor-related Nonlabor-related
----------------------------------------------------------------------------------------------------------------
$2,857.85.................. $1,161.63 $2,812.62 $1,143.24
----------------------------------------------------------------------------------------------------------------
Table 1C.--Adjusted Operating Standardized Amounts For Puerto Rico, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
Large urban areas Other areas
---------------------------------------------------
Labor Nonlabor Labor Nonlabor
----------------------------------------------------------------------------------------------------------------
National.................................................... $2,833.30 $1,151.64 $2,833.30 $1,151.64
Puerto Rico................................................. 1,346.08 541.83 1,324.77 533.25
----------------------------------------------------------------------------------------------------------------
Table 1D.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
Rate
------------------------------------------------------------------------
National................................................... $438.43
Puerto Rico................................................ 204.46
------------------------------------------------------------------------
[[Page 29956]]
Table 3C.--Hospital Case Mix Indexes for Discharges Occurring in Federal Fiscal Year 1996; Hospital Average Hourly Wage for Federal Fiscal Year 1998 Wage Index
Page 1 of 16
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
010001....................... 01.4816 15.78 010095.......... 00.9851 12.06 030004......... 01.0965 13.75 040002......... 01.1972 12.84 040107......... 01.2002 15.29
010004....................... 00.9673 11.63 010097.......... 00.9083 14.47 030006......... 01.5609 18.02 040003......... 01.0142 12.72 040109......... 01.1817 13.56
010005....................... 01.2080 15.57 010098.......... 01.2511 11.65 030007......... 01.3217 16.96 040004......... 01.6321 15.84 040114......... 01.8843 17.60
010006....................... 01.4488 15.81 010099.......... 01.1678 14.38 030008......... 02.3039 19.75 040005......... 01.0108 12.83 040116......... 01.3793 19.05
010007....................... 01.0717 13.52 010100.......... 01.2630 15.26 030009......... 01.3451 16.25 040007......... 01.8418 17.91 040118......... 01.2192 14.54
010008....................... 01.1631 12.11 010101.......... 01.0605 14.05 030010......... 01.4365 17.79 040008......... 01.0326 11.22 040119......... 01.1562 14.58
010009....................... 01.1280 15.17 010102.......... 01.0060 13.60 030011......... 01.5199 18.32 040010......... 01.3163 15.80 040124......... 01.1377 13.82
010010....................... 01.0749 14.78 010103.......... 01.8573 18.70 030012......... 01.2362 16.41 040011......... 00.9931 10.85 040126......... 00.9510 11.98
010011....................... 01.6404 19.62 010104.......... 01.7047 18.20 030013......... 01.2703 19.56 040014......... 01.1907 16.40 040132......... 00.5050 11.69
010012....................... 01.3067 16.65 010108.......... 01.2350 14.48 030014......... 01.4912 18.50 040015......... 01.2905 13.52 050002......... 01.5782 35.29
010015....................... 01.0958 13.70 010109.......... 01.1090 13.36 030016......... 01.2444 17.47 040016......... 01.6623 16.02 050006......... 01.4562 19.54
010016....................... 01.2774 16.88 010110.......... 01.0535 14.12 030017......... 01.5058 18.11 040017......... 01.3308 11.89 050007......... 01.6175 27.21
010018....................... 00.9336 16.77 010112.......... 01.1875 15.28 030018......... 01.8046 19.31 040018......... 01.2282 18.03 050008......... 01.5162 26.68
010019....................... 01.3220 14.52 010113.......... 01.6944 15.80 030019......... 01.2816 19.75 040019......... 01.1372 13.94 050009......... 01.7341 29.57
010021....................... 01.2458 15.75 010114.......... 01.3221 16.45 030022......... 01.4807 15.25 040020......... 01.6074 15.06 050013......... 01.8298 21.70
010022....................... 01.0181 17.25 010115.......... 00.8522 12.02 030023......... 01.3285 18.26 040021......... 01.2537 14.96 050014......... 01.1688 22.16
010023....................... 01.6504 15.43 010117.......... 00.8712 13.59 030024......... 01.7123 20.56 040022......... 01.6764 14.96 050015......... 01.3865 23.94
010024....................... 01.4635 15.95 010118.......... 01.3322 18.41 030025......... 01.1326 14.24 040024......... 01.0654 14.26 050016......... 01.1635 17.87
010025....................... 01.4620 13.24 010119.......... 00.9593 18.53 030027......... 01.0596 15.39 040025......... 00.9155 12.38 050017......... 02.0494 25.36
010027....................... 00.8288 14.12 010120.......... 00.9722 15.39 030030......... 01.7325 18.21 040026......... 01.6071 16.65 050018......... 01.3046 20.37
010029....................... 01.5715 15.54 010121.......... 01.3081 15.80 030033......... 01.2195 15.72 040027......... 01.2929 12.96 050021......... 01.5263 25.59
010031....................... 01.2306 15.57 010123.......... 01.3122 15.81 030034......... 01.0042 15.05 040028......... 01.0932 11.93 050022......... 01.5026 23.58
010032....................... 00.9618 12.86 010124.......... 01.3739 13.53 030035......... 01.2767 18.82 040029......... 01.2899 15.78 050024......... 01.2995 21.10
010033....................... 01.9459 17.26 010125.......... 01.0064 15.83 030036......... 01.1913 18.51 040030......... 00.9480 11.36 050025......... 01.6853 21.84
010034....................... 01.0864 12.64 010126.......... 01.1851 14.11 030037......... 02.0991 19.86 040032......... 00.9572 10.60 050026......... 01.4624 28.03
010035....................... 01.2549 15.94 010127.......... 01.3443 16.36 030038......... 01.6421 18.39 040035......... 00.9651 10.26 050028......... 01.3776 15.43
010036....................... 01.1249 16.08 010128.......... 01.0020 12.39 030040......... 01.1481 16.07 040036......... 01.5225 17.87 050029......... 01.4317 22.42
010038....................... 01.3209 17.78 010129.......... 01.0948 14.62 030041......... 00.9799 13.77 040037......... 01.1133 11.92 050030......... 01.3242 20.23
010039....................... 01.6825 17.26 010130.......... 01.0351 14.47 030043......... 01.2510 17.86 040039......... 01.2290 13.00 050032......... 01.2355 26.01
010040....................... 01.5937 18.14 010131.......... 01.3336 18.57 030044......... 01.0839 16.15 040040......... 00.9725 14.02 050033......... 01.4509 26.08
010043....................... 01.1350 10.75 010134.......... 00.8545 09.70 030046......... 00.9632 18.53 040041......... 01.3625 15.91 050036......... 01.6816 19.57
010044....................... 01.1641 14.54 010137.......... 01.2902 16.93 030047......... 00.9383 20.45 040042......... 01.2370 14.76 050038......... 01.4549 28.87
010045....................... 01.1886 13.05 010138.......... 00.9275 10.96 030049......... 00.9881 14.67 040044......... 01.0305 11.22 050039......... 01.6191 21.51
010046....................... 01.5217 16.79 010139.......... 01.6895 19.60 030054......... 00.8543 12.51 040045......... 01.0233 15.07 050040......... 01.2696 22.01
010047....................... 00.9803 10.30 010143.......... 01.2914 16.04 030055......... 01.2187 16.56 040047......... 01.1375 15.13 050042......... 01.3519 20.78
010049....................... 01.1619 14.77 010144.......... 01.3019 16.49 030059......... 01.3916 18.88 040048......... 01.1836 14.02 050043......... 01.6119 30.35
010050....................... 01.1203 13.88 010145.......... 01.3030 15.59 030060......... 01.1395 16.21 040050......... 01.1609 12.27 050045......... 01.2819 18.28
010051....................... 00.8551 09.93 010146.......... 01.1732 15.81 030061......... 01.6802 17.13 040051......... 01.1004 13.76 050046......... 01.2703 21.20
010052....................... 01.0499 09.88 010148.......... 01.0017 12.52 030062......... 01.2660 15.94 040053......... 01.1198 13.04 050047......... 01.5698 31.60
010053....................... 01.0792 13.31 010149.......... 01.3645 16.73 030064......... 01.7579 18.53 040054......... 01.0614 12.44 050051......... 01.0469 17.04
010054....................... 01.2098 17.02 010150.......... 01.1036 16.28 030065......... 01.7255 19.65 040055......... 01.4708 15.29 050054......... 01.2054 20.60
010055....................... 01.4421 16.99 010152.......... 01.4914 17.56 030067......... 01.0541 15.78 040058......... 01.0292 13.64 050055......... 01.4035 27.81
010056....................... 01.4314 18.78 010155.......... 01.0479 06.99 030068......... 01.0721 15.77 040060......... 00.9858 10.20 050056......... 01.3667 29.73
010058....................... 01.0865 12.93 020001.......... 01.5659 26.31 030069......... 01.3277 20.13 040062......... 01.6837 15.85 050057......... 01.5598 19.64
010059....................... 01.1118 14.92 020002.......... 01.2468 23.88 030071......... 00.9685 ....... 040064......... 01.0588 11.19 050058......... 01.4525 21.47
010061....................... 01.1872 15.20 020004.......... 01.1123 25.46 030072......... 00.8385 ....... 040066......... 01.2238 15.86 050060......... 01.5314 20.46
010062....................... 01.0345 14.36 020005.......... 00.8208 25.53 030073......... 01.0067 ....... 040067......... 01.0916 12.18 050061......... 01.4666 21.87
010064....................... 01.7943 18.52 020006.......... 01.2547 25.07 030074......... 00.8781 ....... 040069......... 01.1556 14.87 050063......... 01.3998 21.02
010065....................... 01.3457 15.39 020007.......... 01.0349 22.76 030075......... 00.8559 ....... 040070......... 00.9325 13.68 050065......... 01.6382 22.84
010066....................... 00.9485 10.41 020008.......... 01.1378 29.10 030076......... 01.1098 ....... 040071......... 01.6792 15.73 050066......... 01.2676 20.99
010068....................... 01.3084 16.70 020009.......... 00.9842 21.88 030077......... 00.8398 ....... 040072......... 01.0978 13.94 050067......... 01.3721 21.53
010069....................... 01.1900 13.10 020010.......... 01.0900 26.44 030078......... 01.1353 ....... 040074......... 01.3194 14.39 050068......... 01.0664 18.92
010072....................... 01.2155 13.45 020011.......... 00.9844 22.61 030079......... 00.8800 ....... 040075......... 01.1179 11.73 050069......... 01.6450 24.14
010073....................... 01.0213 10.31 020012.......... 01.2438 24.23 030080......... 01.5975 21.05 040076......... 01.0526 16.33 050070......... 01.2820 33.06
010078....................... 01.2760 16.51 020013.......... 01.0503 24.21 030083......... 01.3152 21.06 040077......... 00.9257 11.30 050071......... 01.3290 32.76
010079....................... 01.2562 15.43 020014.......... 01.1749 22.13 030084......... 01.0320 ....... 040078......... 01.5605 17.77 050072......... 01.3209 32.63
010080....................... 01.0102 11.89 020017.......... 01.6705 24.50 030085......... 01.5592 23.63 040080......... 01.1210 14.65 050073......... 01.3310 32.63
010081....................... 01.8549 14.84 020018.......... 00.7773 ....... 030086......... 01.3315 18.01 040081......... 00.9561 10.75 050074......... 01.3610 38.56
010083....................... 01.0100 15.43 020019.......... 00.7868 ....... 030087......... 01.6332 18.93 040082......... 01.1568 14.31 050075......... 01.3928 32.75
010084....................... 01.4845 17.66 020020.......... 00.7727 ....... 030088......... 01.4131 19.07 040084......... 01.1207 14.18 050076......... 01.8220 32.11
010085....................... 01.2689 17.11 020021.......... 00.9217 ....... 030089......... 01.5795 19.68 040085......... 01.1916 14.81 050077......... 01.5826 22.86
010086....................... 01.0829 13.70 020024.......... 01.0856 23.72 030092......... 01.6107 20.36 040088......... 01.4006 14.36 050078......... 01.2964 24.76
010087....................... 01.8442 18.51 020025.......... 00.9808 24.32 030093......... 01.4071 17.81 040090......... 00.9231 13.54 050079......... 01.5662 29.34
010089....................... 01.2639 15.60 020026.......... 01.3114 ....... 030094......... 01.3476 18.46 040091......... 01.2636 19.81 050080......... 01.3940 20.59
010090....................... 01.5840 17.57 020027.......... 01.0992 ....... 030095......... 01.1396 18.24 040093......... 01.0221 10.11 050081......... 01.7055 22.17
010091....................... 01.0096 14.57 030001.......... 01.3338 20.07 030098......... 00.9581 ....... 040100......... 01.3213 13.29 050082......... 01.5543 21.60
010092....................... 01.4078 16.49 030002.......... 01.8051 21.04 030099......... 00.9322 ....... 040105......... 01.0263 13.29 050084......... 01.6775 23.55
010094....................... 01.2357 15.11 030003.......... 01.9788 20.23 040001......... 01.1189 12.95 040106......... 01.2177 14.08 050088......... 01.0368 23.02
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 29957]]
Page 2 of 16
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
050089....................... 01.4270 20.50 050188.......... 01.3814 26.59 050298......... 01.2566 21.05 050421......... 01.3715 24.84 050546......... 00.7841 22.14
050090....................... 01.2899 23.06 050189.......... 01.0628 21.87 050299......... 01.3557 22.62 050423......... 01.0305 19.52 050547......... 00.8692 21.94
050091....................... 01.1899 22.02 050191.......... 01.4973 20.99 050300......... 01.3977 22.60 050424......... 01.8000 22.86 050549......... 01.7307 25.79
050092....................... 00.9919 15.98 050192.......... 01.1874 18.17 050301......... 01.3383 22.43 050425......... 01.3230 33.00 050550......... 01.5796 23.60
050093....................... 01.5661 23.33 050193.......... 01.3126 23.13 050302......... 01.3709 27.57 050426......... 01.3336 15.00 050551......... 01.3057 24.63
050095....................... 00.7794 29.00 050194.......... 01.2784 28.01 050305......... 01.5728 30.80 050427......... 00.8401 17.79 050552......... 01.2447 21.99
050096....................... 01.3114 19.75 050195.......... 01.6021 32.79 050307......... 01.3612 21.59 050430......... 00.8449 17.06 050557......... 01.5644 21.58
050097....................... 01.4624 18.53 050196.......... 01.4108 17.33 050308......... 01.5171 28.30 050431......... 01.0903 19.94 050559......... 01.4051 24.92
050099....................... 01.4748 23.23 050197.......... 01.8369 28.44 050309......... 01.3657 24.67 050432......... 01.6711 24.04 050560......... 01.4220 ......
050100....................... 01.7332 28.66 050204.......... 01.4986 24.18 050310......... 01.2224 19.66 050433......... 01.1020 17.37 050561......... 01.1900 32.17
050101....................... 01.4316 28.42 050205.......... 01.3796 17.74 050312......... 01.9978 24.02 050434......... 01.2094 20.09 050564......... 01.1456 17.84
050102....................... 01.4300 18.79 050207.......... 01.2951 20.37 050313......... 01.2181 21.97 050435......... 01.2977 23.02 050565......... 01.1278 21.68
050103....................... 01.6336 26.99 050208.......... 00.9009 28.83 050315......... 01.2135 19.97 050436......... 00.9672 14.81 050566......... 00.9102 23.47
050104....................... 01.5240 22.61 050211.......... 01.3135 30.44 050317......... 01.3276 18.92 050438......... 01.7527 25.46 050567......... 01.6176 24.19
050107....................... 01.4804 20.75 050213.......... 01.5230 21.12 050320......... 01.2950 27.83 050440......... 01.3228 21.46 050568......... 01.3603 19.64
050108....................... 01.7167 21.54 050214.......... 01.4986 20.90 050324......... 01.9039 25.52 050441......... 01.9990 28.23 050569......... 01.3434 23.05
050109....................... 02.4142 24.01 050215.......... 01.5369 28.12 050325......... 01.2371 21.42 050443......... 00.9281 16.07 050570......... 01.7731 23.41
050110....................... 01.3001 19.33 050217.......... 01.3369 20.45 050327......... 01.5881 22.32 050444......... 01.3847 23.82 050571......... 01.4455 22.36
050111....................... 01.3067 19.39 050219.......... 01.1287 20.76 050328......... 01.5403 30.01 050446......... 00.9652 21.02 050573......... 01.6557 23.85
050112....................... 01.5378 24.56 050222.......... 01.5800 32.40 050329......... 01.3530 22.38 050447......... 01.1539 19.37 050575......... 01.2038 ......
050113....................... 01.3294 29.69 050224.......... 01.6083 22.29 050331......... 01.4116 26.07 050448......... 01.2603 20.75 050577......... 01.4073 19.70
050114....................... 01.4974 20.53 050225.......... 01.4961 20.34 050333......... 01.1134 19.36 050449......... 01.3295 20.38 050578......... 01.2091 24.65
050115....................... 01.5820 20.21 050226.......... 01.3728 23.58 050334......... 01.7827 31.52 050454......... 01.8485 27.56 050579......... 01.5011 27.75
050116....................... 01.4915 23.17 050228.......... 01.3595 27.09 050335......... 01.4150 21.78 050455......... 01.8798 21.07 050580......... 01.3781 26.95
050117....................... 01.3267 20.76 050230.......... 01.2951 25.94 050336......... 01.4130 20.42 050456......... 01.1970 20.18 050581......... 01.3780 24.80
050118....................... 01.2333 23.37 050231.......... 01.6985 24.69 050337......... 01.1495 ....... 050457......... 01.9703 28.16 050583......... 01.6354 23.49
050121....................... 01.3937 19.17 050232.......... 01.7553 25.52 050342......... 01.3623 18.03 050459......... 01.2277 28.95 050584......... 01.3226 19.70
050122....................... 01.6961 25.77 050233.......... 01.2032 27.97 050343......... 01.0670 16.57 050464......... 01.8576 23.28 050585......... 01.3155 25.79
050124....................... 01.2423 19.10 050234.......... 01.3174 22.79 050348......... 01.6714 23.57 050468......... 01.4960 16.95 050586......... 01.3724 21.47
050125....................... 01.3763 27.26 050235.......... 01.6109 27.60 050349......... 00.9553 14.75 050469......... 01.1143 18.34 050588......... 01.3158 27.41
050126....................... 01.4878 23.86 050236.......... 01.4932 23.47 050350......... 01.3648 23.74 050470......... 01.1174 18.14 050589......... 01.3257 24.78
050127....................... 01.3437 23.71 050238.......... 01.5338 22.98 050351......... 01.4728 25.95 050471......... 01.8590 22.75 050590......... 01.4087 23.26
050128....................... 01.6436 23.71 050239.......... 01.5382 23.40 050352......... 01.3239 24.08 050476......... 01.3723 21.89 050591......... 01.3400 24.97
050129....................... 01.6051 21.10 050240.......... 01.4190 25.28 050353......... 01.6095 24.23 050477......... 01.5035 30.71 050592......... 01.3555 10.96
050131....................... 01.2869 30.45 050241.......... 01.1960 25.59 050355......... 00.9765 14.97 050478......... 00.9902 20.58 050593......... 01.2968 29.77
050132....................... 01.3955 24.69 050242.......... 01.4397 28.77 050357......... 01.6573 22.99 050481......... 01.4393 25.47 050594......... 01.7813 24.64
050133....................... 01.3425 21.73 050243.......... 01.5606 20.95 050359......... 01.3035 19.88 050482......... 00.9919 17.87 050597......... 01.2725 22.40
050135....................... 01.4336 26.20 050245.......... 01.4468 22.03 050360......... 01.4611 31.81 050483......... 01.2206 22.32 050598......... 01.3740 28.26
050136....................... 01.3719 29.32 050248.......... 01.2339 24.55 050366......... 01.4397 20.59 050485......... 01.6234 22.39 050599......... 01.6928 23.22
050137....................... 01.4283 33.54 050251.......... 01.0786 18.41 050367......... 01.2671 27.02 050486......... 01.4114 24.19 050601......... 01.5776 28.97
050138....................... 01.8936 33.14 050253.......... 00.4249 18.80 050369......... 01.3266 23.77 050488......... 01.3891 29.71 050603......... 01.4318 20.95
050139....................... 01.3165 32.31 050254.......... 01.1859 20.57 050373......... 01.4503 23.73 050491......... 01.2715 24.39 050604......... 01.5600 32.65
050140....................... 01.3987 31.70 050256.......... 01.7909 19.46 050376......... 01.5219 29.05 050492......... 01.3803 21.96 050607......... 01.1803 21.26
050144....................... 01.6121 25.92 050257.......... 01.1417 21.76 050377......... 01.0124 16.26 050494......... 01.3433 24.67 050608......... 01.3295 18.75
050145....................... 01.3641 30.22 050260.......... 00.9856 19.43 050378......... 01.1789 21.42 050496......... 01.7109 32.54 050609......... 01.4415 33.78
050146....................... 01.3641 ....... 050261.......... 01.2236 18.54 050379......... 01.2054 16.93 050497......... 00.7910 ....... 050613......... 01.1557 19.90
050147....................... 00.7180 22.54 050262.......... 01.9911 26.95 050380......... 01.6584 29.85 050498......... 01.2855 22.93 050615......... 01.6609 25.67
050148....................... 01.0787 19.07 050264.......... 01.4171 28.04 050382......... 01.4257 22.15 050502......... 01.6392 21.94 050616......... 01.3575 21.21
050149....................... 01.4959 22.14 050267.......... 01.6375 27.72 050385......... 01.3302 23.94 050503......... 01.3527 23.35 050618......... 01.1704 20.05
050150....................... 01.2339 22.69 050270.......... 01.3328 22.02 050388......... 00.9225 18.08 050506......... 01.3768 24.66 050623......... 01.1288 23.78
050152....................... 01.4212 25.51 050272.......... 01.3318 20.79 050390......... 01.2320 22.09 050510......... 01.3484 32.12 050624......... 01.3772 22.51
050153....................... 01.6647 27.98 050274.......... 00.9872 19.47 050391......... 01.3468 23.34 050512......... 01.5363 33.56 050625......... 01.6035 25.18
050155....................... 01.1114 25.69 050276.......... 01.1317 26.93 050392......... 01.0001 18.23 050515......... 01.3442 31.82 050630......... 01.4327 21.18
050158....................... 01.3645 25.37 050277.......... 01.5093 19.57 050393......... 01.4457 23.72 050516......... 01.5803 24.92 050633......... 01.2943 21.92
050159....................... 01.3879 21.88 050278.......... 01.6159 22.89 050394......... 01.6193 20.12 050517......... 01.3033 20.14 050635......... 01.3173 32.77
050167....................... 01.2549 22.00 050279.......... 01.2261 21.00 050396......... 01.6130 22.02 050522......... 01.3420 31.46 050636......... 01.4701 22.13
050168....................... 01.5423 23.71 050280.......... 01.6858 24.62 050397......... 01.0483 18.22 050523......... 01.3228 29.32 050638......... 01.0334 19.35
050169....................... 01.5157 21.82 050281.......... 01.4700 15.36 050401......... 01.1322 19.06 050526......... 01.3239 24.45 050641......... 01.1904 18.27
050170....................... 01.5731 21.33 050282.......... 01.3631 23.18 050404......... 01.1013 16.60 050528......... 01.3543 21.06 050643......... 00.7614 ......
050172....................... 01.2439 18.44 050283.......... 01.1133 26.91 050406......... 01.0326 15.92 050531......... 01.1911 20.24 050644......... 00.8962 22.79
050173....................... 01.3510 20.24 050286.......... 00.9424 17.82 050407......... 01.3244 28.37 050534......... 01.4107 24.32 050660......... 01.3534 ......
050174....................... 01.6347 29.60 050289.......... 01.8865 26.67 050410......... 01.0841 16.71 050535......... 01.4621 22.87 050661......... 00.8437 20.15
050175....................... 01.3595 27.08 050290.......... 01.6523 20.42 050411......... 01.3695 31.16 050537......... 01.2746 21.53 050662......... 00.8828 22.31
050177....................... 01.2512 20.35 050291.......... 01.2337 25.51 050414......... 01.3022 24.60 050539......... 01.2842 22.25 050663......... 01.1210 25.63
050179....................... 01.3096 19.55 050292.......... 01.0680 21.76 050417......... 01.3212 21.54 050541......... 01.5481 32.88 050666......... 00.8825 20.95
050180....................... 01.6205 30.28 050293.......... 01.1601 18.95 050418......... 01.3206 22.71 050542......... 01.2260 14.92 050667......... 00.9872 24.80
050183....................... 01.1407 20.36 050295.......... 01.4637 21.39 050419......... 01.3491 20.46 050543......... 00.9027 21.76 050668......... 01.1151 28.90
050186....................... 01.3286 23.83 050296.......... 01.2014 22.43 050420......... 01.5295 23.03 050545......... 00.7731 21.20 050670......... 00.8073 ......
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
050674....................... 01.2954 30.71 060047.......... 01.1034 11.84 080004......... 01.3341 18.52 100071......... 01.3325 16.21 100167......... 01.4623 19.21
050675....................... 01.8399 17.60 060049.......... 01.4757 17.92 080005......... 01.3296 18.53 100072......... 01.3143 16.55 100168......... 01.3935 20.23
050676....................... 00.9699 14.37 060050.......... 01.2723 14.36 080006......... 01.3738 19.73 100073......... 01.7698 21.99 100169......... 01.8560 16.01
050677....................... 01.4370 34.53 060052.......... 01.1001 13.04 080007......... 01.4058 17.29 100075......... 01.5932 18.14 100170......... 01.4614 16.86
050678....................... 01.1080 24.44 060053.......... 01.0018 14.81 090001......... 01.5364 21.36 100076......... 01.3528 16.80 100172......... 01.3770 13.93
050680....................... 01.2311 26.19 060054.......... 01.3927 17.69 090002......... 01.3037 19.74 100077......... 01.4090 15.42 100173......... 01.6803 16.87
050682....................... 00.8934 15.55 060056.......... 00.9289 14.05 090003......... 01.3498 23.25 100078......... 01.1911 16.86 100174......... 01.5814 20.80
050684....................... 01.2017 21.85 060057.......... 01.0787 21.47 090004......... 01.8148 23.95 100079......... 01.6046 20.49 100175......... 01.2544 16.65
050685....................... 01.2131 28.69 060058.......... 00.9425 13.87 090005......... 01.3491 17.58 100080......... 01.6282 23.98 100176......... 02.1176 22.94
050686....................... 01.3182 32.30 060060.......... 00.8513 12.53 090006......... 01.3510 19.70 100081......... 01.0520 17.93 100177......... 01.3700 18.76
050688....................... 01.2694 27.87 060062.......... 00.9321 14.11 090007......... 01.2584 20.10 100082......... 01.4548 17.52 100179......... 01.6364 19.38
050689....................... 01.3900 29.96 060063.......... 00.9561 11.82 090008......... 01.5315 23.59 100083......... 01.3327 17.98 100180......... 01.3695 19.01
050690....................... 01.5039 32.26 060064.......... 01.4618 20.71 090010......... 01.1727 22.39 100084......... 01.4579 18.10 100181......... 01.2703 19.10
050693....................... 01.6237 28.58 060065.......... 01.3182 14.86 090011......... 01.9773 24.55 100085......... 01.4195 18.83 100183......... 01.3921 19.62
050694....................... 01.5207 22.78 060066.......... 00.9712 12.79 090015......... 01.1274 ....... 100086......... 01.3141 22.05 100187......... 01.4035 18.31
050695....................... 01.1018 25.42 060068.......... 01.1354 13.46 100001......... 01.5673 18.08 100087......... 01.8739 21.91 100189......... 01.4259 20.87
050696....................... 02.1043 28.17 060070.......... 01.0209 16.03 100002......... 01.4874 19.11 100088......... 01.7311 17.43 100191......... 01.3112 18.63
050697....................... 01.2505 18.05 060071.......... 01.2358 14.39 100004......... 01.0671 13.13 100090......... 01.4104 16.46 100199......... 01.4317 18.30
050698....................... 00.8012 ....... 060073.......... 00.9705 15.25 100006......... 01.6470 19.01 100092......... 01.4498 16.27 100200......... 01.3445 22.72
050699....................... 00.6001 23.01 060075.......... 01.3273 21.20 100007......... 01.8747 19.21 100093......... 01.5386 15.36 100203......... 01.3411 19.70
050700....................... 01.4896 32.32 060076.......... 01.4849 13.62 100008......... 01.7746 20.00 100098......... 01.1597 18.36 100204......... 01.6738 20.97
050701....................... 01.3527 29.00 060085.......... 00.9510 10.30 100009......... 01.5014 19.22 100099......... 01.2979 13.12 100206......... 01.4404 19.98
050702....................... 00.9243 19.02 060087.......... 01.7036 21.04 100010......... 01.5354 22.50 100102......... 01.0888 17.62 100207......... 01.0774 20.37
050704....................... 01.0827 20.41 060088.......... 01.0237 13.86 100012......... 01.6869 15.28 100103......... 01.0707 15.41 100208......... 01.5797 16.92
050707....................... 01.0506 25.90 060090.......... 00.8707 14.19 100014......... 01.4598 18.79 100105......... 01.4627 18.87 100209......... 01.6114 18.40
050708....................... 00.9840 27.17 060096.......... 01.0806 21.65 100015......... 01.3417 18.06 100106......... 01.1273 16.92 100210......... 01.6360 19.34
050709....................... 01.3181 20.44 060100.......... 01.4796 21.75 100017......... 01.5577 16.86 100107......... 01.4057 18.26 100211......... 01.3500 18.47
050710....................... 01.3371 ....... 060103.......... 01.3605 22.66 100018......... 01.3518 20.31 100108......... 01.0616 13.74 100212......... 01.6492 18.75
050711....................... 02.0879 ....... 060104.......... 01.2898 21.84 100019......... 01.5364 18.40 100109......... 01.3631 18.44 100213......... 01.5701 18.46
050712....................... 01.5251 ....... 060107.......... 01.0436 ....... 100020......... 01.3436 20.82 100110......... 01.4229 16.99 100217......... 01.2964 ......
050713....................... 00.8063 ....... 070001.......... 01.7262 26.42 100022......... 01.8721 23.14 100112......... 01.0127 12.61 100220......... 01.9442 18.82
050714....................... 01.3703 ....... 070002.......... 01.7806 26.03 100023......... 01.3697 16.89 100113......... 02.1202 19.34 100221......... 01.6958 19.65
050715....................... 02.2781 ....... 070003.......... 01.1168 25.30 100024......... 01.4016 19.26 100114......... 01.4427 19.70 100222......... 01.4041 18.63
060001....................... 01.5984 20.29 070004.......... 01.2524 23.33 100025......... 01.8800 16.92 100117......... 01.3105 18.77 100223......... 01.4932 16.45
060003....................... 01.2655 18.34 070005.......... 01.4032 25.79 100026......... 01.7148 16.88 100118......... 01.2401 17.18 100224......... 01.4284 21.35
060004....................... 01.3542 20.06 070006.......... 01.3358 28.36 100027......... 00.9139 14.31 100121......... 01.3113 15.75 100225......... 01.4062 20.63
060006....................... 01.1546 16.89 070007.......... 01.4037 23.69 100028......... 01.2619 17.30 100122......... 01.3634 16.54 100226......... 01.4159 18.07
060007....................... 01.2449 14.98 070008.......... 01.2639 23.02 100029......... 01.3393 19.04 100124......... 01.3671 18.33 100228......... 01.3737 20.28
060008....................... 01.0674 14.75 070009.......... 01.3504 23.68 100030......... 01.4017 18.54 100125......... 01.3002 16.50 100229......... 01.3309 16.98
060009....................... 01.4335 19.81 070010.......... 01.6217 23.63 100032......... 01.9242 18.08 100126......... 01.4880 19.41 100230......... 01.4372 15.90
060010....................... 01.5793 21.74 070011.......... 01.3434 25.98 100034......... 01.7166 18.88 100127......... 01.6988 18.39 100231......... 01.6893 16.90
060011....................... 01.2307 20.17 070012.......... 01.2220 23.53 100035......... 01.6482 17.26 100128......... 02.1378 21.19 100232......... 01.2861 18.29
060012....................... 01.4715 17.66 070013.......... 01.3776 26.05 100038......... 01.5648 21.34 100129......... 01.2621 17.91 100234......... 01.5404 19.22
060013....................... 01.3133 19.42 070015.......... 01.4373 24.61 100039......... 01.5732 21.69 100130......... 01.2312 19.48 100235......... 01.4464 18.19
060014....................... 01.7955 22.41 070016.......... 01.3392 24.32 100040......... 01.6729 17.79 100131......... 01.3970 19.68 100236......... 01.4010 18.22
060015....................... 01.5779 20.04 070017.......... 01.3520 24.82 100043......... 01.4528 15.07 100132......... 01.3756 15.46 100237......... 02.1842 21.32
060016....................... 01.1926 13.66 070018.......... 01.4167 27.48 100044......... 01.4332 19.66 100134......... 01.0399 14.63 100238......... 01.5887 16.14
060018....................... 01.2616 16.68 070019.......... 01.1970 25.50 100045......... 01.4239 16.32 100135......... 01.6195 16.63 100239......... 01.4591 19.01
060020....................... 01.6409 14.96 070020.......... 01.3560 25.82 100046......... 01.4950 18.40 100137......... 01.3807 21.08 100240......... 00.9283 19.10
060022....................... 01.6775 18.46 070021.......... 01.2941 25.42 100047......... 01.8196 18.47 100138......... 00.9561 12.12 100241......... 00.9737 13.68
060023....................... 01.6634 15.59 070022.......... 01.8463 24.06 100048......... 00.9771 12.80 100139......... 01.0680 14.97 100242......... 01.4962 16.47
060024....................... 01.7967 23.68 070024.......... 01.3761 24.79 100049......... 01.3198 18.49 100140......... 01.1669 17.64 100243......... 01.4282 17.93
060027....................... 01.6756 20.38 070025.......... 01.8566 25.92 100050......... 01.2296 15.21 100142......... 01.3324 18.12 100244......... 01.4739 18.36
060028....................... 01.5305 20.69 070026.......... 01.1905 25.91 100051......... 01.1793 17.96 100144......... 01.2104 15.29 100246......... 01.4073 20.33
060029....................... 00.9064 11.90 070027.......... 01.2373 25.65 100052......... 01.3796 15.15 100145......... 01.3341 19.01 100248......... 01.7055 17.76
060030....................... 01.2935 18.79 070028.......... 01.5062 24.91 100053......... 01.3598 17.17 100146......... 01.0783 16.01 100249......... 01.3764 19.46
060031....................... 01.6877 18.97 070029.......... 01.4135 22.06 100054......... 01.2986 18.00 100147......... 01.0937 13.18 100252......... 01.2389 19.72
060032....................... 01.5162 17.36 070030.......... 01.3100 26.51 100055......... 01.4205 17.02 100150......... 01.4297 19.30 100253......... 01.4813 19.73
060033....................... 01.1006 12.53 070031.......... 01.2796 22.20 100056......... 01.5140 18.89 100151......... 01.7801 19.37 100254......... 01.6127 17.99
060034....................... 01.4657 22.34 070033.......... 01.3636 26.22 100057......... 01.3902 16.01 100154......... 01.6729 19.96 100255......... 01.2334 19.80
060036....................... 01.0976 14.70 070034.......... 01.3693 27.52 100060......... 01.8124 16.57 100156......... 01.1557 19.34 100256......... 01.9105 18.54
060037....................... 01.0476 13.16 070035.......... 01.4415 23.11 100061......... 01.4729 20.71 100157......... 01.6173 20.46 100258......... 01.6459 21.27
060038....................... 01.0356 12.96 070036.......... 01.6087 27.46 100062......... 01.7513 17.75 100159......... 00.9174 12.79 100259......... 01.4894 17.21
060041....................... 00.9054 14.99 070038.......... 00.6569 ....... 100063......... 01.3311 16.56 100160......... 01.2252 18.48 100260......... 01.4652 18.18
060042....................... 01.1308 16.83 070039.......... 00.9118 ....... 100067......... 01.4572 16.77 100161......... 01.7302 20.07 100262......... 01.4437 18.87
060043....................... 00.9450 13.31 080001.......... 01.6693 24.79 100068......... 01.3737 16.37 100162......... 01.4419 17.78 100263......... 01.4108 17.42
060044....................... 01.2748 16.98 080002.......... 01.2468 17.15 100069......... 01.3912 17.95 100165......... 01.1801 17.55 100264......... 01.3963 17.27
060046....................... 01.0985 16.64 080003.......... 01.3453 20.79 100070......... 01.4493 18.13 100166......... 01.5356 20.44 100265......... 01.3893 14.57
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
100266....................... 01.3543 16.53 110066.......... 01.5373 18.78 110163......... 01.4677 18.54 130010......... 00.9218 15.97 140045......... 01.0701 13.11
100267....................... 01.3514 15.67 110069.......... 01.2620 17.45 110164......... 01.4743 19.38 130011......... 01.3019 17.11 140046......... 01.3156 14.84
100268....................... 01.2084 23.23 110070.......... 01.0204 12.19 110165......... 01.3629 18.35 130012......... 01.0249 20.53 140047......... 01.1477 14.21
100269....................... 01.4373 19.39 110071.......... 01.1790 10.43 110166......... 01.5340 17.45 130013......... 01.2660 17.73 140048......... 01.4300 22.08
100270....................... 00.8331 14.31 110072.......... 01.0020 12.37 110168......... 01.7276 21.92 130014......... 01.3861 16.50 140049......... 01.5619 20.48
100271....................... 01.7336 20.00 110073.......... 01.2235 13.04 110169......... 01.1751 21.80 130015......... 00.8553 13.50 140051......... 01.5442 19.42
100275....................... 01.4056 21.30 110074.......... 01.4581 18.47 110171......... 01.4776 23.10 130016......... 00.9448 17.37 140052......... 01.3719 18.11
100276....................... 01.3013 22.26 110075.......... 01.3606 15.50 110172......... 01.4150 19.98 130017......... 01.1906 12.16 140053......... 01.9805 18.04
100277....................... 01.0705 13.03 110076.......... 01.4330 18.51 110174......... 00.9635 13.19 130018......... 01.7039 17.05 140054......... 01.3509 24.77
100279....................... 01.3599 18.73 110078.......... 01.7041 20.66 110176......... 01.4679 20.47 130019......... 01.1199 14.30 140055......... 01.0282 12.61
100280....................... 01.3737 16.76 110079.......... 01.3878 19.53 110177......... 01.5641 26.95 130021......... 01.0063 11.89 140058......... 01.2459 15.74
100281....................... 01.2632 20.52 110080.......... 01.2776 18.15 110178......... 01.4847 17.04 130022......... 01.2181 16.88 140059......... 01.1721 13.96
100282....................... 01.1209 14.86 110082.......... 02.0374 20.53 110179......... 01.2260 21.81 130024......... 01.1046 16.52 140061......... 01.0962 14.14
110001....................... 01.3058 17.26 110083.......... 01.7844 20.63 110181......... 00.9761 12.32 130025......... 01.0914 14.90 140062......... 01.2671 25.30
110002....................... 01.3046 15.75 110086.......... 01.2415 16.50 110183......... 01.4246 19.97 130026......... 01.1239 17.95 140063......... 01.4646 24.56
110003....................... 01.3363 12.66 110087.......... 01.3388 19.53 110184......... 01.2673 18.82 130027......... 00.9775 17.34 140064......... 01.3532 17.02
110004....................... 01.3702 14.62 110088.......... 00.9425 12.52 110185......... 01.1239 12.44 130028......... 01.2678 18.86 140065......... 01.5856 23.89
110005....................... 01.1514 19.77 110089.......... 01.2376 16.07 110186......... 01.3833 16.69 130029......... 01.0342 15.77 140066......... 01.3043 14.92
110006....................... 01.3756 17.90 110091.......... 01.3391 20.01 110187......... 01.3434 18.27 130030......... 00.9961 17.62 140067......... 01.7847 18.79
110007....................... 01.5428 15.29 110092.......... 01.1754 12.84 110188......... 01.4308 18.16 130031......... 01.0830 12.21 140068......... 01.2187 18.58
110008....................... 01.3479 16.25 110093.......... 00.9511 12.42 110189......... 01.1175 18.39 130034......... 00.9851 17.80 140069......... 01.0051 14.69
110009....................... 00.9912 13.65 110094.......... 01.0069 11.90 110190......... 01.1013 14.95 130035......... 01.0837 19.75 140070......... 01.2390 17.12
110010....................... 02.1120 21.49 110095.......... 01.3192 14.45 110191......... 01.3753 18.34 130036......... 01.3057 13.11 140074......... 00.9695 14.23
110011....................... 01.2439 16.73 110096.......... 01.1454 13.95 110192......... 01.4536 18.88 130037......... 01.1830 16.09 140075......... 01.4767 18.16
110013....................... 01.1025 14.97 110097.......... 01.0230 13.43 110193......... 01.2409 17.43 130043......... 01.0042 15.45 140077......... 01.1605 16.68
110014....................... 01.0251 14.25 110098.......... 01.0549 12.75 110194......... 01.0103 13.81 130044......... 01.1615 12.49 140079......... 01.2434 19.72
110015....................... 01.2373 16.42 110100.......... 01.0948 12.76 110195......... 01.0547 11.35 130045......... 01.0107 12.07 140080......... 01.6408 21.22
110016....................... 01.3073 14.79 110101.......... 01.1688 11.58 110198......... 01.3706 24.04 130048......... 01.0862 13.31 140081......... 01.0883 13.46
110017....................... 00.8645 13.54 110103.......... 00.9623 10.15 110200......... 01.8308 17.05 130049......... 01.2816 18.00 140082......... 01.4304 19.59
110018....................... 01.1509 17.79 110104.......... 01.0884 14.01 110201......... 01.5058 17.52 130054......... 00.8937 17.61 140083......... 01.2423 17.22
110020....................... 01.3489 16.21 110105.......... 01.1793 14.60 110203......... 00.9981 16.30 130056......... 00.8623 11.05 140084......... 01.2287 18.60
110023....................... 01.3467 18.43 110107.......... 01.8204 18.50 110204......... 00.8066 14.34 130058......... 00.7980 14.21 140086......... 01.0844 14.36
110024....................... 01.4873 15.86 110108.......... 00.9459 11.26 110205......... 01.1262 17.06 130060......... 01.3289 19.41 140087......... 01.3932 16.15
110025....................... 01.4274 17.54 110109.......... 01.0965 13.22 110207......... 01.0879 14.02 130061......... 00.9433 ....... 140088......... 01.6631 24.52
110026....................... 01.2118 14.59 110111.......... 01.0973 16.55 110208......... 00.9425 16.97 140001......... 01.2830 14.89 140089......... 01.2551 16.59
110027....................... 01.0878 13.41 110112.......... 01.0848 19.36 110209......... 00.7485 16.39 140002......... 01.3158 18.78 140090......... 01.5315 27.83
110028....................... 01.6494 19.36 110113.......... 01.0936 12.40 110211......... 00.8833 ....... 140003......... 01.0172 14.52 140091......... 01.8017 17.27
110029....................... 01.4094 18.29 110114.......... 01.0742 14.35 110212......... 01.1701 ....... 140004......... 01.1085 16.34 140093......... 01.2049 17.01
110030....................... 01.3314 17.58 110115.......... 01.6026 18.83 110213......... 00.5511 ....... 140005......... 00.9613 09.56 140094......... 01.3951 19.46
110031....................... 01.3083 19.99 110118.......... 00.9744 13.49 120001......... 01.8187 25.27 140007......... 01.4808 21.10 140095......... 01.3952 20.09
110032....................... 01.2678 12.68 110120.......... 01.0246 12.28 120002......... 01.1919 21.80 140008......... 01.5798 19.43 140097......... 00.9670 12.49
110033....................... 01.4341 19.79 110121.......... 01.2022 12.83 120003......... 00.9988 22.69 140010......... 01.3776 22.90 140100......... 01.2499 18.78
110034....................... 01.6158 17.89 110122.......... 01.3880 15.07 120004......... 01.2650 21.72 140011......... 01.1965 16.24 140101......... 01.2224 18.49
110035....................... 01.4328 20.02 110124.......... 01.0850 15.63 120005......... 01.2505 18.94 140012......... 01.2713 18.60 140102......... 01.1118 14.37
110036....................... 01.6901 18.85 110125.......... 01.2330 15.97 120006......... 01.3095 24.62 140013......... 01.5804 15.59 140103......... 01.3585 16.25
110037....................... 01.1697 11.02 110127.......... 00.9362 18.26 120007......... 01.6730 20.90 140014......... 01.1703 16.36 140105......... 01.3031 20.28
110038....................... 01.4654 15.98 110128.......... 01.1824 19.01 120009......... 01.0345 20.40 140015......... 01.2864 14.20 140107......... 01.0708 11.82
110039....................... 01.3778 18.62 110129.......... 01.7854 15.69 120010......... 01.8705 22.71 140016......... 00.9579 11.89 140108......... 01.3575 21.81
110040....................... 01.1216 15.52 110130.......... 01.1667 11.11 120011......... 01.2427 31.56 140018......... 01.4000 19.38 140109......... 01.1766 13.08
110041....................... 01.2723 15.82 110132.......... 01.1264 12.99 120012......... 00.9018 20.20 140019......... 01.1706 12.65 140110......... 01.1931 17.31
110042....................... 01.2740 14.90 110134.......... 00.8904 12.19 120014......... 01.4446 22.59 140024......... 01.0067 13.99 140112......... 01.2240 13.42
110043....................... 01.7886 16.83 110135.......... 01.2960 14.04 120015......... 00.9683 22.77 140025......... 01.0618 16.65 140113......... 01.5112 17.90
110044....................... 01.1491 14.51 110136.......... 01.1904 17.74 120016......... 00.8833 24.58 140026......... 01.2848 15.90 140114......... 01.3527 19.55
110045....................... 01.3219 21.18 110140.......... 01.0308 16.75 120018......... 00.9540 20.92 140027......... 01.3401 16.37 140115......... 01.3235 19.66
110046....................... 01.3498 17.14 110141.......... 00.9566 12.29 120019......... 01.2393 19.16 140029......... 01.3537 21.43 140116......... 01.3021 20.98
110048....................... 01.3678 13.59 110142.......... 00.9492 11.78 120021......... 00.9401 18.74 140030......... 01.8105 21.56 140117......... 01.5387 20.42
110049....................... 01.1275 14.58 110143.......... 01.4530 20.77 120022......... 01.7012 20.74 140031......... 01.2692 13.76 140118......... 01.6525 23.74
110050....................... 01.2031 13.35 110144.......... 01.1556 17.41 120026......... 01.2605 24.26 140032......... 01.2649 16.71 140119......... 01.7173 23.27
110051....................... 01.0351 16.68 110146.......... 01.1397 15.09 120027......... 01.5865 23.43 140033......... 01.2696 19.82 140120......... 01.4595 15.45
110052....................... 01.1211 10.83 110149.......... 01.1585 17.31 120028......... 01.0161 ....... 140034......... 01.1737 17.31 140121......... 01.5411 11.54
110054....................... 01.3426 16.74 110150.......... 01.3211 17.62 130001......... 01.0074 15.75 140035......... 00.9195 11.22 140122......... 01.6593 21.47
110056....................... 01.1733 14.40 110152.......... 01.1023 14.44 130002......... 01.4327 15.30 140036......... 01.2057 16.60 140124......... 01.2337 23.81
110059....................... 01.3170 13.38 110153.......... 01.0180 17.19 130003......... 01.3671 19.28 140037......... 01.1044 12.49 140125......... 01.3616 15.71
110061....................... 01.0750 12.61 110154.......... 00.8218 13.98 130005......... 01.5290 19.49 140038......... 01.1781 16.23 140127......... 01.3910 17.45
110062....................... 00.8945 10.97 110155.......... 01.0541 13.62 130006......... 01.8432 17.59 140040......... 01.2866 14.72 140128......... 01.1137 14.92
110063....................... 01.1481 12.76 110156.......... 01.0382 12.34 130007......... 01.6299 18.20 140041......... 01.3305 16.02 140129......... 01.2232 14.94
110064....................... 01.3361 17.46 110161.......... 01.3274 21.00 130008......... 01.0035 11.00 140042......... 01.0146 14.16 140130......... 01.3672 21.74
110065....................... 01.0387 13.40 110162.......... 00.7936 ....... 130009......... 00.9623 10.74 140043......... 01.2329 17.04 140132......... 01.4410 19.03
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
140133....................... 01.3400 21.21 140231.......... 01.5870 20.80 150044......... 01.2616 18.32 150128......... 01.2192 19.14 160074......... 01.0986 14.30
140135....................... 01.3070 14.91 140233.......... 01.7833 18.47 150045......... 01.1013 15.68 150129......... 01.2359 22.47 160075......... 01.1442 13.73
140137....................... 01.0581 14.58 140234.......... 01.2879 16.47 150046......... 01.5287 15.90 150130......... 01.3560 16.61 160076......... 01.0721 15.50
140138....................... 00.9783 12.15 140236.......... 00.9655 13.24 150047......... 01.5605 22.77 150132......... 01.4103 19.24 160077......... 01.1832 10.60
140139....................... 01.1368 14.70 140239.......... 01.6835 18.73 150048......... 01.2059 16.52 150133......... 01.2128 14.12 160079......... 01.4062 16.28
140140....................... 01.1377 13.06 140240.......... 01.4846 20.44 150049......... 01.1576 13.29 150134......... 01.1751 17.17 160080......... 01.2016 16.06
140141....................... 01.2472 13.84 140242.......... 01.6315 21.68 150050......... 01.2017 14.73 150136......... 01.0663 18.42 160081......... 01.0645 14.77
140143....................... 01.1457 16.54 140245.......... 01.1638 14.66 150051......... 01.4787 18.34 150138......... 01.2073 17.33 160082......... 01.8251 16.81
140144....................... 01.0257 17.83 140246.......... 01.0831 12.05 150052......... 01.1501 14.14 150139......... 01.4731 14.62 160083......... 01.6764 18.37
140145....................... 01.1812 15.14 140250.......... 01.3778 21.98 150053......... 01.0493 18.10 160001......... 01.2878 17.61 160085......... 01.0834 11.50
140146....................... 01.0443 16.38 140251.......... 01.3828 19.16 150054......... 01.1551 12.55 160002......... 01.1687 13.74 160086......... 00.9998 13.93
140147....................... 01.2805 16.29 140252.......... 01.4489 23.41 150056......... 01.7685 22.38 160003......... 01.0196 12.61 160088......... 01.1633 12.63
140148....................... 01.8467 17.11 140253.......... 01.4151 17.49 150057......... 02.3203 18.94 160005......... 01.1311 13.80 160089......... 01.1878 14.80
140150....................... 01.6206 25.55 140258.......... 01.5776 20.93 150058......... 01.7210 19.57 160007......... 01.0312 12.37 160090......... 00.9814 15.58
140151....................... 01.1093 16.64 140271.......... 01.0919 13.06 150059......... 01.4075 19.81 160008......... 01.1302 13.78 160091......... 01.0794 10.80
140152....................... 01.1163 22.91 140275.......... 01.2383 16.50 150060......... 01.1786 14.93 160009......... 01.2377 13.73 160092......... 01.0801 13.23
140155....................... 01.2995 16.96 140276.......... 01.9625 21.37 150061......... 01.2371 15.73 160012......... 01.0291 13.15 160093......... 01.1951 13.86
140158....................... 01.3072 21.36 140280.......... 01.3139 17.16 150062......... 01.1015 16.55 160013......... 01.2292 15.35 160094......... 01.1253 14.17
140160....................... 01.2239 15.93 140281.......... 01.6445 20.89 150063......... 01.0944 17.57 160014......... 01.0153 12.59 160095......... 01.0906 12.79
140161....................... 01.2177 17.76 140285.......... 01.2804 15.37 150064......... 01.2152 15.84 160016......... 01.2509 16.32 160097......... 01.1359 13.00
140162....................... 01.7534 17.96 140286.......... 01.1234 17.93 150065......... 01.1597 18.49 160018......... 00.9242 13.27 160098......... 00.9679 14.70
140164....................... 01.3867 17.44 140288.......... 01.8467 23.17 150066......... 00.9997 15.93 160020......... 01.0709 12.38 160099......... 00.9646 11.69
140165....................... 01.1387 12.90 140289.......... 01.3203 15.75 150067......... 01.1300 15.48 160021......... 01.0687 13.57 160101......... 01.1660 18.64
140166....................... 01.3636 17.21 140290.......... 01.4618 20.95 150069......... 01.2618 16.90 160023......... 01.0402 12.35 160102......... 01.3899 17.51
140167....................... 01.1291 14.97 140291.......... 01.4050 22.95 150070......... 01.0287 18.09 160024......... 01.5249 16.77 160103......... 01.0446 13.57
140168....................... 01.1873 15.57 140292.......... 01.1495 20.63 150071......... 01.1161 13.86 160026......... 01.0600 14.43 160104......... 01.3168 17.37
140170....................... 01.1138 12.53 140294.......... 01.1852 16.20 150072......... 01.2073 15.48 160027......... 01.1589 13.19 160106......... 01.0593 14.03
140171....................... 00.9150 13.87 140297.......... 01.5631 27.06 150073......... 01.0115 19.47 160028......... 01.3379 17.39 160107......... 01.1798 14.12
140172....................... 01.6113 18.71 140300.......... 01.4454 18.71 150074......... 01.5934 18.80 160029......... 01.5125 18.14 160108......... 01.2054 14.95
140173....................... 00.9277 13.77 150001.......... 01.1133 17.36 150075......... 01.1691 14.49 160030......... 01.3826 17.37 160109......... 01.0404 12.35
140174....................... 01.5699 18.33 150002.......... 01.5414 18.35 150076......... 01.2161 20.39 160031......... 01.1167 13.37 160110......... 01.5247 17.97
140176....................... 01.3078 21.33 150003.......... 01.7125 19.57 150077......... 01.1793 16.58 160032......... 01.0998 15.56 160111......... 01.0180 11.04
140177....................... 01.1662 16.52 150004.......... 01.4341 19.97 150078......... 01.0763 15.66 160033......... 01.7830 16.80 160112......... 01.4226 15.00
140179....................... 01.3202 20.12 150005.......... 01.1919 18.43 150079......... 01.1320 13.96 160034......... 01.2076 14.53 160113......... 01.0012 12.03
140180....................... 01.5077 21.03 150006.......... 01.2247 17.31 150082......... 01.5096 17.44 160035......... 01.0372 12.57 160114......... 01.0662 14.21
140181....................... 01.3839 19.20 150007.......... 01.2098 17.98 150084......... 01.8769 22.28 160036......... 00.9736 14.66 160115......... 01.0262 14.32
140182....................... 01.3671 20.67 150008.......... 01.3547 20.70 150086......... 01.3257 16.45 160037......... 01.1645 15.14 160116......... 01.1796 15.68
140184....................... 01.2548 14.26 150009.......... 01.3733 17.26 150088......... 01.3481 17.20 160039......... 01.0816 15.84 160117......... 01.4541 15.96
140185....................... 01.4162 16.78 150010.......... 01.1830 15.87 150089......... 01.4270 18.39 160040......... 01.3227 16.30 160118......... 01.0209 13.15
140186....................... 01.3504 17.74 150011.......... 01.2275 17.83 150090......... 01.2518 18.72 160041......... 01.0845 13.45 160120......... 01.0221 10.62
140187....................... 01.4914 16.54 150012.......... 01.6921 21.01 150091......... 01.1366 15.75 160043......... 01.0364 13.44 160122......... 01.1309 16.24
140188....................... 01.0421 10.77 150013.......... 01.1237 13.90 150092......... 01.0316 15.04 160044......... 01.3189 13.86 160123......... 01.0588 13.19
140189....................... 01.1944 16.64 150014.......... 01.5046 19.79 150094......... 01.0077 16.85 160045......... 01.7635 17.72 160124......... 01.2795 15.87
140190....................... 01.1407 15.99 150015.......... 01.2149 18.14 150095......... 01.1046 17.97 160046......... 01.0030 12.75 160126......... 01.0158 13.59
140191....................... 01.4516 21.87 150017.......... 01.8590 17.20 150096......... 01.1653 17.34 160047......... 01.3670 15.37 160129......... 01.0246 13.75
140193....................... 01.0427 13.31 150018.......... 01.2907 18.23 150097......... 01.1390 17.09 160048......... 01.0373 11.54 160130......... 01.1767 13.02
140197....................... 01.2638 16.96 150019.......... 01.1001 15.47 150098......... 01.1528 13.03 160049......... 00.9469 12.21 160131......... 01.0519 13.55
140199....................... 01.1019 15.72 150020.......... 01.1480 12.96 150099......... 01.2917 17.79 160050......... 01.0771 14.64 160134......... 01.0526 11.84
140200....................... 01.4726 21.79 150021.......... 01.6365 18.34 150100......... 01.7156 17.65 160051......... 00.9637 13.54 160135......... 01.0985 13.67
140202....................... 01.3552 19.71 150022.......... 01.0915 16.65 150101......... 01.1103 14.50 160052......... 01.0883 14.79 160138......... 01.1359 14.36
140203....................... 01.1613 19.32 150023.......... 01.5060 18.19 150102......... 01.0408 14.93 160054......... 01.0719 12.37 160140......... 01.1723 14.75
140205....................... 00.8789 13.64 150024.......... 01.4332 15.82 150103......... 01.0084 15.02 160055......... 00.9789 12.37 160142......... 01.0866 13.98
140206....................... 01.0990 20.81 150025.......... 01.3792 17.57 150104......... 01.0962 15.63 160056......... 01.0863 13.11 160143......... 01.0288 14.24
140207....................... 01.3958 19.86 150026.......... 01.1848 18.29 150105......... 01.3476 16.20 160057......... 01.3468 15.91 160145......... 01.1210 14.16
140208....................... 01.6902 24.07 150027.......... 01.0464 15.55 150106......... 01.0814 16.06 160058......... 01.7356 19.00 160146......... 01.4325 14.59
140209....................... 01.6613 15.85 150029.......... 01.3153 20.17 150109......... 01.4622 16.85 160060......... 01.0454 13.44 160147......... 01.3032 16.09
140210....................... 01.1163 14.00 150030.......... 01.2106 16.69 150110......... 00.9996 17.16 160061......... 01.0424 14.27 160151......... 01.0503 13.74
140211....................... 01.1915 20.84 150031.......... 01.0708 15.56 150111......... 01.1600 14.02 160062......... 00.9471 12.22 160152......... 00.9953 13.78
140212....................... 01.2953 22.47 150032.......... 01.8803 19.50 150112......... 01.3072 17.78 160063......... 01.1653 15.88 160153......... 01.7411 17.48
140213....................... 01.2786 22.67 150033.......... 01.6072 21.09 150113......... 01.2223 17.88 160064......... 01.7118 17.38 170001......... 01.1836 16.35
140215....................... 01.1334 13.49 150034.......... 01.3818 21.18 150114......... 01.0013 14.58 160065......... 01.0236 14.73 170004......... 01.0749 13.28
140217....................... 01.3176 21.67 150035.......... 01.5327 18.97 150115......... 01.3813 17.55 160066......... 01.1729 14.74 170006......... 01.1484 15.02
140218....................... 00.9967 13.65 150036.......... 01.0338 17.43 150122......... 01.1229 17.11 160067......... 01.4129 17.13 170008......... 01.0274 14.53
140220....................... 01.0930 15.16 150037.......... 01.2700 18.20 150123......... 01.2055 12.98 160068......... 01.0648 13.52 170009......... 01.1970 16.31
140223....................... 01.6460 28.23 150038.......... 01.4024 17.22 150124......... 01.1018 15.97 160069......... 01.4530 16.42 170010......... 01.2510 15.77
140224....................... 01.3861 22.97 150039.......... 00.9659 16.33 150125......... 01.3901 18.69 160070......... 01.0492 14.47 170011......... 01.2378 15.40
140228....................... 01.6912 18.22 150042.......... 01.2935 16.00 150126......... 01.5100 20.17 160072......... 01.0731 11.60 170012......... 01.4736 16.07
140230....................... 00.9252 10.84 150043.......... 01.0842 21.96 150127......... 01.0222 13.90 160073......... 00.9698 12.18 170013......... 01.3223 15.33
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
170014....................... 01.0370 16.40 170099.......... 01.2690 11.34 180024......... 01.3887 17.24 180123......... 01.4782 20.98 190089......... 01.0797 11.47
170015....................... 01.0654 14.36 170100.......... 00.9894 14.47 180025......... 01.2127 17.17 180124......... 01.4883 16.52 190090......... 01.1658 16.84
170016....................... 01.6878 19.52 170101.......... 00.9489 13.26 180026......... 01.2402 12.39 180125......... 00.9989 16.46 190092......... 01.3924 ......
170017....................... 01.2514 15.34 170102.......... 00.9926 13.11 180027......... 01.2872 15.58 180126......... 01.2403 12.22 190095......... 01.0682 14.66
170018....................... 01.1580 13.13 170103.......... 01.2089 15.62 180028......... 00.9956 16.39 180127......... 01.4064 17.22 190098......... 01.5365 18.91
170019....................... 01.2248 15.65 170104.......... 01.4523 19.81 180029......... 01.2726 15.97 180128......... 01.1777 16.64 190099......... 01.1522 17.98
170020....................... 01.2902 14.98 170105.......... 01.0963 15.91 180030......... 01.2394 13.31 180129......... 01.0122 14.45 190102......... 01.5599 17.77
170022....................... 01.1764 14.80 170106.......... 00.8931 12.18 180031......... 01.2156 12.60 180130......... 01.4719 17.90 190103......... 00.8797 09.75
170023....................... 01.4631 16.42 170109.......... 01.0364 14.50 180032......... 00.9268 15.83 180132......... 01.2955 15.20 190106......... 01.1725 17.69
170024....................... 01.1492 12.84 170110.......... 00.9602 13.67 180033......... 01.1365 12.86 180133......... 01.3516 24.67 190109......... 01.2172 13.50
170025....................... 01.2269 15.81 170112.......... 00.9859 13.90 180034......... 01.2666 14.14 180134......... 01.0388 13.87 190110......... 00.9373 12.43
170026....................... 01.0364 12.83 170113.......... 01.1485 14.95 180035......... 01.5519 18.73 180136......... 01.6117 16.47 190111......... 01.5969 18.33
170027....................... 01.3447 15.50 170114.......... 01.0128 13.80 180036......... 01.2054 17.01 180137......... 01.8051 18.38 190112......... 01.5890 19.46
170030....................... 01.0153 13.99 170115.......... 01.0256 11.34 180037......... 01.3404 19.24 180138......... 01.2089 17.99 190113......... 01.3609 18.49
170031....................... 00.9092 12.62 170116.......... 01.0473 15.74 180038......... 01.4099 15.04 180139......... 01.1534 18.64 190114......... 01.0160 12.20
170032....................... 01.1650 14.89 170117.......... 00.9415 13.50 180040......... 02.0155 19.20 180140......... 00.8781 ....... 190115......... 01.2261 18.33
170033....................... 01.3716 14.59 170119.......... 00.9812 12.09 180041......... 01.1039 13.42 180141......... 01.7722 ....... 190116......... 01.1859 ......
170034....................... 00.9986 14.61 170120.......... 01.2988 16.06 180042......... 01.1997 13.59 190001......... 00.8676 17.98 190118......... 01.0970 12.38
170035....................... 00.8593 14.82 170122.......... 01.7448 19.93 180043......... 01.0024 15.90 190002......... 01.6866 18.15 190120......... 00.9968 13.75
170036....................... 00.9019 13.19 170123.......... 01.7674 18.76 180044......... 01.1640 16.29 190003......... 01.3870 17.41 190122......... 01.2395 15.70
170037....................... 01.2455 16.31 170124.......... 01.0109 14.25 180045......... 01.2625 16.79 190004......... 01.4157 15.24 190124......... 01.6469 20.23
170038....................... 00.9237 11.46 170126.......... 00.9450 11.50 180046......... 01.2350 16.65 190005......... 01.6124 17.60 190125......... 01.5554 17.99
170039....................... 01.1505 13.62 170128.......... 00.9794 14.42 180047......... 01.0274 13.80 190006......... 01.3045 14.32 190128......... 01.0863 18.56
170040....................... 01.6034 18.83 170131.......... 01.2140 09.38 180048......... 01.2862 16.16 190007......... 01.0078 13.52 190130......... 01.0375 12.09
170041....................... 00.9985 11.29 170133.......... 01.1290 14.20 180049......... 01.3311 15.45 190008......... 01.6673 17.72 190131......... 01.2029 17.84
170043....................... 01.0095 13.49 170134.......... 00.9481 12.48 180050......... 01.2534 16.12 190009......... 01.1641 13.79 190133......... 00.9749 12.08
170044....................... 01.1071 14.42 170137.......... 01.1889 17.30 180051......... 01.4337 14.78 190010......... 01.0476 16.62 190134......... 01.0178 14.79
170045....................... 01.0563 10.72 170139.......... 01.0392 11.82 180053......... 01.0870 14.30 190011......... 01.1711 14.41 190135......... 01.4595 22.58
170049....................... 01.2895 18.28 170142.......... 01.3506 16.49 180054......... 01.1032 13.92 190013......... 01.3959 15.95 190136......... 01.2005 11.22
170051....................... 00.9202 13.66 170143.......... 01.1130 13.82 180055......... 01.1664 14.00 190014......... 01.1136 15.35 190138......... 00.8846 17.51
170052....................... 01.0579 12.60 170144.......... 01.6118 14.73 180056......... 01.0755 16.38 190015......... 01.2530 17.78 190140......... 01.0159 12.16
170053....................... 00.9493 15.39 170145.......... 01.1398 14.83 180058......... 00.9913 12.63 190017......... 01.4476 16.02 190142......... 00.9058 12.39
170054....................... 01.0865 13.19 170146.......... 01.5215 19.54 180059......... 00.9162 12.59 190018......... 01.1915 15.92 190144......... 01.3106 15.22
170055....................... 01.0974 14.55 170147.......... 01.2724 20.70 180060......... 01.0317 10.17 190019......... 01.6064 18.39 190145......... 00.9991 13.66
170056....................... 00.9193 13.72 170148.......... 01.4116 17.64 180063......... 00.9932 10.79 190020......... 01.1832 15.85 190146......... 01.6309 19.61
170057....................... 01.0322 13.90 170150.......... 01.0943 13.41 180064......... 01.3330 14.03 190025......... 01.3568 13.62 190147......... 01.0221 13.69
170058....................... 01.1684 15.80 170151.......... 01.0380 11.66 180065......... 01.0489 10.82 190026......... 01.4936 16.17 190148......... 00.9041 12.77
170060....................... 01.0552 13.41 170152.......... 00.9840 12.99 180066......... 01.1569 18.09 190027......... 01.5788 16.49 190149......... 01.0591 11.47
170061....................... 01.1327 12.90 170160.......... 00.9803 11.17 180067......... 01.8083 16.40 190029......... 01.1538 15.40 190151......... 01.2260 11.73
170063....................... 00.8933 10.92 170164.......... 00.9859 14.42 180069......... 01.0091 15.33 190033......... 00.9378 09.66 190152......... 01.5214 21.27
170064....................... 01.0420 12.09 170166.......... 01.1972 13.65 180070......... 01.1191 14.66 190034......... 01.2430 ....... 190155......... 01.0392 12.29
170066....................... 00.9793 12.58 170168.......... 00.9222 09.33 180072......... 01.0659 13.91 190035......... 01.4118 ....... 190156......... 00.8732 11.99
170067....................... 01.1330 11.76 170171.......... 01.0743 11.22 180075......... 00.9983 14.13 190036......... 01.6967 19.09 190158......... 01.1908 21.59
170068....................... 01.3072 15.24 170175.......... 01.3540 17.53 180078......... 01.1598 17.57 190037......... 00.8920 10.84 190160......... 01.3271 17.03
170069....................... 00.8338 14.01 170176.......... 01.6202 19.83 180079......... 01.3369 13.03 190039......... 01.4018 17.21 190161......... 01.1264 12.65
170070....................... 01.0108 12.56 170182.......... 01.2299 19.43 180080......... 01.0551 15.57 190040......... 01.4401 19.32 190162......... 01.0457 18.47
170073....................... 01.0686 14.67 170183.......... 02.0352 ....... 180085......... 02.3962 17.70 190041......... 01.5646 19.72 190164......... 01.2250 16.05
170074....................... 01.2471 14.34 170184.......... 01.1905 ....... 180087......... 01.1701 13.74 190043......... 01.0428 10.34 190166......... 00.9327 14.04
170075....................... 00.9439 10.67 180001.......... 01.2316 17.03 180088......... 01.5598 19.99 190044......... 01.1694 17.11 190167......... 01.2322 18.49
170076....................... 01.0567 11.60 180002.......... 01.0603 16.78 180092......... 01.2643 15.25 190045......... 01.4023 20.17 190170......... 00.9471 13.08
170077....................... 00.9418 12.07 180004.......... 01.1035 14.42 180093......... 01.3779 16.05 190046......... 01.4623 17.58 190173......... 01.4783 20.12
170079....................... 01.0260 12.66 180005.......... 01.1740 18.54 180094......... 01.0364 11.51 190048......... 01.2789 13.72 190175......... 01.3210 20.26
170080....................... 00.9810 10.65 180006.......... 00.9885 08.94 180095......... 01.2462 12.94 190049......... 00.9967 15.70 190176......... 01.7349 19.11
170081....................... 01.0204 10.44 180007.......... 01.5360 16.29 180099......... 01.3197 12.31 190050......... 01.0290 14.58 190177......... 01.6625 22.84
170082....................... 01.0284 10.80 180009.......... 01.4054 19.11 180101......... 01.3214 18.01 190053......... 01.0739 12.11 190178......... 00.9580 10.87
170084....................... 00.9523 10.93 180010.......... 01.8420 18.19 180102......... 01.4763 16.35 190054......... 01.3377 14.09 190182......... 00.9720 20.02
170085....................... 00.9654 12.69 180011.......... 01.2795 15.29 180103......... 02.1547 17.93 190059......... 00.9194 13.44 190183......... 01.1242 14.79
170086....................... 01.7214 18.21 180012.......... 01.4058 17.50 180104......... 01.5746 18.07 190060......... 01.4488 15.43 190184......... 01.0785 13.09
170087....................... 16.1090 18.78 180013.......... 01.4535 16.63 180105......... 01.0040 12.82 190064......... 01.5938 18.33 190185......... 01.3607 18.53
170088....................... 00.9760 10.80 180014.......... 01.7162 19.99 180106......... 00.8943 12.27 190065......... 01.4991 14.71 190186......... 00.9454 13.16
170089....................... 00.9506 15.53 180015.......... 01.3127 15.02 180108......... 00.8581 13.54 190071......... 00.9010 12.15 190189......... 01.0752 13.17
170090....................... 01.0355 09.80 180016.......... 01.3250 14.50 180115......... 01.0279 14.65 190077......... 00.9526 13.65 190190......... 00.9250 12.66
170092....................... 00.8276 11.80 180017.......... 01.3434 13.87 180116......... 01.4586 15.66 190078......... 01.1684 11.60 190191......... 01.3301 17.54
170093....................... 01.0000 11.76 180018.......... 01.2521 15.27 180117......... 01.1156 17.03 190079......... 01.2501 16.98 190196......... 00.8663 16.29
170094....................... 00.9536 15.42 180019.......... 01.3262 16.70 180118......... 01.0381 12.03 190081......... 00.9078 10.23 190197......... 01.2379 18.98
170095....................... 01.1355 13.69 180020.......... 01.0743 15.86 180120......... 01.0578 13.12 190083......... 01.0626 15.02 190199......... 01.1913 16.26
170097....................... 01.0695 13.17 180021.......... 01.1152 13.69 180121......... 01.2250 13.68 190086......... 01.4134 15.47 190200......... 01.5587 21.70
170098....................... 01.0500 17.00 180023.......... 00.8814 13.12 180122......... 01.0903 15.01 190088......... 01.3480 ....... 190201......... 01.2833 18.93
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[[Page 29962]]
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
190202....................... 01.4766 17.85 210016.......... 01.7183 23.30 220052......... 01.3219 23.88 230020......... 01.7229 22.21 230119......... 01.2933 22.31
190203....................... 01.5123 20.83 210017.......... 01.2282 14.51 220053......... 01.2587 19.48 230021......... 01.6139 17.90 230120......... 01.1815 17.47
190204....................... 01.5847 20.85 210018.......... 01.2505 21.26 220055......... 01.3458 23.52 230022......... 01.3630 18.27 230121......... 01.2515 19.69
190205....................... 01.9222 17.90 210019.......... 01.4996 18.17 220057......... 01.4090 21.39 230024......... 01.4377 23.71 230122......... 01.4048 19.20
190206....................... 01.5538 21.53 210022.......... 01.4510 20.79 220058......... 01.0836 16.26 230027......... 01.1378 15.73 230124......... 01.1675 16.89
190207....................... 01.2984 16.42 210023.......... 01.3643 20.78 220060......... 01.3023 25.32 230029......... 01.5813 20.36 230125......... 01.2969 14.51
190208....................... 00.8122 11.17 210024.......... 01.5608 19.73 220062......... 00.5837 18.78 230030......... 01.2185 16.47 230128......... 01.3868 21.24
190218....................... 01.2002 15.33 210025.......... 01.4079 18.21 220063......... 01.2284 19.40 230031......... 01.4399 19.72 230129......... 01.7831 19.91
190223....................... 00.4249 16.58 210026.......... 01.3745 19.52 220064......... 01.2327 20.51 230032......... 01.7422 19.08 230130......... 01.6706 23.74
190227....................... 00.8285 ....... 210027.......... 01.3025 18.58 220065......... 01.2262 19.58 230034......... 01.2308 17.99 230132......... 01.4109 23.25
190231....................... 01.3101 16.00 210028.......... 01.2213 17.19 220066......... 01.3308 20.73 230035......... 01.1162 16.17 230133......... 01.2205 15.07
190233....................... 02.1157 ....... 210029.......... 01.3148 17.99 220067......... 01.2855 22.58 230036......... 01.2797 19.20 230134......... 01.1074 17.91
190234....................... 01.0506 ....... 210030.......... 01.1531 19.44 220068......... 00.5284 16.67 230037......... 01.1244 17.40 230135......... 01.2667 20.25
190235....................... 01.2925 ....... 210031.......... 01.5487 16.42 220070......... 01.2510 18.77 230038......... 01.7094 21.21 230137......... 01.1940 18.51
190236....................... 01.2520 ....... 210032.......... 01.1786 17.97 220071......... 01.9203 21.67 230040......... 01.2241 20.53 230141......... 01.6811 22.44
200001....................... 01.3789 16.92 210033.......... 01.2619 18.58 220073......... 01.4122 24.14 230041......... 01.2166 20.75 230142......... 01.2194 18.90
200002....................... 01.0690 17.70 210034.......... 01.3724 20.34 220074......... 01.1891 22.82 230042......... 01.2296 19.32 230143......... 01.3149 16.58
200003....................... 01.0950 16.03 210035.......... 01.2687 18.11 220075......... 01.2648 19.51 230046......... 01.8829 25.32 230144......... 01.2245 21.19
200006....................... 01.0479 14.97 210037.......... 01.2430 17.38 220076......... 01.1779 25.46 230047......... 01.3366 20.37 230145......... 01.1813 15.96
200007....................... 01.1177 17.01 210038.......... 01.3268 21.63 220077......... 01.7898 22.92 230053......... 01.6418 24.16 230146......... 01.3082 19.56
200008....................... 01.2260 20.19 210039.......... 01.1902 15.94 220079......... 01.1685 21.68 230054......... 01.8205 21.45 230147......... 01.4359 19.70
200009....................... 01.8101 19.95 210040.......... 01.3322 21.01 220080......... 01.2694 19.58 230055......... 01.1631 18.26 230149......... 01.1837 15.51
200012....................... 01.1118 16.55 210043.......... 01.3061 21.32 220081......... 01.0022 24.81 230056......... 00.9878 14.55 230151......... 01.3894 22.02
200013....................... 01.1203 15.69 210044.......... 01.2653 19.38 220082......... 01.3094 23.04 230058......... 01.1530 18.69 230153......... 01.1308 19.70
200015....................... 01.2329 17.41 210045.......... 01.0746 11.42 220083......... 01.1973 20.43 230059......... 01.4442 19.01 230154......... 00.9371 12.43
200016....................... 01.0114 15.76 210048.......... 01.2062 23.30 220084......... 01.3131 23.23 230060......... 01.3135 17.97 230155......... 00.9376 16.93
200017....................... 01.2508 17.94 210049.......... 01.1553 17.77 220086......... 01.6454 26.01 230062......... 01.0219 14.41 230156......... 01.7147 22.91
200018....................... 01.1950 15.20 210051.......... 01.4237 20.03 220088......... 01.6091 22.68 230063......... 01.3162 19.15 230157......... 01.2050 20.15
200019....................... 01.2411 18.59 210054.......... 01.3298 21.05 220089......... 01.3364 22.69 230065......... 01.3398 19.44 230159......... 01.4900 19.64
200020....................... 01.1431 20.96 210055.......... 01.2663 24.26 220090......... 01.2573 20.95 230066......... 01.3895 20.58 230162......... 01.0467 15.60
200021....................... 01.1730 17.78 210056.......... 01.3807 17.67 220092......... 01.2338 20.66 230068......... 01.4452 22.15 230165......... 01.8500 21.91
200023....................... 00.9047 16.15 210057.......... 01.4127 25.76 220094......... 01.4159 19.82 230069......... 01.1623 21.95 230167......... 01.8077 19.21
200024....................... 01.3239 19.84 210058.......... 01.5368 18.09 220095......... 01.2495 19.06 230070......... 01.5719 19.57 230169......... 01.3462 20.88
200025....................... 01.0831 19.51 210059.......... 01.2633 21.44 220098......... 01.2547 19.71 230071......... 01.1318 22.00 230171......... 01.0260 14.42
200026....................... 01.0264 15.97 210060.......... 01.1827 23.61 220100......... 01.2637 23.69 230072......... 01.2319 19.32 230172......... 01.2802 18.87
200027....................... 01.1198 17.27 210061.......... 01.1772 17.65 220101......... 01.4389 23.41 230075......... 01.4721 19.41 230174......... 01.2980 19.50
200028....................... 00.9739 16.24 220001.......... 01.2891 21.80 220104......... 01.2663 24.79 230076......... 01.3549 22.67 230175......... 03.2600 11.15
200031....................... 01.2810 15.26 220002.......... 01.5403 23.02 220105......... 01.2690 22.16 230077......... 02.0661 18.62 230176......... 01.2365 20.69
200032....................... 01.3464 18.90 220003.......... 01.0737 16.71 220106......... 01.2609 22.14 230078......... 01.1320 15.79 230178......... 01.0169 17.92
200033....................... 01.7900 20.16 220004.......... 01.1625 18.66 220107......... 01.1935 19.21 230080......... 01.2235 20.92 230180......... 01.1055 15.79
200034....................... 01.2370 18.05 220006.......... 01.4299 21.04 220108......... 01.1996 21.13 230081......... 01.2880 16.73 230184......... 01.1528 17.45
200037....................... 01.1965 16.09 220008.......... 01.2944 20.45 220110......... 02.0104 31.74 230082......... 01.2051 15.97 230186......... 01.2241 17.37
200038....................... 01.1089 18.23 220010.......... 01.3126 21.44 220111......... 01.2673 21.76 230085......... 01.1173 17.76 230188......... 01.1832 16.01
200039....................... 01.2710 19.03 220011.......... 01.1495 27.00 220116......... 01.9996 24.40 230086......... 00.9982 14.88 230189......... 00.9248 14.93
200040....................... 01.1083 17.37 220012.......... 01.3759 30.46 220118......... 02.0700 27.44 230087......... 01.0511 17.12 230190......... 01.0342 20.21
200041....................... 01.0939 16.19 220015.......... 01.2326 20.94 220119......... 01.3155 24.27 230089......... 01.2833 21.86 230191......... 00.9127 16.65
200043....................... 00.5261 16.46 220016.......... 01.3818 20.87 220123......... 01.0410 22.86 230092......... 01.3125 18.29 230193......... 01.2154 16.97
200050....................... 01.1881 17.84 220017.......... 01.3923 23.16 220126......... 01.3402 20.63 230093......... 01.2189 18.91 230194......... 01.1126 15.94
200051....................... 00.9540 18.29 220019.......... 01.1528 17.57 220128......... 01.2030 22.97 230095......... 01.1979 16.51 230195......... 01.3113 20.94
200052....................... 00.9785 14.12 220020.......... 01.2405 18.68 220133......... 00.8368 29.15 230096......... 01.1742 20.60 230197......... 01.3274 21.41
200055....................... 01.1748 15.29 220021.......... 01.3591 23.88 220135......... 01.2410 24.67 230097......... 01.5896 19.03 230199......... 01.1798 16.61
200062....................... 00.9125 15.03 220023.......... 01.1731 19.92 220153......... 00.9842 19.37 230099......... 01.1193 18.90 230201......... 01.1765 14.03
200063....................... 01.2559 18.27 220024.......... 01.1999 20.61 220154......... 01.0045 20.83 230100......... 01.2045 14.82 230204......... 01.3907 20.13
200066....................... 01.2145 15.65 220025.......... 01.2157 19.07 220162......... 01.1096 ....... 230101......... 01.0786 17.28 230205......... 01.0309 13.00
210001....................... 01.4356 19.45 220028.......... 01.4895 21.29 220163......... 02.0500 24.21 230103......... 01.0544 17.37 230207......... 01.2603 21.19
210002....................... 02.0230 16.46 220029.......... 01.1509 23.54 220171......... 01.6484 21.72 230104......... 01.6079 21.24 230208......... 01.2419 18.18
210003....................... 01.5440 22.78 220030.......... 01.1149 17.02 230001......... 01.1916 18.72 230105......... 01.6872 19.47 230211......... 00.9353 14.11
210004....................... 01.3603 21.20 220031.......... 02.0045 27.24 230002......... 01.2647 18.80 230106......... 01.3041 18.64 230212......... 01.0711 22.89
210005....................... 01.2340 18.52 220033.......... 01.3841 19.62 230003......... 01.1461 18.79 230107......... 00.9245 11.54 230213......... 01.0327 13.19
210006....................... 01.0978 17.09 220035.......... 01.3154 19.49 230004......... 01.6848 24.03 230108......... 01.2343 18.02 230216......... 01.6063 19.50
210007....................... 01.6805 20.55 220036.......... 01.5943 22.33 230005......... 01.2552 18.69 230110......... 01.3941 17.31 230217......... 01.2397 19.60
210008....................... 01.3375 19.03 220038.......... 01.2899 21.60 230006......... 01.1051 15.91 230111......... 00.9878 20.02 230219......... 00.9329 16.58
210009....................... 01.8279 19.93 220041.......... 01.2094 21.02 230007......... 01.0602 17.82 230113......... 00.9779 18.07 230221......... 01.1053 17.78
210010....................... 01.1891 16.40 220042.......... 01.2025 25.43 230012......... 00.8670 11.92 230114......... 00.6687 25.66 230222......... 01.3897 18.46
210011....................... 01.2786 21.24 220046.......... 01.3746 22.27 230013......... 01.3024 20.55 230115......... 01.0054 15.79 230223......... 01.3120 21.86
210012....................... 01.6309 21.50 220049.......... 01.3183 21.16 230015......... 01.1332 19.54 230116......... 00.9536 14.84 230227......... 01.4688 22.63
210013....................... 01.2397 18.65 220050.......... 01.0938 18.78 230017......... 01.5764 20.51 230117......... 01.9408 25.77 230230......... 01.6754 21.30
210015....................... 01.2814 18.58 220051.......... 01.2100 20.56 230019......... 01.4991 22.60 230118......... 01.2214 16.37 230232......... 00.9775 18.31
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
230235....................... 01.0781 14.12 240066.......... 01.4071 18.87 240153......... 01.0196 15.01 250058......... 01.1577 13.20 260013......... 01.1118 13.85
230236....................... 01.2952 21.82 240069.......... 01.2110 18.58 240154......... 01.0483 14.45 250059......... 01.0878 14.15 260014......... 01.7489 18.62
230239....................... 01.1617 16.38 240071.......... 01.1304 17.67 240155......... 00.9544 16.25 250060......... 00.7824 10.79 260015......... 01.3467 12.13
230241....................... 01.1064 17.56 240072.......... 01.0864 17.53 240157......... 01.1171 11.54 250061......... 00.8592 09.59 260017......... 01.2916 14.90
230244....................... 01.3649 21.20 240073.......... 00.9499 15.03 240160......... 00.9811 15.61 250063......... 00.8532 12.96 260018......... 00.9287 10.14
230253....................... 00.9665 18.09 240075.......... 01.1872 19.26 240161......... 00.9741 14.77 250065......... 00.9879 11.60 260019......... 01.0354 12.50
230254....................... 01.2851 21.85 240076.......... 01.1127 20.82 240162......... 00.9969 15.08 250066......... 00.9303 14.05 260020......... 01.6667 20.95
230257....................... 00.8588 18.77 240077.......... 00.9355 12.01 240163......... 00.9492 14.68 250067......... 01.1448 15.22 260021......... 01.5105 18.46
230259....................... 01.1900 19.63 240078.......... 01.5064 21.81 240166......... 01.0768 15.70 250068......... 00.8507 09.05 260022......... 01.2935 16.51
230264....................... 01.0350 19.01 240079.......... 01.0497 13.53 240169......... 00.9590 15.46 250069......... 01.4085 13.92 260023......... 01.3238 16.81
230269....................... 01.3679 22.82 240080.......... 01.4036 21.73 240170......... 01.1704 14.40 250071......... 00.9017 10.90 260024......... 00.9481 12.58
230270....................... 01.2231 20.42 240082.......... 01.0921 15.87 240171......... 01.0490 14.30 250072......... 01.3515 16.19 260025......... 01.2386 14.22
230273....................... 01.5750 21.61 240083.......... 01.3718 16.80 240172......... 01.0622 14.86 250076......... 01.5698 08.95 260027......... 01.5497 20.66
230275....................... 00.5014 16.62 240084.......... 01.3050 17.76 240173......... 00.9755 14.79 250077......... 00.9412 11.54 260029......... 01.1498 16.88
230276....................... 00.6978 17.39 240085.......... 00.9625 15.55 240179......... 01.0886 15.05 250078......... 01.4494 14.35 260030......... 01.1773 10.35
230277....................... 01.2413 21.07 240086.......... 01.0751 15.22 240184......... 01.0883 11.77 250079......... 00.8992 13.59 260031......... 01.5413 18.47
230278....................... 01.8525 21.54 240087.......... 01.1768 15.74 240187......... 01.1726 18.89 250081......... 01.3362 15.13 260032......... 01.6098 18.24
230279....................... 00.6928 15.06 240088.......... 01.4371 18.72 240193......... 01.0850 15.54 250082......... 01.2704 12.99 260034......... 01.0286 15.30
230280....................... 01.0834 14.88 240089.......... 00.9741 15.79 240196......... 00.6150 22.86 250083......... 01.0222 10.67 260035......... 01.0464 11.67
240001....................... 01.5829 22.07 240090.......... 01.0683 13.53 240200......... 00.9031 13.54 250084......... 01.1161 15.95 260036......... 01.0354 18.28
240002....................... 01.7321 20.58 240093.......... 01.3423 16.86 240205......... 01.0263 ....... 250085......... 00.9835 12.43 260037......... 01.4487 15.56
240004....................... 01.5187 21.05 240094.......... 00.9944 17.38 240206......... 00.9489 ....... 250088......... 00.9095 14.66 260039......... 01.1663 12.17
240005....................... 01.0260 15.07 240096.......... 00.9798 14.74 240207......... 01.2775 22.23 250089......... 01.1705 13.27 260040......... 01.6606 15.94
240006....................... 01.1157 20.02 240097.......... 01.1033 16.59 240210......... 01.2460 22.69 250093......... 01.1086 12.75 260042......... 01.2618 16.91
240007....................... 01.0770 15.81 240098.......... 00.9404 16.39 240211......... 00.9749 11.52 250094......... 01.2615 14.92 260044......... 01.0947 14.86
240008....................... 01.0674 16.32 240099.......... 01.0613 10.76 250001......... 01.4462 16.92 250095......... 01.0173 14.72 260047......... 01.4608 15.90
240009....................... 01.0015 14.35 240100.......... 01.2931 18.57 250002......... 00.8377 14.44 250096......... 01.2796 15.77 260048......... 01.2353 19.25
240010....................... 01.9721 21.16 240101.......... 01.1796 17.70 250003......... 01.0188 15.17 250097......... 01.3210 13.86 260050......... 01.0944 14.63
240011....................... 01.1609 15.71 240102.......... 00.9246 12.87 250004......... 01.4728 16.68 250098......... 00.8666 14.72 260052......... 01.3374 16.89
240013....................... 01.3128 16.96 240103.......... 01.0718 13.76 250005......... 01.0621 10.43 250099......... 01.3193 12.67 260053......... 01.1600 10.83
240014....................... 01.0888 19.10 240104.......... 01.1878 21.72 250006......... 00.9609 14.73 250100......... 01.2720 14.27 260054......... 01.3127 14.83
240016....................... 01.3772 16.31 240105.......... 01.0170 12.35 250007......... 01.2969 18.24 250101......... 00.8782 09.75 260055......... 01.0240 08.93
240017....................... 01.1960 15.66 240106.......... 01.3854 23.85 250008......... 00.9267 11.91 250102......... 01.6506 14.59 260057......... 01.1561 14.12
240018....................... 01.3341 17.17 240107.......... 00.9699 14.74 250009......... 01.1981 15.81 250104......... 01.4465 16.31 260059......... 01.2358 11.75
240019....................... 01.1978 20.69 240108.......... 00.9818 12.35 250010......... 01.0279 11.88 250105......... 00.9253 11.52 260061......... 01.1336 11.91
240020....................... 01.1520 20.05 240109.......... 00.9741 12.06 250012......... 00.9496 13.18 250107......... 00.8880 14.99 260062......... 01.2041 17.75
240021....................... 01.0040 13.13 240110.......... 00.9880 14.66 250015......... 01.1038 10.43 250109......... 00.9626 12.97 260063......... 01.1241 15.61
240022....................... 01.1175 18.13 240111.......... 01.0008 15.65 250017......... 00.9756 14.92 250112......... 00.9502 14.95 260064......... 01.3140 15.06
240023....................... 01.1030 16.17 240112.......... 01.0031 14.22 250018......... 01.0885 11.21 250117......... 01.0120 13.39 260065......... 01.7943 16.07
240025....................... 01.1264 14.54 240114.......... 00.8987 13.21 250019......... 01.4959 16.51 250119......... 01.1151 11.59 260066......... 01.0288 15.31
240027....................... 01.0390 15.50 240115.......... 01.6552 21.53 250020......... 00.9499 11.47 250120......... 01.0895 13.47 260067......... 00.9511 10.89
240028....................... 01.1812 18.14 240116.......... 00.9626 12.54 250021......... 00.9247 08.33 250122......... 01.2652 ....... 260068......... 01.6948 19.07
240029....................... 01.2178 17.00 240117.......... 01.1416 17.40 250023......... 00.8534 ....... 250123......... 01.3253 18.31 260070......... 01.0659 12.16
240030....................... 01.2841 17.33 240119.......... 00.8875 17.45 250024......... 00.9649 08.37 250124......... 00.9106 11.28 260073......... 01.0302 11.87
240031....................... 00.9917 13.83 240121.......... 00.9321 17.85 250025......... 01.1328 15.43 250125......... 01.3287 18.00 260074......... 01.3216 17.26
240036....................... 01.5683 19.89 240122.......... 01.0774 16.25 250027......... 01.0193 11.14 250126......... 00.9981 13.81 260077......... 01.7111 16.86
240037....................... 01.0458 17.05 240123.......... 01.0910 13.80 250029......... 00.8793 11.91 250127......... 00.7920 10.67 260078......... 01.2189 14.84
240038....................... 01.4741 24.33 240124.......... 00.9979 16.84 250030......... 00.9896 11.25 250128......... 01.1005 11.81 260079......... 01.0347 11.96
240040....................... 01.1842 19.00 240125.......... 00.8791 12.16 250031......... 01.3389 17.65 250131......... 00.9868 10.41 260080......... 01.0511 10.85
240041....................... 01.2649 15.42 240127.......... 01.1121 12.16 250032......... 01.2654 15.27 250134......... 00.9827 15.67 260081......... 01.5218 18.50
240043....................... 01.2140 17.60 240128.......... 01.1105 14.99 250033......... 01.1181 12.63 250136......... 00.9255 15.06 260082......... 01.1931 13.85
240044....................... 01.1785 16.75 240129.......... 01.0693 13.13 250034......... 01.6285 13.70 250138......... 01.2517 16.52 260085......... 01.5637 18.89
240045....................... 01.1184 18.25 240130.......... 01.0707 15.14 250035......... 00.8781 13.38 250141......... 01.2420 16.11 260086......... 00.9979 13.83
240047....................... 01.5057 19.66 240132.......... 01.2513 21.26 250036......... 01.0177 10.97 250145......... 00.9900 ....... 260089......... 01.0806 12.16
240048....................... 01.2505 21.83 240133.......... 01.1407 16.89 250037......... 00.8362 09.52 250146......... 01.0321 12.44 260091......... 01.6471 20.21
240049....................... 01.7838 21.16 240135.......... 00.8896 11.98 250038......... 00.9499 12.49 250148......... 01.1361 15.43 260094......... 01.2145 17.53
240050....................... 01.1393 22.26 240137.......... 01.2269 15.99 250039......... 01.0330 12.23 250149......... 00.9132 13.16 260095......... 01.4120 15.92
240051....................... 00.9412 14.60 240138.......... 00.9554 12.39 250040......... 01.3374 16.36 260001......... 01.6349 16.67 260096......... 01.5939 23.01
240052....................... 01.2644 18.14 240139.......... 00.9722 14.07 250042......... 01.2430 13.72 260002......... 01.4569 20.60 260097......... 01.1570 16.79
240053....................... 01.5109 19.37 240141.......... 01.1688 18.92 250043......... 01.0013 11.48 260003......... 00.9755 13.10 260100......... 01.0555 13.31
240056....................... 01.2706 21.66 240142.......... 01.1018 15.56 250044......... 00.9982 14.17 260004......... 01.0307 12.81 260102......... 01.0503 17.58
240057....................... 01.7848 21.08 240143.......... 01.1208 11.76 250045......... 01.1343 17.75 260005......... 01.6937 20.17 260103......... 01.3951 16.96
240058....................... 00.9673 10.32 240144.......... 01.0057 13.66 250047......... 00.9900 11.39 260006......... 01.4647 16.81 260104......... 01.7016 19.61
240059....................... 01.1120 19.63 240145.......... 00.9274 12.01 250048......... 01.5333 14.39 260007......... 01.6398 14.42 260105......... 01.8395 21.04
240061....................... 01.7782 21.05 240146.......... 00.9883 18.68 250049......... 00.9030 11.19 260008......... 01.2717 16.18 260107......... 01.4283 19.39
240063....................... 01.5142 22.26 240148.......... 01.0886 08.84 250050......... 01.2902 12.79 260009......... 01.2279 15.64 260108......... 01.8648 18.57
240064....................... 01.2569 20.39 240150.......... 00.8880 12.16 250051......... 00.8720 08.88 260011......... 01.6382 17.12 260109......... 00.9885 11.86
240065....................... 01.0639 10.79 240152.......... 01.0422 18.29 250057......... 01.2899 14.84 260012......... 01.1117 12.21 260110......... 01.5646 14.92
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[[Page 29964]]
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
260113....................... 01.0840 14.31 270036.......... 00.9396 09.94 280051......... 01.1961 13.85 290022......... 01.6834 20.50 310043......... 01.2814 19.99
260115....................... 01.2379 14.59 270039.......... 01.0701 12.96 280052......... 00.9828 12.52 290027......... 00.9705 15.03 310044......... 01.3355 20.03
260116....................... 01.1035 13.89 270040.......... 01.0918 19.79 280054......... 01.2699 16.10 290032......... 01.4454 18.24 310045......... 01.4264 27.62
260119....................... 01.1902 13.28 270041.......... 01.0742 11.52 280055......... 00.9226 12.19 290036......... 01.0395 13.90 310047......... 01.3550 24.05
260120....................... 01.2141 14.60 270044.......... 01.1489 14.40 280056......... 01.0135 13.28 290038......... 00.9396 17.61 310048......... 01.2514 21.34
260122....................... 01.1460 13.40 270046.......... 00.9270 13.70 280057......... 00.9801 15.61 290039......... 01.3445 ....... 310049......... 01.3215 23.91
260123....................... 01.0152 14.74 270048.......... 01.0798 14.13 280058......... 01.3647 14.36 300001......... 01.3832 21.03 310050......... 01.2306 21.48
260127....................... 00.9860 13.88 270049.......... 01.8351 19.31 280060......... 01.5777 18.24 300003......... 01.8909 21.59 310051......... 01.3464 23.27
260128....................... 01.0214 09.22 270050.......... 01.0761 17.43 280061......... 01.4895 15.95 300005......... 01.2724 19.13 310052......... 01.2876 21.19
260129....................... 01.2044 13.52 270051.......... 01.3392 18.76 280062......... 01.1457 12.55 300006......... 01.1393 17.36 310054......... 01.3052 23.97
260131....................... 01.4057 15.91 270052.......... 01.0912 12.73 280064......... 01.0808 13.94 300007......... 01.1629 17.04 310056......... 01.3867 20.63
260134....................... 01.1566 14.28 270053.......... 00.9396 09.78 280065......... 01.2724 17.49 300008......... 01.2128 18.30 310057......... 01.2933 23.67
260137....................... 01.5528 14.25 270057.......... 01.2166 12.70 280066......... 01.0334 11.48 300009......... 01.1536 18.16 310058......... 01.0905 26.79
260138....................... 01.8916 21.17 270058.......... 00.9506 11.51 280068......... 01.0867 09.89 300010......... 01.2286 17.88 310060......... 01.1999 18.73
260141....................... 01.9538 17.10 270059.......... 00.8656 15.65 280070......... 01.0111 10.30 300011......... 01.3592 22.07 310061......... 01.2544 20.23
260142....................... 01.2385 13.99 270060.......... 00.9132 13.26 280073......... 01.0115 13.94 300012......... 01.3391 21.42 310062......... 01.2896 24.98
260143....................... 00.9915 11.96 270063.......... 00.9457 14.23 280074......... 01.1316 12.68 300013......... 01.1451 17.06 310063......... 01.3667 21.28
260147....................... 01.0192 12.91 270068.......... 00.9009 15.59 280075......... 01.2286 13.10 300014......... 01.2207 19.36 310064......... 01.2739 22.29
260148....................... 00.9522 09.30 270072.......... 00.7732 11.39 280076......... 01.0462 12.93 300015......... 01.1783 18.08 310067......... 01.3277 23.76
260158....................... 01.1073 11.77 270073.......... 01.1623 11.16 280077......... 01.3438 17.26 300016......... 01.2027 15.73 310069......... 01.2844 20.03
260159....................... 01.0850 19.81 270074.......... 00.8727 ....... 280079......... 01.2143 10.42 300017......... 01.2359 21.96 310070......... 01.4051 22.98
260160....................... 01.0956 11.84 270075.......... 00.9757 ....... 280080......... 01.0583 12.11 300018......... 01.2174 19.62 310072......... 01.2857 20.57
260162....................... 01.5758 19.55 270076.......... 00.7920 ....... 280081......... 01.6898 18.79 300019......... 01.2701 18.77 310073......... 01.6784 23.53
260163....................... 01.3316 15.35 270079.......... 00.9171 13.66 280082......... 01.0127 13.48 300020......... 01.2718 20.72 310074......... 01.4649 22.61
260164....................... 00.9996 12.17 270080.......... 01.2061 15.83 280083......... 01.0991 14.54 300021......... 01.1855 15.34 310075......... 01.3852 23.13
260166....................... 01.2350 21.39 270081.......... 01.0741 12.39 280084......... 01.0433 11.01 300022......... 01.1119 17.22 310076......... 01.4347 28.74
260172....................... 00.9974 13.47 270082.......... 01.0739 14.18 280088......... 01.7879 17.98 300023......... 01.2955 19.78 310077......... 01.5659 23.51
260173....................... 01.0051 11.78 270083.......... 01.0517 16.28 280089......... 01.0322 14.37 300024......... 01.1815 16.74 310078......... 01.2978 24.59
260175....................... 01.1637 14.99 270084.......... 00.9318 14.12 280090......... 00.9935 13.49 300028......... 01.2393 16.75 310081......... 01.2833 21.29
260176....................... 01.7266 18.43 280001.......... 01.1165 12.98 280091......... 01.2101 14.18 300029......... 01.3274 22.44 310083......... 01.2856 22.33
260177....................... 01.3281 20.42 280003.......... 02.0364 18.79 280092......... 00.8896 12.18 300033......... 01.1182 13.69 310084......... 01.3535 20.99
260178....................... 01.4918 18.91 280005.......... 01.4366 16.76 280094......... 01.0535 14.07 300034......... 02.0357 23.32 310086......... 01.2273 21.30
260179....................... 01.6454 18.70 280009.......... 01.7536 17.25 280097......... 01.0852 12.27 310001......... 01.7927 25.90 310087......... 01.2824 19.26
260180....................... 01.6989 20.07 280011.......... 00.8644 11.91 280098......... 00.9677 10.40 310002......... 01.7252 26.26 310088......... 01.2278 20.64
260183....................... 01.5585 16.14 280012.......... 01.3033 15.43 280101......... 01.0917 13.18 310003......... 01.2649 24.08 310090......... 01.2311 24.50
260186....................... 01.2994 15.97 280013.......... 01.8329 20.31 280102......... 01.1442 12.76 310005......... 01.2313 20.54 310091......... 01.3337 20.80
260188....................... 01.2526 18.64 280014.......... 00.9614 13.39 280104......... 00.9770 10.84 310006......... 01.2035 19.56 310092......... 01.3119 20.70
260189....................... 00.8480 11.26 280015.......... 01.0138 15.19 280105......... 01.3787 17.28 310008......... 01.3813 22.73 310093......... 01.1685 19.79
260190....................... 01.2487 18.90 280017.......... 01.1011 13.94 280106......... 00.9285 13.93 310009......... 01.2826 22.80 310096......... 01.8614 23.17
260191....................... 01.2524 17.92 280018.......... 01.0931 13.35 280107......... 01.0876 11.13 310010......... 01.2543 20.81 310105......... 01.2399 23.63
260193....................... 01.2325 18.75 280020.......... 01.6141 18.93 280108......... 01.2094 13.96 310011......... 01.2880 21.55 310108......... 01.4305 21.85
260195....................... 01.1677 14.49 280021.......... 01.3229 15.49 280109......... 00.9160 09.80 310012......... 01.5919 24.30 310110......... 01.2375 20.38
260197....................... 01.1436 17.26 280022.......... 01.0087 12.52 280110......... 01.0169 11.19 310013......... 01.2782 21.84 310111......... 01.3032 20.46
260198....................... 01.3417 15.86 280023.......... 01.4104 14.77 280111......... 01.2167 15.63 310014......... 01.6890 24.26 310112......... 01.3240 21.02
260200....................... 01.3591 19.10 280024.......... 00.9413 13.05 280114......... 00.9785 12.99 310015......... 01.9538 24.97 310113......... 01.2381 20.60
270002....................... 01.2857 15.06 280025.......... 00.9422 12.14 280115......... 00.9481 14.77 310016......... 01.2557 22.34 310115......... 01.2937 19.31
270003....................... 01.2209 19.76 280026.......... 01.0322 15.28 280117......... 01.1926 14.47 310017......... 01.3633 23.40 310116......... 01.2358 21.84
270004....................... 01.7072 19.74 280028.......... 01.0549 14.53 280118......... 00.9922 15.17 310018......... 01.1279 20.55 310118......... 01.2541 22.53
270006....................... 01.0910 14.78 280029.......... 01.2160 14.02 280119......... 00.8653 ....... 310019......... 01.6089 23.53 310119......... 01.6063 30.37
270007....................... 00.9226 13.18 280030.......... 01.7242 24.40 280123......... 00.9506 15.63 310020......... 01.2426 21.55 310120......... 01.0681 17.44
270009....................... 01.0828 15.34 280031.......... 01.0182 13.10 290001......... 01.6689 21.85 310021......... 01.3936 22.03 310121......... 01.1650 20.34
270011....................... 01.0735 15.52 280032.......... 01.3285 15.57 290002......... 00.9842 17.79 310022......... 01.2809 21.47 320001......... 01.4673 17.14
270012....................... 01.6735 18.11 280033.......... 01.1021 14.24 290003......... 01.6564 20.74 310024......... 01.3576 22.85 320002......... 01.3450 20.13
270013....................... 01.4138 17.77 280034.......... 01.3125 13.86 290005......... 01.4911 19.03 310025......... 01.2579 22.27 320003......... 01.1854 15.65
270014....................... 01.7993 16.86 280035.......... 00.9238 11.81 290006......... 01.1665 16.15 310026......... 01.2329 22.67 320004......... 01.2651 17.19
270016....................... 00.9333 13.23 280037.......... 01.0189 14.28 290007......... 01.9072 27.06 310027......... 01.3359 20.94 320005......... 01.3181 18.87
270017....................... 01.3074 18.67 280038.......... 01.0809 14.53 290008......... 01.1850 18.73 310028......... 01.1829 21.21 320006......... 01.3623 15.96
270019....................... 01.0378 14.02 280039.......... 01.1314 13.99 290009......... 01.5619 22.25 310029......... 01.9763 22.49 320009......... 01.5982 16.52
270021....................... 01.1585 16.23 280040.......... 01.6182 18.67 290010......... 01.1281 11.93 310031......... 02.8592 24.35 320011......... 01.0288 17.06
270023....................... 01.3591 20.08 280041.......... 00.9200 11.80 290011......... 01.0270 14.67 310032......... 01.3459 21.17 320012......... 00.9809 16.21
270024....................... 00.9898 13.05 280042.......... 01.1024 13.11 290012......... 01.3986 20.67 310034......... 01.2650 21.26 320013......... 01.1612 19.19
270026....................... 00.9412 12.95 280043.......... 01.0606 14.76 290013......... 01.0582 15.39 310036......... 01.1459 19.86 320014......... 01.1014 11.24
270027....................... 01.0785 11.91 280045.......... 01.2844 13.63 290014......... 01.0288 16.38 310037......... 01.3381 26.92 320016......... 01.1858 13.77
270028....................... 01.0843 15.37 280046.......... 01.1494 11.04 290015......... 01.0017 15.15 310038......... 02.0243 23.35 320017......... 01.1639 16.85
270029....................... 00.9485 16.24 280047.......... 01.0939 15.34 290016......... 01.2292 19.81 310039......... 01.2854 21.42 320018......... 01.5091 17.37
270032....................... 01.1184 15.80 280048.......... 01.1833 12.06 290019......... 01.3453 19.06 310040......... 01.2606 24.06 320019......... 01.5428 22.95
270033....................... 00.8853 12.19 280049.......... 01.0480 13.30 290020......... 01.0868 17.66 310041......... 01.3379 21.96 320021......... 01.7525 17.31
270035....................... 01.0156 17.11 280050.......... 00.9680 13.11 290021......... 01.6469 19.51 310042......... 01.2137 22.13 320022......... 01.2437 16.07
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
320023....................... 00.9909 16.72 330059.......... 01.5929 29.90 330171......... 01.3206 21.95 330268......... 01.0351 14.44 340023......... 01.4078 17.97
320030....................... 01.0522 18.27 330061.......... 01.3120 23.60 330175......... 01.1547 14.34 330270......... 01.9728 32.47 340024......... 01.1778 15.07
320031....................... 00.9076 12.36 330062.......... 01.1602 15.58 330177......... 01.0010 13.74 330273......... 01.3703 23.35 340025......... 01.1795 14.80
320032....................... 00.9382 15.10 330064.......... 01.4487 29.63 330179......... 00.8711 14.38 330275......... 01.3086 18.58 340027......... 01.1882 15.59
320033....................... 01.1251 20.90 330065.......... 01.1874 17.24 330180......... 01.1878 16.40 330276......... 01.1943 17.02 340028......... 01.5461 17.32
320035....................... 00.9732 14.60 330066.......... 01.3105 17.53 330181......... 01.3086 30.46 330277......... 01.1399 16.32 340030......... 02.0657 20.58
320037....................... 01.2259 15.59 330067.......... 01.3362 20.60 330182......... 02.4681 28.41 330279......... 01.3463 18.52 340031......... 01.0087 11.97
320038....................... 01.2177 13.85 330072.......... 01.3519 27.86 330183......... 01.5110 18.72 330285......... 01.7826 22.52 340032......... 01.3862 18.60
320046....................... 01.2515 18.15 330073.......... 01.1568 14.87 330184......... 01.3693 26.85 330286......... 01.3178 24.25 340035......... 01.1812 15.73
320048....................... 01.3042 17.40 330074.......... 01.2164 17.15 330185......... 01.3284 25.44 330290......... 01.7803 29.90 340036......... 01.2483 17.33
320056....................... 00.9777 ....... 330075.......... 01.0811 17.25 330186......... 00.8858 19.79 330293......... 01.1544 13.43 340037......... 01.1212 15.85
320057....................... 00.9961 ....... 330078.......... 01.3881 17.05 330188......... 01.2058 18.28 330304......... 01.2543 26.20 340038......... 01.0711 15.42
320058....................... 00.8563 ....... 330079.......... 01.2322 17.05 330189......... 01.4328 16.85 330306......... 01.4671 27.44 340039......... 01.2888 19.52
320059....................... 01.1577 ....... 330080.......... 01.4470 27.21 330191......... 01.3327 17.06 330307......... 01.2478 19.43 340040......... 01.7915 18.22
320060....................... 00.9420 ....... 330084.......... 01.0602 16.46 330193......... 01.3167 27.97 330308......... 01.2513 29.68 340041......... 01.2345 17.24
320061....................... 01.1055 ....... 330085.......... 01.3285 18.64 330194......... 01.8377 25.39 330309......... 01.2698 24.10 340042......... 01.1974 14.01
320062....................... 00.9114 ....... 330086.......... 01.2430 24.99 330195......... 01.6497 29.85 330314......... 01.4597 22.18 340044......... 01.0183 13.44
320063....................... 01.2900 12.84 330088.......... 01.0583 24.62 330196......... 01.3112 28.36 330315......... 16.1090 25.23 340045......... 00.9957 09.61
320065....................... 01.3717 16.38 330090.......... 01.5512 16.76 330197......... 01.0557 14.99 330316......... 01.2631 21.85 340047......... 01.8712 18.39
320067....................... 00.8637 17.64 330091.......... 01.3277 18.50 330198......... 01.4009 22.87 330327......... 00.9920 16.17 340048......... 00.9368 14.02
320068....................... 00.8811 14.99 330092.......... 01.1181 14.07 330199......... 01.4019 26.06 330331......... 01.2272 29.77 340049......... 00.6961 13.94
320069....................... 00.9953 10.67 330094.......... 01.1757 16.51 330201......... 01.6400 27.62 330332......... 01.2979 25.01 340050......... 01.1971 17.37
320070....................... 00.9025 ....... 330095.......... 01.2329 17.55 330202......... 01.6494 28.76 330333......... 01.2530 23.81 340051......... 01.3335 16.08
320074....................... 01.0790 17.04 330096.......... 01.0910 15.45 330203......... 01.3914 19.06 330336......... 01.3462 28.99 340052......... 01.0094 18.41
320079....................... 01.1541 17.22 330097.......... 01.2372 15.36 330204......... 01.3917 28.09 330338......... 01.2385 23.09 340053......... 01.6620 19.08
330001....................... 01.1750 25.49 330100.......... 00.7187 26.07 330205......... 01.1520 20.29 330339......... 00.8847 18.73 340054......... 01.1119 13.09
330002....................... 01.4149 25.22 330101.......... 01.7628 33.56 330208......... 01.2512 24.55 330340......... 01.1888 21.17 340055......... 01.1909 17.40
330003....................... 01.3160 17.67 330102.......... 01.3509 17.47 330209......... 01.2145 23.11 330350......... 01.8002 28.27 340060......... 01.1481 16.69
330004....................... 01.3302 19.08 330103.......... 01.2729 16.46 330211......... 01.1985 17.23 330353......... 01.3364 30.33 340061......... 01.6989 19.91
330005....................... 01.7965 20.49 330104.......... 01.3856 26.74 330212......... 01.1045 21.12 330354......... 01.5239 ....... 340063......... 01.0467 13.08
330006....................... 01.2737 23.92 330106.......... 01.5963 34.42 330213......... 01.1784 15.72 330357......... 01.3755 33.49 340064......... 01.2127 17.10
330007....................... 01.3460 17.71 330107.......... 01.3256 21.55 330214......... 01.7511 29.72 330359......... 00.9233 19.54 340065......... 01.3418 14.39
330008....................... 01.2046 15.62 330108.......... 01.2169 16.28 330215......... 01.2278 15.66 330372......... 01.2025 24.47 340067......... 01.2760 15.88
330009....................... 01.3758 30.32 330111.......... 01.0618 14.81 330218......... 01.1332 17.94 330381......... 01.1984 28.03 340068......... 01.2350 14.77
330010....................... 01.2804 15.07 330114.......... 00.9802 16.13 330219......... 01.6757 19.13 330385......... 01.1745 26.83 340069......... 01.7385 19.47
330011....................... 01.3292 17.98 330115.......... 01.2205 15.23 330221......... 01.3401 27.53 330386......... 01.1994 23.03 340070......... 01.3821 17.57
330012....................... 01.7032 31.01 330116.......... 00.9768 14.21 330222......... 01.2792 17.64 330387......... 01.0268 23.95 340071......... 01.0850 15.08
330013....................... 02.0647 17.36 330118.......... 01.6278 18.94 330223......... 01.0631 15.37 330389......... 01.7543 29.43 340072......... 01.0658 15.20
330014....................... 01.3775 28.72 330119.......... 01.7614 33.48 330224......... 01.2427 18.20 330390......... 01.2733 30.36 340073......... 01.5479 20.23
330016....................... 01.0528 15.47 330121.......... 01.0392 16.10 330225......... 01.1712 24.38 330393......... 01.7116 27.22 340075......... 01.2024 16.26
330019....................... 01.2906 25.33 330122.......... 01.0841 21.84 330226......... 01.2737 16.28 330394......... 01.5398 18.37 340080......... 01.0616 12.72
330020....................... 01.0589 15.26 330125.......... 01.8638 19.53 330229......... 01.3073 15.69 330395......... 01.2975 30.64 340084......... 01.0587 15.61
330023....................... 01.2488 23.30 330126.......... 01.1887 22.34 330230......... 01.4289 28.69 330396......... 01.3518 31.58 340085......... 01.1725 15.65
330024....................... 01.8102 30.17 330127.......... 01.3382 25.03 330231......... 01.0965 29.91 330397......... 01.2796 25.47 340087......... 01.1033 16.01
330025....................... 01.1843 16.20 330128.......... 01.3718 27.71 330232......... 01.2398 16.42 330398......... 01.2707 26.92 340088......... 01.1389 16.22
330027....................... 01.4582 30.93 330132.......... 01.0795 14.60 330233......... 01.5355 29.70 330399......... 01.2655 29.65 340089......... 01.0362 12.85
330028....................... 01.4159 24.95 330133.......... 01.3670 30.50 330234......... 02.2504 29.60 340001......... 01.5501 19.47 340090......... 01.1535 17.15
330029....................... 01.0093 19.09 330135.......... 01.1584 18.28 330235......... 01.1446 18.33 340002......... 01.8976 18.38 340091......... 01.7185 19.42
330030....................... 01.2056 16.22 330136.......... 01.2983 16.54 330236......... 01.4017 27.87 340003......... 01.1485 17.08 340093......... 01.0725 12.10
330033....................... 01.2685 13.82 330140.......... 01.7550 17.51 330238......... 01.2317 14.19 340004......... 01.4880 17.16 340094......... 01.4425 17.65
330034....................... 00.7483 32.72 330141.......... 01.3513 24.27 330239......... 01.1938 15.39 340005......... 01.1584 13.24 340096......... 01.1689 17.33
330036....................... 01.2233 22.66 330144.......... 00.9795 13.70 330240......... 01.3306 27.41 340006......... 01.0906 14.60 340097......... 01.1822 16.61
330037....................... 01.1592 14.92 330148.......... 01.0842 14.58 330241......... 01.9041 22.30 340007......... 01.1627 16.20 340098......... 01.7248 19.46
330038....................... 01.2091 14.81 330151.......... 01.0739 14.55 330242......... 01.3798 23.99 340008......... 01.1478 16.55 340099......... 01.1578 12.70
330039....................... 00.8379 14.25 330152.......... 01.4451 28.88 330245......... 01.3025 17.35 340009......... 01.4763 19.70 340101......... 01.1697 11.80
330041....................... 01.3314 30.19 330153.......... 01.7110 17.15 330246......... 01.3563 25.33 340010......... 01.3230 16.97 340104......... 00.8557 12.36
330043....................... 01.3067 26.43 330154.......... 01.6447 ....... 330247......... 00.7683 25.98 340011......... 01.1353 14.36 340105......... 01.3824 17.94
330044....................... 01.2714 17.50 330157.......... 01.3606 19.48 330249......... 01.1711 15.98 340012......... 01.3201 15.92 340106......... 01.2125 18.52
330045....................... 01.4023 26.05 330158.......... 01.4101 23.06 330250......... 01.3091 16.77 340013......... 01.2494 15.63 340107......... 01.4157 16.68
330046....................... 01.4855 29.75 330159.......... 01.3179 18.08 330252......... 00.8801 15.72 340014......... 01.5841 22.01 340109......... 01.3465 16.84
330047....................... 01.2553 16.37 330160.......... 01.4447 28.65 330254......... 01.1655 15.21 340015......... 01.2963 17.05 340111......... 01.1815 13.75
330048....................... 01.2233 16.94 330161.......... 00.7222 16.75 330258......... 01.3709 26.99 340016......... 01.2058 15.58 340112......... 01.0676 13.87
330049....................... 01.3230 17.81 330162.......... 01.2585 26.51 330259......... 01.5058 22.66 340017......... 01.2663 15.96 340113......... 01.9984 21.03
330053....................... 01.1834 15.15 330163.......... 01.2525 18.88 330261......... 01.2898 25.24 340018......... 01.1806 15.29 340114......... 01.5616 19.74
330055....................... 01.4840 31.04 330164.......... 01.3791 19.40 330263......... 01.0205 18.52 340019......... 01.0455 13.86 340115......... 01.5419 18.15
330056....................... 01.3098 27.72 330166.......... 01.0009 15.11 330264......... 01.2445 23.18 340020......... 01.2079 17.65 340116......... 01.8193 20.54
330057....................... 01.6936 16.97 330167.......... 01.7072 28.82 330265......... 01.3598 16.53 340021......... 01.2692 16.22 340119......... 01.2909 16.28
330058....................... 01.3085 16.22 330169.......... 01.4102 32.57 330267......... 01.2237 23.35 340022......... 01.0376 14.98 340120......... 01.0939 12.31
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
340121....................... 01.1272 15.36 350043.......... 01.7063 16.69 360064......... 01.6051 21.61 360145......... 01.6513 17.67 370015......... 01.2714 14.88
340123....................... 01.1203 16.92 350044.......... 00.8706 10.29 360065......... 01.2767 17.59 360147......... 01.2402 15.85 370016......... 01.4234 15.52
340124....................... 01.0590 13.70 350047.......... 01.1747 16.78 360066......... 01.4340 18.88 360148......... 01.1244 17.65 370017......... 01.0984 11.48
340125....................... 01.4925 18.36 350049.......... 01.2578 10.74 360067......... 01.2694 12.77 360149......... 01.2274 17.72 370018......... 01.3359 16.48
340126....................... 01.4255 16.47 350050.......... 00.9351 10.74 360068......... 01.7278 22.41 360150......... 01.2493 19.17 370019......... 01.2722 13.17
340127....................... 01.2939 15.72 350051.......... 00.9967 15.46 360069......... 01.1325 16.74 360151......... 01.3575 17.46 370020......... 01.2996 12.51
340129....................... 01.2947 17.50 350053.......... 01.0948 10.34 360070......... 01.7308 17.18 360152......... 01.4717 17.88 370021......... 00.8951 09.76
340130....................... 01.4418 17.46 350055.......... 00.8596 12.12 360071......... 01.3511 16.78 360153......... 01.1783 14.12 370022......... 01.2960 16.91
340131....................... 01.5306 17.10 350056.......... 00.9765 12.81 360072......... 01.2123 16.99 360154......... 01.0363 12.79 370023......... 01.3264 15.36
340132....................... 01.4381 13.48 350058.......... 00.8581 12.32 360074......... 01.3755 19.42 360155......... 01.3328 19.43 370025......... 01.3632 16.03
340133....................... 01.0955 14.59 350060.......... 00.7725 07.81 360075......... 01.4503 20.74 360156......... 01.3471 17.17 370026......... 01.4139 16.34
340137....................... 01.1470 16.93 350061.......... 01.0750 14.05 360076......... 01.3497 17.88 360159......... 01.2236 19.63 370028......... 01.9000 19.01
340138....................... 01.0564 14.77 350063.......... 00.8496 ....... 360077......... 01.5372 19.34 360161......... 01.2522 19.38 370029......... 01.2231 13.67
340141....................... 01.6712 19.46 350064.......... 00.9598 ....... 360078......... 01.3085 20.54 360162......... 01.2461 18.42 370030......... 01.2222 15.66
340142....................... 01.2328 14.52 350066.......... 00.4249 ....... 360079......... 01.8680 21.00 360163......... 01.8359 19.83 370032......... 01.5723 15.46
340143....................... 01.4477 17.07 360001.......... 01.3378 16.97 360080......... 01.1089 15.47 360164......... 00.9012 14.82 370033......... 01.0214 11.30
340144....................... 01.3647 18.62 360002.......... 01.2156 16.93 360081......... 01.3825 19.32 360165......... 01.1732 14.70 370034......... 01.2608 13.35
340145....................... 01.4178 16.83 360003.......... 01.7711 21.00 360082......... 01.3422 20.33 360166......... 01.2022 14.95 370035......... 01.6224 16.49
340146....................... 01.0449 12.52 360006.......... 01.7569 20.88 360083......... 01.2835 16.28 360170......... 01.3679 17.38 370036......... 01.1150 10.48
340147....................... 01.3116 18.57 360007.......... 01.0845 16.02 360084......... 01.6050 19.41 360172......... 01.3918 16.51 370037......... 01.7463 17.69
340148....................... 01.5003 18.58 360008.......... 01.2538 17.40 360085......... 01.7758 20.40 360174......... 01.3082 17.57 370038......... 00.9813 11.67
340151....................... 01.2153 15.08 360009.......... 01.3941 17.80 360086......... 01.4419 18.21 360175......... 01.2537 18.78 370039......... 01.4120 14.24
340153....................... 01.8958 19.07 360010.......... 01.1953 16.42 360087......... 01.4087 17.90 360176......... 01.1682 14.85 370040......... 01.0735 12.21
340155....................... 01.4075 20.03 360011.......... 01.3112 18.17 360088......... 01.2554 16.38 360177......... 01.3012 16.97 370041......... 01.0348 14.17
340156....................... 00.8391 ....... 360012.......... 01.2910 19.29 360089......... 01.1463 17.74 360178......... 01.1912 16.88 370042......... 00.8602 12.67
340158....................... 01.2118 16.64 360013.......... 01.1166 17.72 360090......... 01.2393 19.06 360179......... 01.2984 19.34 370043......... 00.9396 13.83
340159....................... 01.1739 17.58 360014.......... 01.1725 17.98 360091......... 01.2353 19.17 360180......... 02.1422 22.61 370045......... 01.0172 10.45
340160....................... 01.1173 13.34 360016.......... 01.5863 17.93 360092......... 01.1745 18.70 360184......... 00.4826 16.57 370046......... 01.0071 11.67
340162....................... 01.1881 17.44 360017.......... 01.8234 20.42 360093......... 01.2346 16.69 360185......... 01.2323 17.09 370047......... 01.3660 15.46
340164....................... 01.5854 18.61 360018.......... 01.6349 19.27 360094......... 01.3179 19.51 360186......... 01.1303 14.23 370048......... 01.2382 14.10
340166....................... 01.3581 20.11 360019.......... 01.2464 19.11 360095......... 01.2963 17.00 360187......... 01.3922 16.45 370049......... 01.3876 15.65
340168....................... 00.5171 14.86 360020.......... 01.4455 19.77 360096......... 01.1048 16.11 360188......... 00.9743 15.83 370051......... 00.9683 12.64
340171....................... 01.1309 20.34 360021.......... 01.2171 17.75 360098......... 01.3545 17.96 360189......... 01.0832 16.02 370054......... 01.4892 15.09
340173....................... 01.2673 ....... 360024.......... 01.4066 18.60 360099......... 01.0438 15.01 360192......... 01.3251 20.42 370056......... 01.5847 18.24
350001....................... 01.0123 11.96 360025.......... 01.2789 18.44 360100......... 01.2631 16.54 360193......... 01.3592 16.93 370057......... 01.1516 13.78
350002....................... 01.7485 15.76 360026.......... 01.3183 16.15 360101......... 01.5633 19.00 360194......... 01.2185 16.98 370059......... 01.1145 17.59
350003....................... 01.1883 16.16 360027.......... 01.5006 19.53 360102......... 01.3173 20.31 360195......... 01.1450 18.15 370060......... 01.0938 12.84
350004....................... 01.9386 17.55 360028.......... 01.3927 16.15 360103......... 01.3791 19.64 360197......... 01.2415 18.15 370063......... 01.0275 13.43
350005....................... 01.1692 12.94 360029.......... 01.1968 17.00 360106......... 01.0835 14.96 360200......... 01.0110 14.16 370064......... 01.0078 10.63
350006....................... 01.4616 15.92 360030.......... 01.2855 16.35 360107......... 01.2884 17.73 360203......... 01.1551 15.13 370065......... 00.9984 15.50
350007....................... 00.9387 11.95 360031.......... 01.3350 18.56 360108......... 01.0393 15.34 360204......... 01.1958 17.97 370071......... 01.0541 11.99
350008....................... 00.9665 15.65 360032.......... 01.0939 18.26 360109......... 01.0943 17.32 360210......... 01.1513 19.78 370072......... 00.9059 12.83
350009....................... 01.2060 15.95 360034.......... 01.2933 13.90 360112......... 01.8152 22.51 360211......... 01.2508 18.78 370076......... 01.2821 12.00
350010....................... 01.2000 12.15 360035.......... 01.5996 20.13 360113......... 01.3358 19.54 360212......... 01.3943 19.17 370077......... 01.1968 16.27
350011....................... 01.9051 17.35 360036.......... 01.3867 17.62 360114......... 01.0899 17.10 360213......... 01.1498 17.17 370078......... 01.6755 14.49
350012....................... 01.2168 11.99 360037.......... 02.0410 20.51 360115......... 01.2893 17.95 360218......... 01.3251 16.46 370079......... 00.9520 12.41
350013....................... 01.0734 15.32 360038.......... 01.5770 18.07 360116......... 01.1193 16.64 360230......... 01.5118 19.37 370080......... 00.9631 11.68
350014....................... 01.0043 15.46 360039.......... 01.3058 16.07 360118......... 01.3823 18.32 360231......... 01.0811 12.11 370082......... 00.8621 13.46
350015....................... 01.6873 15.63 360040.......... 01.4255 17.31 360121......... 01.2332 17.90 360234......... 01.3514 18.54 370083......... 00.9402 11.35
350016....................... 01.0383 10.92 360041.......... 01.3554 18.33 360123......... 01.1988 18.37 360236......... 01.2821 17.59 370084......... 01.1283 11.02
350017....................... 01.4320 15.24 360042.......... 01.1544 17.62 360125......... 01.0770 17.38 360239......... 01.3231 19.51 370085......... 00.8919 14.52
350018....................... 01.0665 11.21 360044.......... 01.1752 15.64 360126......... 01.2087 20.09 360241......... 00.5984 18.86 370086......... 01.1210 07.79
350019....................... 01.6314 18.43 360045.......... 01.5364 20.90 360127......... 01.2267 16.48 360242......... 01.6845 ....... 370089......... 01.2563 13.16
350020....................... 01.7038 20.24 360046.......... 01.1470 19.88 360128......... 01.1952 14.73 360243......... 00.7548 15.52 370091......... 01.7651 17.18
350021....................... 01.0657 11.41 360047.......... 01.1546 13.65 360129......... 01.0119 14.59 360244......... 00.6196 15.74 370092......... 01.0486 14.38
350023....................... 00.9037 15.30 360048.......... 01.7847 21.55 360130......... 01.1375 15.59 360245......... 00.7558 14.33 370093......... 01.8654 18.71
350024....................... 01.0898 15.40 360049.......... 01.2053 18.18 360131......... 01.3635 17.38 360247......... 00.4249 ....... 370094......... 01.4086 17.00
350025....................... 01.0197 13.34 360050.......... 01.1555 12.37 360132......... 01.3113 18.78 370001......... 01.7020 18.73 370095......... 00.9433 11.66
350027....................... 00.9438 12.32 360051.......... 01.6065 22.36 360133......... 01.4867 18.44 370002......... 01.2595 13.98 370097......... 01.4514 18.02
350029....................... 00.8818 13.02 360052.......... 01.7593 18.41 360134......... 01.7147 19.43 370004......... 01.3100 15.35 370099......... 01.1946 12.65
350030....................... 00.9790 15.93 360054.......... 01.2902 15.83 360135......... 01.1776 16.82 370005......... 01.0107 13.12 370100......... 00.9605 13.45
350033....................... 00.9672 14.33 360055.......... 01.2729 19.12 360136......... 01.0797 15.96 370006......... 01.2229 15.08 370103......... 00.9375 15.07
350034....................... 00.9622 14.56 360056.......... 01.4338 16.47 360137......... 01.6205 18.82 370007......... 01.2258 13.82 370105......... 01.9925 16.23
350035....................... 00.8570 09.95 360057.......... 01.1143 13.87 360140......... 01.0283 16.19 370008......... 01.4034 16.68 370106......... 01.5287 16.46
350038....................... 01.0474 14.07 360058.......... 01.3442 16.66 360141......... 01.4692 21.06 370011......... 01.0552 12.95 370108......... 01.0528 11.73
350039....................... 01.0412 13.84 360059.......... 01.5702 20.39 360142......... 00.9974 15.98 370012......... 00.8901 09.07 370112......... 01.0761 13.21
350041....................... 00.9787 14.99 360062.......... 01.5152 19.27 360143......... 01.3979 18.13 370013......... 01.7959 19.41 370113......... 01.2411 16.23
350042....................... 01.0876 11.16 360063.......... 01.1537 18.08 360144......... 01.3184 20.77 370014......... 01.2915 18.49 370114......... 01.6734 15.49
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
370121....................... 01.1456 17.38 380035.......... 01.3707 19.01 390037......... 01.3363 18.93 390118......... 01.2116 16.26 390211......... 01.2753 16.99
370122....................... 01.1334 07.58 380036.......... 01.0573 20.26 390039......... 01.1242 15.66 390119......... 01.3751 17.59 390213......... 01.0005 16.41
370123....................... 01.2119 12.32 380037.......... 01.1645 19.53 390040......... 00.9636 13.13 390121......... 01.3408 17.47 390215......... 01.2741 21.06
370125....................... 01.0078 13.37 380038.......... 01.3353 22.64 390041......... 01.3184 17.07 390122......... 01.0708 17.57 390217......... 01.2339 18.51
370126....................... 00.9515 15.34 380039.......... 01.3785 29.30 390042......... 01.5616 21.73 390123......... 01.3538 20.71 390219......... 01.3280 19.67
370131....................... 01.0025 12.88 380040.......... 01.2637 19.96 390043......... 01.1718 14.85 390125......... 01.2277 15.61 390220......... 01.1974 19.37
370133....................... 01.1482 10.09 380042.......... 01.1658 20.57 390044......... 01.6542 19.63 390126......... 01.2947 21.03 390222......... 01.3127 20.33
370138....................... 01.1319 15.23 380047.......... 01.7042 22.12 390045......... 01.7640 18.05 390127......... 01.2463 20.96 390223......... 01.5485 23.11
370139....................... 01.1351 12.56 380048.......... 01.0410 14.68 390046......... 01.6118 19.79 390128......... 01.2129 18.14 390224......... 00.9185 13.35
370140....................... 00.9528 10.99 380050.......... 01.3882 17.45 390047......... 01.7879 28.26 390130......... 01.1528 17.20 390225......... 01.2038 17.25
370141....................... 01.3712 17.30 380051.......... 01.5603 20.05 390048......... 01.1662 16.60 390131......... 01.2893 16.30 390226......... 01.7722 24.15
370146....................... 01.0068 10.73 380052.......... 01.1841 16.75 390049......... 01.6471 20.69 390132......... 01.3456 15.42 390228......... 01.2584 19.38
370148....................... 01.5163 18.46 380055.......... 01.1753 24.14 390050......... 02.1332 22.39 390133......... 01.8248 21.71 390231......... 01.3380 25.11
370149....................... 01.2715 15.35 380056.......... 01.0662 17.36 390051......... 02.2314 25.28 390135......... 01.3067 21.05 390233......... 01.3166 17.22
370153....................... 01.1566 13.86 380060.......... 01.4332 21.98 390052......... 01.2173 19.41 390136......... 01.1980 15.39 390235......... 01.6737 24.38
370154....................... 00.9918 13.05 380061.......... 01.5328 22.07 390054......... 01.2362 16.08 390137......... 01.5014 16.35 390236......... 01.2218 15.88
370156....................... 01.0804 12.49 380062.......... 01.1673 14.40 390055......... 01.8446 21.81 390138......... 01.3175 17.93 390237......... 01.5879 20.36
370158....................... 00.9865 11.75 380063.......... 01.2839 19.01 390056......... 01.1627 16.81 390139......... 01.5583 23.54 390238......... 01.4187 16.51
370159....................... 01.2579 15.59 380064.......... 01.3699 21.25 390057......... 01.2722 18.70 390142......... 01.6478 23.18 390242......... 01.2892 18.48
370163....................... 00.8584 12.16 380065.......... 01.0989 22.49 390058......... 01.3320 18.67 390145......... 01.3920 19.48 390244......... 00.8955 09.83
370165....................... 01.2002 12.46 380066.......... 01.4293 18.58 390060......... 01.1507 16.92 390146......... 01.2908 16.44 390245......... 01.3725 23.05
370166....................... 01.1412 16.32 380068.......... 01.0536 19.05 390061......... 01.4904 19.08 390147......... 01.2386 19.08 390246......... 01.2495 17.25
370169....................... 01.0923 11.25 380069.......... 01.1444 18.59 390062......... 01.2096 16.01 390150......... 01.1114 18.10 390247......... 01.0371 18.26
370170....................... 01.0998 ....... 380070.......... 01.3975 21.24 390063......... 01.7632 19.24 390151......... 01.2811 18.58 390249......... 00.9800 12.06
370171....................... 01.0602 ....... 380071.......... 01.3430 20.07 390065......... 01.2783 19.30 390152......... 01.0751 18.81 390256......... 01.8447 23.21
370172....................... 00.9962 ....... 380072.......... 00.9558 14.66 390066......... 01.3181 17.77 390153......... 01.2365 22.46 390258......... 01.2636 20.08
370173....................... 01.1720 ....... 380075.......... 01.4074 19.72 390067......... 01.7805 18.91 390154......... 01.2353 16.67 390260......... 01.2223 21.36
370174....................... 01.1211 ....... 380078.......... 01.1136 17.41 390068......... 01.2705 17.23 390155......... 01.2835 19.44 390262......... 02.1044 17.77
370176....................... 01.1786 15.29 380081.......... 01.0882 18.84 390069......... 01.2052 17.75 390156......... 01.4384 21.37 390263......... 01.4788 19.16
370177....................... 01.0146 10.09 380082.......... 01.3415 22.96 390070......... 01.2877 20.39 390157......... 01.3442 17.99 390265......... 01.2975 18.82
370178....................... 01.0038 10.96 380083.......... 01.2329 20.06 390071......... 01.1345 13.41 390158......... 01.5815 18.96 390266......... 01.1903 16.81
370179....................... 00.8178 17.33 380084.......... 01.3178 21.43 390072......... 01.0884 15.91 390160......... 01.2481 18.50 390267......... 01.2766 19.80
370180....................... 00.9743 ....... 380087.......... 01.0131 15.38 390073......... 01.6228 19.03 390161......... 01.1216 14.43 390268......... 01.3984 20.44
370183....................... 01.0112 12.06 380088.......... 01.0312 16.16 390074......... 01.3104 16.05 390162......... 01.4567 19.59 390270......... 01.3195 16.67
370186....................... 01.0207 13.15 380089.......... 01.3743 22.25 390075......... 01.3024 16.41 390163......... 01.2442 15.99 390272......... 00.5086 ......
370189....................... 00.9532 07.82 380090.......... 01.3216 25.71 390076......... 01.3560 21.07 390164......... 02.1520 20.37 390277......... 00.5135 22.55
370190....................... 01.5726 15.31 380091.......... 01.2636 25.13 390078......... 01.0405 16.88 390166......... 01.1028 18.31 390278......... 00.6667 18.42
370192....................... 01.3093 17.57 390001.......... 01.3377 18.25 390079......... 01.7573 16.81 390167......... 01.3539 21.30 390279......... 01.0585 15.32
370194....................... 01.8498 ....... 390002.......... 01.3642 18.62 390080......... 01.3310 19.14 390168......... 01.2630 18.43 390281......... 02.6697 ......
370195....................... 01.7510 ....... 390003.......... 01.2533 15.88 390081......... 01.3720 22.88 390169......... 01.2861 18.72 390282......... 02.8720 ......
370196....................... 01.2186 ....... 390004.......... 01.4312 18.12 390083......... 01.1651 22.01 390170......... 01.9027 21.25 400001......... 01.3075 08.65
370197....................... 01.0898 ....... 390005.......... 01.0800 14.24 390084......... 01.1937 15.57 390173......... 01.1957 17.78 400002......... 01.5650 11.00
380001....................... 01.3595 21.21 390006.......... 01.7512 18.17 390086......... 01.2015 15.86 390174......... 01.7556 25.41 400003......... 01.2778 08.44
380002....................... 01.1948 19.35 390007.......... 01.1629 21.90 390088......... 01.3108 22.62 390176......... 01.1738 18.14 400004......... 01.1644 08.18
380003....................... 01.2011 20.71 390008.......... 01.1581 15.47 390090......... 01.8609 18.97 390178......... 01.2971 18.44 400005......... 01.0829 06.61
380004....................... 01.7699 23.34 390009.......... 01.6156 17.81 390091......... 01.1345 17.40 390179......... 01.3028 22.12 400006......... 01.1988 07.59
380005....................... 01.2498 21.15 390010.......... 01.1928 17.10 390093......... 01.1545 14.99 390180......... 01.5562 23.40 400007......... 01.2163 07.46
380006....................... 01.3682 19.26 390011.......... 01.2677 16.82 390095......... 01.1947 14.46 390181......... 01.0663 18.59 400009......... 01.0136 07.71
380007....................... 01.5884 23.43 390012.......... 01.2600 19.73 390096......... 01.3337 17.00 390183......... 01.2197 18.03 400010......... 00.9361 08.53
380008....................... 01.0562 17.82 390013.......... 01.2411 16.90 390097......... 01.3295 21.56 390184......... 01.1453 18.07 400011......... 00.9932 08.12
380009....................... 01.8380 23.30 390015.......... 01.1668 13.12 390098......... 01.7987 20.75 390185......... 01.2103 16.34 400012......... 01.2302 07.40
380010....................... 01.1162 20.67 390016.......... 01.2453 16.40 390100......... 01.6689 20.03 390189......... 01.0957 15.96 400013......... 01.2495 08.19
380011....................... 01.0890 20.97 390017.......... 01.1322 15.43 390101......... 01.2433 16.62 390191......... 01.1789 14.33 400014......... 01.3919 09.06
380013....................... 01.2719 17.76 390018.......... 01.3522 20.05 390102......... 01.3985 20.58 390192......... 01.1862 16.36 400015......... 01.2207 10.98
380014....................... 01.5562 20.77 390019.......... 01.1189 15.59 390103......... 01.0990 18.00 390193......... 01.2159 16.13 400016......... 01.3485 10.89
380017....................... 01.8262 23.17 390022.......... 01.3277 ....... 390104......... 01.0912 14.99 390194......... 01.0905 18.91 400017......... 01.2423 07.70
380018....................... 01.7650 21.22 390023.......... 01.3020 18.98 390106......... 01.0779 15.15 390195......... 01.8842 22.93 400018......... 01.2939 09.80
380019....................... 01.3206 19.33 390024.......... 00.9902 23.26 390107......... 01.2940 19.04 390196......... 01.4403 ....... 400019......... 01.8123 09.34
380020....................... 01.4383 21.87 390025.......... 00.6319 15.97 390108......... 01.3549 20.08 390197......... 01.3000 18.49 400021......... 01.4962 08.79
380021....................... 01.2983 19.44 390026.......... 01.2842 20.94 390109......... 01.1618 14.14 390198......... 01.2260 15.75 400022......... 01.3207 10.01
380022....................... 01.2237 21.01 390027.......... 01.9139 25.88 390110......... 01.5969 18.05 390199......... 01.3087 15.40 400024......... 00.9888 07.79
380023....................... 01.2422 17.43 390028.......... 01.9063 17.78 390111......... 01.8405 27.77 390200......... 01.0941 14.88 400026......... 00.9734 06.74
380025....................... 01.2509 22.55 390029.......... 01.9567 18.83 390112......... 01.1937 12.26 390201......... 01.2601 19.26 400027......... 01.1951 09.06
380026....................... 01.1673 17.54 390030.......... 01.2362 17.37 390113......... 01.2115 16.25 390203......... 01.3880 20.96 400028......... 01.0432 07.89
380027....................... 01.3334 23.09 390031.......... 01.1652 17.15 390114......... 01.2440 22.27 390204......... 01.2807 18.56 400029......... 01.1384 09.92
380029....................... 01.1591 18.45 390032.......... 01.2748 18.10 390115......... 01.3799 22.31 390205......... 01.4152 20.63 400031......... 01.1944 08.50
380031....................... 01.0213 18.48 390035.......... 01.2522 17.79 390116......... 01.2575 21.78 390206......... 01.4067 20.14 400032......... 01.1883 08.21
380033....................... 01.7400 24.13 390036.......... 01.4191 18.06 390117......... 01.1969 15.62 390209......... 01.0490 15.09 400044......... 01.2161 09.13
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
400048....................... 01.2242 07.12 420056.......... 01.1507 13.66 430062......... 00.8088 10.50 440072......... 01.4213 14.81 440208......... 01.9916 ......
400061....................... 01.5742 13.14 420057.......... 01.1643 15.20 430064......... 01.1702 12.48 440073......... 01.3464 18.39 440209......... 01.7950 ......
400079....................... 01.3004 08.37 420059.......... 00.9868 13.80 430065......... 01.0035 10.34 440078......... 01.0317 13.14 440211......... 00.8607 ......
400087....................... 01.4245 08.10 420061.......... 01.1719 16.99 430066......... 00.9891 11.87 440081......... 01.1813 15.86 450002......... 01.5247 15.76
400094....................... 01.1019 09.07 420062.......... 01.3818 16.51 430073......... 01.0151 13.25 440082......... 02.0414 21.47 450004......... 01.2254 12.21
400098....................... 01.2325 07.84 420064.......... 01.1548 14.32 430076......... 00.9907 10.30 440083......... 01.1353 12.16 450005......... 01.2214 13.65
400102....................... 01.2159 07.59 420065.......... 01.3523 17.37 430077......... 01.6483 16.77 440084......... 01.1861 12.89 450007......... 01.2627 13.51
400103....................... 01.4404 09.09 420066.......... 00.9284 15.38 430079......... 01.0189 11.63 440090......... 00.8532 11.62 450008......... 01.3666 14.74
400104....................... 01.4125 09.01 420067.......... 01.2688 16.48 430081......... 00.9311 ....... 440091......... 01.6476 16.91 450010......... 01.4032 15.09
400105....................... 01.3335 09.08 420068.......... 01.3427 17.07 430082......... 00.9287 ....... 440100......... 01.0717 13.60 450011......... 01.6018 14.66
400106....................... 01.2054 07.87 420069.......... 01.0615 14.29 430083......... 00.7707 ....... 440102......... 01.0749 12.64 450014......... 01.0418 14.53
400109....................... 01.4891 09.67 420070.......... 01.2880 15.76 430084......... 00.9960 ....... 440103......... 01.2611 16.57 450015......... 01.5262 15.25
400110....................... 01.1489 08.39 420071.......... 01.3268 17.29 430085......... 00.8973 ....... 440104......... 01.6975 18.53 450016......... 01.6392 17.49
400111....................... 01.1258 08.52 420072.......... 01.0362 11.62 430087......... 00.9273 08.64 440105......... 01.0672 16.52 450018......... 01.5953 21.98
400112....................... 01.2481 08.03 420073.......... 01.3173 18.17 430089......... 00.8485 ....... 440109......... 01.1135 12.71 450020......... 01.0239 16.23
400113....................... 01.2690 07.41 420074.......... 00.9872 11.49 440001......... 01.1428 12.99 440110......... 00.9608 16.41 450021......... 01.8331 21.68
400114....................... 01.0608 07.55 420075.......... 00.9616 14.51 440002......... 01.6292 16.75 440111......... 01.3704 18.75 450023......... 01.4566 16.60
400115....................... 01.0263 07.86 420078.......... 01.7953 19.92 440003......... 01.1369 15.46 440114......... 01.0812 12.28 450024......... 01.3230 16.74
400117....................... 01.1722 09.01 420079.......... 01.5952 17.29 440006......... 01.4817 18.40 440115......... 01.0718 15.34 450025......... 01.5940 15.72
400118....................... 01.2085 09.52 420080.......... 01.3266 21.07 440007......... 00.9709 11.94 440120......... 01.5405 18.26 450028......... 01.5631 18.19
400120....................... 01.3142 09.23 420081.......... 01.2360 19.59 440008......... 01.0209 12.34 440125......... 01.4775 18.20 450029......... 01.4549 14.12
400121....................... 01.0939 06.53 420082.......... 01.4198 19.00 440009......... 01.2686 14.38 440130......... 01.2126 13.33 450031......... 01.5168 16.40
400122....................... 01.0238 06.66 420083.......... 01.2843 17.31 440010......... 00.9443 10.15 440131......... 01.1300 13.71 450032......... 01.2480 12.89
400123....................... 01.1445 09.36 420085.......... 01.5070 17.06 440011......... 01.3311 16.51 440132......... 01.1379 14.75 450033......... 01.6134 17.70
400124....................... 02.3594 11.32 420086.......... 01.3720 16.96 440012......... 01.5149 18.04 440133......... 01.5674 18.67 450034......... 01.7067 18.08
410001....................... 01.3373 22.95 420087.......... 01.6970 16.86 440014......... 01.1197 09.84 440135......... 01.2783 17.25 450035......... 01.5310 19.16
410004....................... 01.3108 20.70 420088.......... 01.1977 15.27 440015......... 01.7227 18.12 440137......... 01.0167 13.14 450037......... 01.6277 18.03
410005....................... 01.3532 22.65 420089.......... 01.2349 20.60 440016......... 00.9968 12.59 440141......... 01.0482 14.12 450039......... 01.3300 15.55
410006....................... 01.3138 20.73 420091.......... 01.2859 15.25 440017......... 01.6389 20.72 440142......... 01.0271 11.05 450040......... 01.5616 17.73
410007....................... 01.7020 21.60 420093.......... 01.0323 ....... 440018......... 01.4094 17.06 440143......... 01.1050 15.73 450042......... 01.7484 15.78
410008....................... 01.2204 21.52 420094.......... 01.0179 ....... 440019......... 01.7169 17.21 440144......... 01.2388 18.01 450044......... 01.6262 18.91
410009....................... 01.3136 21.34 430004.......... 01.1109 15.06 440020......... 01.2203 15.78 440145......... 00.9912 14.42 450046......... 01.3343 15.81
410010....................... 01.0657 25.32 430005.......... 01.3614 14.44 440022......... 01.1220 14.01 440147......... 01.5238 23.56 450047......... 01.0984 11.06
410011....................... 01.2324 23.69 430007.......... 01.0857 12.77 440023......... 01.0808 13.04 440148......... 01.1480 15.54 450050......... 01.0051 14.35
410012....................... 01.8245 20.26 430008.......... 01.1123 13.56 440024......... 01.3172 16.88 440149......... 01.1537 15.28 450051......... 01.6250 18.53
410013....................... 01.3313 27.36 430010.......... 01.1579 11.70 440025......... 01.1300 13.54 440150......... 01.2962 19.97 450052......... 01.0403 13.01
420002....................... 01.3770 20.19 430011.......... 01.2798 14.49 440029......... 01.2918 16.93 440151......... 01.3053 16.20 450053......... 01.0959 13.82
420004....................... 01.8223 18.16 430012.......... 01.2820 15.03 440030......... 01.2279 12.15 440152......... 01.7854 17.68 450054......... 01.6711 21.71
420005....................... 01.2080 14.51 430013.......... 01.2916 15.39 440031......... 01.0160 13.14 440153......... 01.2929 15.19 450055......... 01.1378 13.89
420006....................... 01.1685 17.19 430014.......... 01.3110 16.99 440032......... 01.0578 14.47 440156......... 01.5822 19.18 450056......... 01.6884 17.92
420007....................... 01.4966 16.92 430015.......... 01.2134 15.17 440033......... 01.1116 14.61 440157......... 01.0406 13.83 450058......... 01.5849 16.46
420009....................... 01.2388 16.92 430016.......... 01.8671 17.78 440034......... 01.5553 17.68 440159......... 01.3164 14.02 450059......... 01.2856 13.85
420010....................... 01.1193 15.13 430018.......... 00.9520 13.13 440035......... 01.3293 16.53 440161......... 01.8760 20.06 450063......... 00.9511 10.66
420011....................... 01.1234 15.28 430022.......... 00.9351 11.95 440039......... 01.6928 17.44 440162......... 01.0104 16.30 450064......... 01.4865 15.57
420014....................... 01.0951 14.36 430023.......... 00.9521 10.34 440040......... 01.0082 10.81 440166......... 01.5684 18.25 450065......... 01.1163 14.73
420015....................... 01.3662 16.84 430024.......... 00.9521 12.07 440041......... 01.0593 12.23 440168......... 01.0424 12.43 450068......... 01.8875 21.36
420016....................... 01.0745 14.21 430026.......... 01.0086 11.18 440046......... 01.2853 15.30 440173......... 01.5484 17.50 450072......... 01.2285 18.67
420018....................... 01.8185 20.00 430027.......... 01.7827 17.63 440047......... 00.9404 14.52 440174......... 01.0215 12.74 450073......... 01.1020 12.06
420019....................... 01.1984 14.70 430028.......... 01.1366 13.29 440048......... 01.8480 17.82 440175......... 01.1777 18.60 450076......... 01.6669 ......
420020....................... 01.3480 16.94 430029.......... 00.9657 13.84 440049......... 01.6757 16.37 440176......... 01.4491 19.17 450078......... 00.9704 11.75
420023....................... 01.4482 18.50 430031.......... 00.9226 11.58 440050......... 01.3472 16.52 440178......... 01.2515 17.07 450079......... 01.4553 21.93
420026....................... 01.8746 ....... 430033.......... 01.0529 13.10 440051......... 00.9680 13.82 440180......... 01.2303 16.96 450080......... 01.2792 15.99
420027....................... 01.3574 16.82 430034.......... 01.1146 11.59 440052......... 01.1954 14.76 440181......... 01.0357 12.37 450081......... 01.0888 14.50
420030....................... 01.2767 16.95 430036.......... 01.0229 11.83 440053......... 01.3492 16.28 440182......... 01.0196 12.53 450082......... 01.0008 14.70
420031....................... 00.9777 11.88 430037.......... 00.9883 13.15 440054......... 01.2010 14.55 440183......... 01.5112 19.69 450083......... 01.7831 19.58
420033....................... 01.1637 18.91 430038.......... 01.0476 10.83 440056......... 01.1009 13.57 440184......... 01.3998 18.96 450085......... 01.0851 17.24
420036....................... 01.3500 16.42 430040.......... 01.0238 12.64 440057......... 01.0218 12.15 440185......... 01.2194 17.48 450087......... 01.4649 18.74
420037....................... 01.2806 20.66 430041.......... 00.9678 12.47 440058......... 01.2498 16.30 440186......... 01.0749 15.77 450090......... 01.2173 13.26
420038....................... 01.2733 14.80 430043.......... 01.2174 11.82 440059......... 01.3794 14.85 440187......... 01.1423 14.65 450092......... 01.2090 11.88
420039....................... 01.1655 15.64 430044.......... 00.8368 14.07 440060......... 01.3032 14.20 440189......... 01.5094 19.13 450094......... 01.3357 17.87
420042....................... 01.1364 14.05 430047.......... 01.0865 11.92 440061......... 01.1966 15.89 440192......... 01.1998 15.37 450096......... 01.5725 17.19
420043....................... 01.2714 19.12 430048.......... 01.2962 15.48 440063......... 01.6337 17.90 440193......... 01.2956 18.60 450097......... 01.4817 18.51
420048....................... 01.1481 15.56 430049.......... 00.9274 12.70 440064......... 01.1162 14.56 440194......... 01.2216 17.13 450098......... 01.1764 15.10
420049....................... 01.2072 15.85 430051.......... 00.9319 13.84 440065......... 01.2912 17.78 440197......... 01.3735 19.23 450099......... 01.3101 23.18
420051....................... 01.6308 18.01 430054.......... 01.0413 12.79 440067......... 01.2815 14.99 440200......... 01.0981 15.64 450101......... 01.4883 15.44
420053....................... 01.2774 14.99 430056.......... 00.8740 09.56 440068......... 01.2253 17.28 440203......... 00.9109 13.09 450102......... 01.7049 17.58
420054....................... 01.2582 17.08 430057.......... 00.9229 10.73 440070......... 01.1015 14.28 440205......... 01.1096 15.47 450104......... 01.2444 14.23
420055....................... 01.0221 14.59 430060.......... 00.9262 08.64 440071......... 01.3899 16.32 440206......... 01.0802 13.80 450107......... 01.6233 22.05
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[[Page 29969]]
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
450108....................... 00.9815 12.48 450222.......... 01.6052 18.35 450388......... 01.8099 17.12 450597......... 01.0314 14.53 450716......... 01.2930 19.56
450109....................... 00.9148 14.70 450224.......... 01.3658 20.66 450389......... 01.3230 17.71 450603......... 00.7195 16.81 450717......... 01.2558 23.86
450110....................... 01.2769 19.30 450229.......... 01.5642 15.41 450393......... 01.3196 19.70 450604......... 01.4409 14.00 450718......... 01.2324 19.03
450111....................... 01.2174 18.93 450231.......... 01.6420 18.25 450395......... 01.0474 13.74 450605......... 01.3903 17.67 450723......... 01.3871 18.21
450112....................... 01.3148 14.31 450234.......... 01.0004 13.07 450399......... 01.0593 15.59 450609......... 00.9173 11.77 450724......... 01.3694 17.44
450113....................... 01.2852 17.93 450235.......... 01.0302 13.46 450400......... 01.1860 11.76 450610......... 01.5468 17.21 450725......... 00.9483 17.49
450118....................... 01.5829 20.36 450236.......... 01.2196 13.99 450403......... 01.2999 21.22 450614......... 01.0061 12.53 450727......... 01.2086 10.80
450119....................... 01.3813 17.13 450237.......... 01.6231 16.83 450411......... 00.9126 12.20 450615......... 01.0935 12.80 450728......... 00.9365 12.62
450121....................... 01.5542 19.99 450239.......... 01.0605 13.70 450417......... 01.0959 19.31 450617......... 01.3517 20.12 450730......... 01.3301 21.46
450123....................... 01.0936 15.98 450241.......... 00.9264 12.67 450418......... 01.4986 21.43 450620......... 01.1357 12.16 450733......... 01.3644 16.88
450124....................... 01.7106 16.25 450243.......... 00.7792 09.65 450419......... 01.2778 17.19 450623......... 01.1891 16.71 450735......... 01.0419 12.02
450126....................... 01.3628 16.01 450246.......... 00.9464 17.09 450422......... 00.8249 24.65 450626......... 01.0657 16.03 450742......... 01.2935 19.47
450128....................... 01.1960 12.44 450249.......... 00.9685 09.95 450423......... 01.5847 21.56 450628......... 00.9294 12.34 450743......... 01.4234 17.79
450130....................... 01.4849 16.93 450250.......... 00.9480 11.36 450424......... 01.2491 17.77 450630......... 01.6663 23.25 450746......... 01.0195 13.81
450131....................... 01.4085 18.24 450253.......... 01.3010 11.92 450429......... 01.1054 12.87 450631......... 01.7531 20.15 450747......... 01.3630 17.04
450132....................... 01.7189 16.46 450258.......... 01.1072 10.85 450431......... 01.6301 18.76 450632......... 00.9769 11.39 450749......... 01.0131 14.63
450133....................... 01.5938 17.90 450259.......... 01.1636 18.29 450438......... 01.2603 11.50 450633......... 01.6373 20.20 450750......... 01.0217 12.20
450135....................... 01.6826 23.54 450264.......... 00.8770 13.08 450446......... 00.6484 12.67 450634......... 01.6146 23.56 450751......... 01.3430 15.58
450137....................... 01.5005 22.19 450269.......... 01.0728 13.96 450447......... 01.3879 18.07 450638......... 01.5891 22.00 450754......... 00.9520 13.49
450140....................... 00.9941 17.44 450270.......... 01.2548 08.84 450451......... 01.1562 16.96 450639......... 01.4390 21.06 450755......... 01.1665 15.54
450142....................... 01.4559 20.28 450271.......... 01.2644 14.84 450457......... 01.7826 17.34 450641......... 01.0419 13.24 450757......... 00.9463 13.62
450143....................... 01.0346 11.10 450272.......... 01.3480 15.38 450460......... 01.0543 12.46 450643......... 01.2287 17.43 450758......... 02.0308 21.92
450144....................... 01.0940 15.29 450276.......... 01.0121 12.63 450462......... 01.7703 20.49 450644......... 01.5108 19.07 450760......... 01.2570 18.35
450145....................... 00.8190 13.36 450278.......... 00.9870 13.64 450464......... 01.0046 15.15 450646......... 01.6546 31.36 450761......... 01.1320 09.57
450146....................... 00.9883 20.32 450280.......... 01.5295 23.09 450465......... 01.3413 16.93 450647......... 01.9647 23.27 450763......... 01.0156 16.60
450147....................... 01.4166 17.72 450283.......... 01.1089 12.43 450467......... 00.9719 14.01 450648......... 00.9843 09.48 450766......... 02.0743 20.76
450148....................... 01.2606 20.21 450286.......... 01.0057 16.36 450469......... 01.3764 17.25 450649......... 01.0397 14.06 450769......... 00.9968 13.40
450149....................... 01.4187 19.53 450288.......... 01.2657 13.67 450473......... 00.9945 15.03 450651......... 01.7497 22.80 450770......... 01.0425 14.57
450150....................... 00.9226 13.75 450289.......... 01.4333 19.14 450475......... 01.1405 14.96 450652......... 00.8637 13.96 450771......... 01.7860 22.32
450151....................... 01.1247 14.16 450292.......... 01.2492 21.03 450484......... 01.4464 18.03 450653......... 01.2233 15.20 450774......... 01.0941 21.24
450152....................... 01.2598 15.74 450293.......... 00.9756 12.41 450488......... 01.3242 16.08 450654......... 00.9512 12.28 450775......... 01.2818 17.09
450153....................... 01.6202 18.44 450296.......... 01.3760 15.38 450489......... 01.0196 12.72 450656......... 01.5372 17.19 450776......... 00.9164 11.18
450154....................... 01.1969 13.12 450299.......... 01.3407 13.00 450497......... 01.1733 12.88 450658......... 00.9714 12.32 450777......... 01.0384 16.60
450155....................... 01.0262 14.09 450303.......... 00.9926 11.50 450498......... 01.0536 13.15 450659......... 01.5376 20.54 450779......... 01.2550 21.36
450157....................... 00.9708 12.80 450306.......... 01.2021 12.82 450508......... 01.4210 13.21 450661......... 01.2312 18.51 450780......... 01.4170 16.91
450160....................... 00.9461 17.12 450307.......... 00.7810 14.25 450514......... 01.1932 18.47 450662......... 01.6120 17.38 450781......... 01.5749 11.01
450162....................... 01.2508 18.76 450309.......... 01.0665 14.17 450517......... 00.9085 11.11 450665......... 00.9174 12.95 450785......... 01.0228 16.39
450163....................... 01.1399 16.82 450315.......... 01.0404 18.63 450518......... 01.5597 16.38 450666......... 01.3365 19.72 450788......... 01.4465 19.31
450164....................... 01.1216 12.83 450320.......... 01.3540 18.45 450523......... 01.5809 19.54 450668......... 01.5985 19.60 450794......... 01.4278 16.20
450165....................... 01.0205 10.46 450321.......... 01.0170 13.51 450530......... 01.3722 14.27 450669......... 01.3372 19.26 450795......... 00.8684 20.22
450166....................... 01.0252 13.06 450322.......... 00.8216 16.61 450534......... 01.0396 18.02 450670......... 01.3101 17.24 450797......... 00.7374 16.67
450169....................... 01.0085 11.97 450324.......... 01.6983 15.77 450535......... 01.2947 21.25 450672......... 01.6189 20.69 450798......... 00.8432 08.88
450170....................... 00.9952 12.46 450325.......... 00.9022 11.47 450537......... 01.3071 19.69 450673......... 01.0516 12.14 450801......... 01.4775 22.80
450176....................... 01.2954 15.32 450327.......... 01.0143 12.60 450538......... 01.2092 20.77 450674......... 00.9786 19.88 450802......... 01.2334 ......
450177....................... 01.2766 11.10 450330.......... 01.1500 15.62 450539......... 01.4110 14.67 450675......... 01.5234 20.99 450803......... 00.8631 ......
450178....................... 01.0184 15.84 450334.......... 01.0516 12.11 450544......... 01.3641 19.25 450677......... 01.4283 17.43 450804......... 01.5585 ......
450181....................... 01.0644 14.13 450337.......... 01.1601 13.85 450545......... 01.2684 20.93 450678......... 01.5025 20.85 450807......... 00.9198 ......
450184....................... 01.5231 13.53 450340.......... 01.3229 12.68 450547......... 01.1540 15.13 450683......... 01.3410 17.23 450808......... 00.9783 ......
450185....................... 01.0793 08.69 450341.......... 01.0487 15.87 450550......... 01.0672 18.37 450684......... 01.3031 21.41 450809......... 01.6796 ......
450187....................... 01.2402 16.51 450346.......... 01.4259 15.73 450551......... 01.2241 13.01 450686......... 01.6052 14.14 450810......... 01.3049 ......
450188....................... 01.0927 12.80 450347.......... 01.1507 16.68 450558......... 01.7279 20.85 450688......... 01.3639 19.63 450811......... 02.1669 ......
450190....................... 01.1709 ....... 450348.......... 00.9843 11.20 450559......... 00.9392 12.26 450690......... 01.4058 21.41 450812......... 01.5923 ......
450191....................... 01.0842 15.87 450351.......... 01.1951 17.71 450561......... 01.6915 17.18 450691......... 00.9630 ....... 460001......... 01.8018 20.73
450192....................... 01.2916 17.51 450352.......... 01.1046 16.53 450563......... 01.2766 23.92 450694......... 01.1385 18.16 460003......... 01.6984 17.86
450193....................... 02.0357 21.80 450353.......... 01.2637 16.98 450565......... 01.2685 16.10 450696......... 01.9697 22.02 460004......... 01.7275 21.45
450194....................... 01.2661 17.65 450355.......... 01.1523 13.03 450570......... 01.0784 15.81 450697......... 01.4970 13.82 460005......... 01.6827 18.56
450196....................... 01.4873 16.93 450358.......... 02.0795 20.80 450571......... 01.4769 15.53 450698......... 00.9778 11.65 460006......... 01.4501 19.40
450200....................... 01.4249 17.40 450362.......... 01.1675 13.83 450573......... 01.0612 14.35 450700......... 00.9476 13.15 460007......... 01.3572 20.40
450201....................... 01.0038 15.45 450369.......... 01.0553 13.10 450574......... 00.9359 11.72 450702......... 01.5805 18.94 460008......... 01.3860 15.91
450203....................... 01.2170 17.46 450370.......... 01.2765 11.11 450575......... 01.0735 16.62 450703......... 01.5428 18.24 460009......... 01.8462 19.39
450209....................... 01.4952 21.78 450371.......... 01.1605 12.16 450578......... 00.9338 12.99 450704......... 01.4192 18.02 460010......... 02.0177 20.86
450210....................... 01.1667 12.30 450372.......... 01.3132 21.02 450580......... 01.1376 13.29 450705......... 00.9145 18.50 460011......... 01.4613 16.34
450211....................... 01.4111 16.52 450373.......... 01.1587 13.38 450583......... 00.9816 13.04 450706......... 01.2508 22.63 460013......... 01.5206 16.74
450213....................... 01.6457 15.42 450374.......... 00.9148 11.66 450584......... 01.1817 13.02 450709......... 01.3400 19.78 460014......... 01.0850 15.12
450214....................... 01.4227 19.51 450376.......... 01.4827 17.78 450586......... 01.0491 11.16 450711......... 01.5979 18.18 460015......... 01.2184 20.40
450217....................... 01.0015 11.56 450378.......... 01.1028 19.87 450587......... 01.2525 15.98 450712......... 00.7899 11.12 460016......... 00.9611 12.50
450219....................... 01.1518 14.78 450379.......... 01.5239 21.62 450591......... 01.1497 18.92 450713......... 01.4954 20.85 460017......... 01.5581 16.40
450221....................... 01.1688 14.40 450381.......... 00.9929 12.86 450596......... 01.3942 17.15 450715......... 01.3740 18.59 460018......... 00.9973 15.45
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[[Page 29970]]
Page 15 of 16
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Avg. Avg. Avg. Avg. Avg.
Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour Provider Case mix hour
index wage index wage index wage index wage index wage
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
460019....................... 01.1179 14.45 490035.......... 01.1338 13.02 490130......... 01.2939 15.07 500097......... 01.2116 17.46 510071......... 01.3174 15.64
460020....................... 01.0427 16.33 490037.......... 01.2373 13.99 490131......... 00.9879 14.74 500098......... 01.0380 15.44 510072......... 01.0597 13.24
460021....................... 01.3861 19.46 490038.......... 01.2643 13.43 490132......... 01.0342 ....... 500101......... 01.0064 15.92 510077......... 01.1812 15.36
460022....................... 00.9383 19.23 490040.......... 01.4769 21.68 500001......... 01.3664 21.66 500102......... 01.0235 19.46 510080......... 01.2137 11.53
460023....................... 01.2249 21.08 490041.......... 01.2707 16.21 500002......... 01.4348 19.10 500104......... 01.3261 19.88 510081......... 01.1592 12.97
460024....................... 01.0133 14.78 490042.......... 01.3538 15.75 500003......... 01.3881 25.32 500106......... 00.9016 20.08 510082......... 01.2159 12.89
460025....................... 00.8148 13.73 490043.......... 01.4488 20.60 500005......... 01.8225 21.58 500107......... 01.1551 15.79 510084......... 00.9547 13.24
460026....................... 00.9812 17.03 490044.......... 01.3525 17.15 500007......... 01.3876 21.79 500108......... 01.7177 21.74 510085......... 01.3537 17.90
460027....................... 00.9312 19.08 490045.......... 01.2318 18.29 500008......... 01.9449 23.18 500110......... 01.2300 19.44 510086......... 01.0856 15.08
460029....................... 01.0389 18.60 490046.......... 01.4958 17.80 500011......... 01.4259 22.64 500118......... 01.1761 21.92 520002......... 01.2177 18.84
460030....................... 01.1718 17.32 490047.......... 01.0908 16.50 500012......... 01.4808 21.18 500119......... 01.3377 20.39 520003......... 01.1201 15.41
460032....................... 01.0291 21.16 490048.......... 01.6102 17.44 500014......... 01.4972 20.92 500122......... 01.2814 21.99 520004......... 01.1861 16.78
460033....................... 00.9685 17.97 490050.......... 01.4630 21.02 500015......... 01.3782 21.85 500123......... 00.8465 18.56 520006......... 01.0231 18.17
460035....................... 00.9265 12.17 490052.......... 01.6078 15.45 500016......... 01.4757 23.26 500124......... 01.3142 22.83 520007......... 01.2287 14.55
460036....................... 01.0220 20.05 490053.......... 01.2686 14.77 500019......... 01.3364 21.38 500125......... 01.0100 11.61 520008......... 01.5752 22.49
460037....................... 00.9878 17.48 490054.......... 01.1012 14.36 500021......... 01.5592 21.91 500129......... 01.7381 23.35 520009......... 01.6581 17.31
460039....................... 01.0927 20.36 490057.......... 01.5483 17.69 500023......... 01.2130 19.53 500132......... 00.9524 18.51 520010......... 01.1686 19.33
460041....................... 01.2537 20.90 490059.......... 01.6177 19.41 500024......... 01.6817 22.23 500134......... 00.6974 15.59 520011......... 01.2161 16.85
460042....................... 01.4822 17.04 490060.......... 01.0839 17.79 500025......... 01.8740 23.44 500138......... 03.9749 ....... 520013......... 01.3799 18.80
460043....................... 01.2702 21.71 490063.......... 01.7052 22.93 500026......... 01.4019 23.85 500139......... 01.5091 21.25 520014......... 01.1396 16.08
460044....................... 01.1845 19.83 490066.......... 01.3637 18.00 500027......... 01.5352 25.23 500141......... 01.3275 22.22 520015......... 01.1912 16.72
460046....................... 00.9068 12.27 490067.......... 01.2271 15.82 500028......... 01.1235 14.69 500143......... 00.7385 15.20 520016......... 01.1027 13.21
460047....................... 01.7432 19.82 490069.......... 01.4520 14.96 500029......... 00.9534 13.71 500146......... 01.1734 26.11 520017......... 01.1540 17.45
460049....................... 01.9647 17.85 490071.......... 01.5024 18.60 500030......... 01.5279 22.55 510001......... 01.8125 17.35 520018......... 01.1214 16.17
460050....................... 01.2748 21.99 490073.......... 01.4695 17.55 500031......... 01.3419 20.58 510002......... 01.2928 14.18 520019......... 01.3048 16.63
460051....................... 01.2923 32.89 490074.......... 01.3688 16.77 500033......... 01.2759 18.41 510004......... 01.1211 13.65 520021......... 01.3122 19.90
470001....................... 01.1614 18.73 490075.......... 01.3977 16.37 500036......... 01.3202 19.95 510005......... 00.9608 14.19 520024......... 01.0463 13.11
470003....................... 01.7901 20.70 490077.......... 01.2584 17.87 500037......... 01.1682 18.70 510006......... 01.2948 17.42 520025......... 01.1116 18.58
470004....................... 01.1007 15.85 490079.......... 01.3240 15.15 500039......... 01.3867 22.10 510007......... 01.4908 17.98 520026......... 01.0837 17.49
470005....................... 01.2726 20.26 490083.......... 00.7754 15.02 500041......... 01.2893 23.23 510008......... 01.1457 15.55 520027......... 01.2413 19.27
470006....................... 01.2468 17.83 490084.......... 01.3000 15.43 500042......... 01.3518 22.37 510012......... 01.1036 14.37 520028......... 01.3033 17.76
470008....................... 01.1912 16.76 490085.......... 01.2391 13.39 500043......... 01.1927 17.16 510013......... 01.1691 15.80 520029......... 00.9692 16.94
470010....................... 01.1212 19.03 490088.......... 01.1817 14.44 500044......... 01.9850 20.96 510015......... 00.9444 12.51 520030......... 01.6451 21.19
470011....................... 01.1945 19.82 490089.......... 01.1287 16.18 500045......... 01.1350 20.81 510016......... 00.9168 12.66 520031......... 01.1198 15.24
470012....................... 01.2433 17.88 490090.......... 01.2018 15.17 500048......... 00.9633 16.46 510018......... 01.1807 15.26 520032......... 01.2371 15.25
470015....................... 01.2218 16.67 490091.......... 01.2793 18.78 500049......... 01.4916 19.24 510020......... 01.1194 10.56 520033......... 01.1663 16.22
470018....................... 01.2205 20.53 490092.......... 01.2074 15.13 500050......... 01.4321 20.96 510022......... 01.8872 19.16 520034......... 01.1973 17.64
470020....................... 00.9787 15.18 490093.......... 01.3622 15.83 500051......... 01.6718 23.18 510023......... 01.1987 16.62 520035......... 01.3370 15.87
470023....................... 01.2848 19.08 490094.......... 01.1740 14.52 500052......... 01.3138 ....... 510024......... 01.4379 18.43 520037......... 01.6533 19.06
470024....................... 01.1442 18.26 490095.......... 01.4751 16.79 500053......... 01.3072 20.42 510026......... 01.0140 12.33 520038......... 01.3030 16.45
490001....................... 01.2391 19.51 490097.......... 01.1539 14.52 500054......... 01.8790 21.08 510027......... 00.9461 14.62 520039......... 00.9943 16.33
490002....................... 01.0988 14.56 490098.......... 01.2285 11.67 500055......... 01.1227 20.13 510028......... 01.0819 18.99 520040......... 01.4729 19.34
490003....................... 00.5817 17.19 490099.......... 00.9532 16.51 500057......... 01.3062 17.22 510029......... 01.2900 16.78 520041......... 01.1752 14.93
490004....................... 01.2302 16.97 490100.......... 01.4486 17.21 500058......... 01.5259 20.32 510030......... 01.0514 14.39 520042......... 01.0956 16.42
490005....................... 01.5903 16.31 490101.......... 01.2168 22.93 500059......... 01.1436 20.76 510031......... 01.4818 15.97 520044......... 01.4078 16.15
490006....................... 01.1307 13.82 490104.......... 00.8468 16.07 500060......... 01.4042 23.27 510033......... 01.3546 15.30 520045......... 01.7365 18.68
490007....................... 02.0885 17.16 490105.......... 00.6278 18.83 500061......... 01.0337 18.19 510035......... 01.3607 16.81 520047......... 00.9913 15.41
490009....................... 01.8640 18.27 490106.......... 00.8554 16.48 500062......... 01.1311 18.80 510036......... 01.0693 11.64 520048......... 01.4698 18.11
490010....................... 01.1608 17.32 490107.......... 01.3315 22.98 500064......... 01.5874 22.08 510038......... 01.1630 13.36 520049......... 02.0300 18.52
490011....................... 01.4254 17.33 490108.......... 00.9003 15.39 500065......... 01.2122 18.72 510039......... 01.3322 15.48 520051......... 01.7856 20.21
490012....................... 01.2232 15.30 490109.......... 00.9328 17.44 500068......... 01.0306 18.40 510043......... 00.9306 11.52 520053......... 01.1223 15.45
490013....................... 01.2160 16.75 490110.......... 01.4165 15.07 500069......... 01.2223 19.76 510046......... 01.2749 15.91 520054......... 01.0828 17.03
490014....................... 01.4808 22.42 490111.......... 01.2440 15.83 500071......... 01.2861 19.80 510047......... 01.2457 18.06 520056......... 01.7830 18.87
490015....................... 01.4311 18.76 490112.......... 01.6006 18.51 500072......... 01.2065 22.83 510048......... 01.0990 18.22 520057......... 01.1254 16.59
490017....................... 01.3601 16.73 490113.......... 01.3494 21.59 500073......... 01.0524 16.74 510050......... 01.5722 16.11 520058......... 01.1042 18.17
490018....................... 01.2981 17.15 490114.......... 01.1413 15.47 500074......... 01.1555 15.67 510053......... 01.0304 14.12 520059......... 01.4123 18.74
490019....................... 01.1876 16.46 490115.......... 01.2226 14.46 500077......... 01.3811 21.68 510055......... 01.2691 19.68 520060......... 01.4284 15.26
490020....................... 01.2060 15.76 490116.......... 01.3299 15.48 500079......... 01.3672 21.40 510058......... 01.1974 17.03 520062......... 01.3510 16.73
490021....................... 01.2422 17.30 490117.......... 01.1828 12.41 500080......... 00.8662 11.72 510059......... 01.4747 14.25 520063......... 01.1983 17.63
490022....................... 01.4383 19.31 490118.......... 01.7803 21.05 500084......... 01.1847 20.78 510060......... 01.1523 15.55 520064......... 01.7057 20.15
490023....................... 01.2993 18.01 490119.......... 01.3740 16.40 500085......... 01.0690 19.55 510061......... 01.0363 13.37 520066......... 01.5302 18.82
490024....................... 01.8166 16.27 490120.......... 01.3266 17.49 500086......... 01.3071 20.03 510062......... 01.1784 15.77 520068......... 00.9859 16.85
490027....................... 01.1596 13.29 490122.......... 01.4671 21.19 500088......... 01.3442 23.37 510063......... 00.9557 16.84 520069......... 01.1921 17.13
490028....................... 01.3111 20.17 490123.......... 01.1856 15.29 500089......... 01.0273 15.05 510065......... 01.0484 11.49 520070......... 01.6335 17.38
490030....................... 01.1728 10.83 490124.......... 01.2023 17.12 500090......... 00.9361 13.67 510066......... 01.1335 11.93 520071......... 01.1575 17.53
490031....................... 01.1124 13.00 490126.......... 01.4227 14.85 500092......... 01.0544 17.86 510067......... 01.2735 17.97 520074......... 01.0679 15.42
490032....................... 01.7731 19.42 490127.......... 01.0020 14.52 500094......... 00.9089 15.30 510068......... 01.1169 14.34 520075......... 01.4644 18.02
490033....................... 01.2333 16.48 490129.......... 01.1425 19.20 500096......... 00.9886 18.51 510070......... 01.3315 15.86 520076......... 01.1607 15.11
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
[[Page 29971]]
Page 16 of 16
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Case Avg. Case Avg.
Provider mix hour Provider mix hour
index wage index wage
----------------------------------------------------------------------------------------------------
520077.............................. 00.8551 14.03 530003................. 01.0202 12.47
520078.............................. 01.6182 18.63 530004................. 00.9980 14.18
520082.............................. 01.2818 16.43 530005................. 01.0061 13.47
520083.............................. 01.6772 21.60 530006................. 01.1369 16.52
520084.............................. 01.0951 16.87 530007................. 01.0829 12.98
520087.............................. 01.6988 18.12 530008................. 01.3394 16.82
520088.............................. 01.3099 17.98 530009................. 01.0060 16.77
520089.............................. 01.5179 19.50 530010................. 01.4102 16.12
520090.............................. 01.2381 16.18 530011................. 01.1085 16.94
520091.............................. 01.3629 18.13 530012................. 01.5449 18.11
520092.............................. 01.1204 15.74 530014................. 01.4213 15.18
520094.............................. 00.7915 16.12 530015................. 01.2755 18.00
520095.............................. 01.3651 17.84 530016................. 01.2972 14.93
520096.............................. 01.4356 18.94 530017................. 00.8748 16.97
520097.............................. 01.3151 18.65 530018................. 01.0355 18.67
520098.............................. 01.8153 20.17 530019................. 01.0136 15.32
520100.............................. 01.2531 16.72 530022................. 01.0909 16.71
520101.............................. 01.1237 16.09 530023................. 00.8526 18.57
520102.............................. 01.2023 19.37 530025................. 01.2398 18.76
520103.............................. 01.3275 17.94 530026................. 01.0928 15.48
520107.............................. 01.3021 17.50 530027................. 00.9181 10.62
520109.............................. 01.0056 17.63 530029................. 01.0278 13.46
520110.............................. 01.1489 17.94 530031................. 00.8952 11.67
520111.............................. 00.9540 16.01 530032................. 01.0874 17.89
520112.............................. 01.1191 16.89
520113.............................. 01.2037 19.18
520114.............................. 01.0845 13.27
520115.............................. 01.2574 16.02
520116.............................. 01.2507 18.13
520117.............................. 01.0619 15.78
520118.............................. 00.9442 10.53
520120.............................. 00.9138 12.70
520121.............................. 00.9503 15.67
520122.............................. 00.9742 14.73
520123.............................. 01.0924 16.93
520124.............................. 01.1427 14.93
520130.............................. 01.0475 13.47
520131.............................. 01.0271 16.78
520132.............................. 01.1689 14.48
520134.............................. 01.0805 15.97
520135.............................. 00.9428 17.28
520136.............................. 01.5019 19.05
520138.............................. 01.8566 19.44
520139.............................. 01.2786 19.89
520140.............................. 01.6085 21.15
520141.............................. 01.0486 15.86
520142.............................. 00.8723 13.20
520144.............................. 01.0324 16.42
520145.............................. 00.9102 16.59
520146.............................. 01.0848 13.94
520148.............................. 01.0827 15.34
520149.............................. 00.9713 13.44
520151.............................. 01.0919 15.42
520152.............................. 01.1630 17.07
520153.............................. 00.9224 13.81
520154.............................. 01.0978 17.71
520156.............................. 01.1062 16.69
520157.............................. 01.0441 13.77
520159.............................. 00.9343 16.85
520160.............................. 01.7963 19.07
520161.............................. 01.0063 15.94
520170.............................. 01.2376 19.95
520171.............................. 00.9321 13.23
520173.............................. 01.1559 18.34
520174.............................. 01.3534 21.51
520177.............................. 01.5919 20.16
520178.............................. 01.0908 15.23
530002.............................. 01.1953 19.16
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Case mix indexes do not include discharges from PPS-exempt units.
Case mix indexes include cases received in HCFA central office through December 1996
[[Page 29972]]
Table 4A.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Urban Areas
------------------------------------------------------------------------
Wage
Urban area (constituent counties) index GAF
------------------------------------------------------------------------
0040 Abilene, TX................................... 0.8294 0.8798
Taylor, TX
0060 Aguadilla, PR................................. 0.4191 0.5513
Aguada, PR
Aguadilla, PR
Moca, PR
0080 Akron, OH..................................... 0.9736 0.9818
Portage, OH
Summit, OH
0120 Albany, GA.................................... 0.7920 0.8524
Dougherty, GA
Lee, GA
0160 Albany-Schenectady-Troy, NY................... 0.8485 0.8936
Albany, NY
Montgomery, NY
Rensselaer, NY
Saratoga, NY
Schenectady, NY
Schoharie, NY
0200 Albuquerque, NM............................... 0.9336 0.9540
Bernalillo, NM
Sandoval, NM
Valencia, NM
0220 Alexandria, LA................................ 0.8275 0.8784
Rapides, LA
0240 Allentown-Bethlehem-Easton, PA................ 1.0093 1.0064
Carbon, PA
Lehigh, PA
Northampton, PA
0280 Altoona, PA................................... 0.9144 0.9406
Blair, PA
0320 Amarillo, TX.................................. 0.9503 0.9657
Potter, TX
Randall, TX
0380 Anchorage, AK................................. 1.3015 1.1978
Anchorage, AK
0440 Ann Arbor, MI................................. 1.1794 1.1196
Lenawee, MI
Livingston, MI
Washtenaw, MI
0450 Anniston, AL.................................. 0.8272 0.8782
Calhoun, AL
0460 Appleton-Oshkosh-Neenah, WI................... 0.9003 0.9306
Calumet, WI
Outagamie, WI
Winnebago, WI
0470 Arecibo, PR................................... 0.4221 0.5540
Arecibo, PR
Camuy, PR
Hatillo, PR
0480 Asheville, NC................................. 0.9078 0.9359
Buncombe, NC
Madison, NC
0500 Athens, GA.................................... 0.9093 0.9370
Clarke, GA
Madison, GA
Oconee, GA
0520 *Atlanta, GA.................................. 0.9812 0.9871
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......................... 1.0732 1.0496
Atlantic, NJ
Cape May, NJ
0600 Augusta-Aiken, GA-SC.......................... 0.9341 0.9544
Columbia, GA
McDuffie, GA
Richmond, GA
Aiken, SC
Edgefield, SC
0640 Austin-San Marcos, TX......................... 0.8690 0.9083
Bastrop, TX
Caldwell, TX
Hays, TX
Travis, TX
Williamson, TX
0680 Bakersfield, CA............................... 1.0021 1.0014
Kern, CA
0720 *Baltimore, MD................................ 0.9696 0.9791
Anne Arundel, MD
Baltimore, MD
Baltimore City, MD
Carroll, MD
Harford, MD
Howard, MD
Queen Anne's, MD
0733 Bangor, ME.................................... 0.9485 0.9644
Penobscot, ME
0743 Barnstable-Yarmouth, MA....................... 1.4302 1.2777
Barnstable, MA
0760 Baton Rouge, LA............................... 0.8416 0.8886
Ascension, LA
East Baton Rouge, LA
Livingston, LA
West Baton Rouge, LA
0840 Beaumont-Port Arthur, TX...................... 0.8576 0.9001
Hardin, TX
Jefferson, TX
Orange, TX
0860 Bellingham, WA................................ 1.1229 1.0826
Whatcom, WA
0870 Benton Harbor, MI............................. 0.8640 0.9047
Berrien, MI
0875 *Bergen-Passaic, NJ........................... 1.1573 1.1052
Bergen, NJ
Passaic, NJ
0880 Billings, MT.................................. 0.9728 0.9813
Yellowstone, MT
0920 Biloxi-Gulfport-Pascagoula, MS................ 0.8422 0.8890
Hancock, MS
Harrison, MS
Jackson, MS
0960 Binghamton, NY................................ 0.9088 0.9366
Broome, NY
Tioga, NY
1000 Birmingham, AL................................ 0.8933 0.9256
Blount, AL
Jefferson, AL
St. Clair, AL
Shelby, AL
1010 Bismarck, ND.................................. 0.7874 0.8490
Burleigh, ND
Morton, ND
1020 Bloomington, IN............................... 0.9134 0.9399
Monroe, IN
1040 Bloomington-Normal, IL........................ 0.8783 0.9150
McLean, IL
1080 Boise City, ID................................ 0.8893 0.9228
Ada, ID
Canyon, ID
1123 *Boston-Worcester-Lawrence-Lowell-Brockton, MA-
NH................................................. 1.1430 1.0958
Bristol, MA
Essex, MA
Middlesex, MA
Norfolk, MA
Plymouth, MA
Suffolk, MA
Worcester, MA
Hillsborough, NH
Merrimack, NH
Rockingham, NH
Strafford, NH
1125 Boulder-Longmont, CO.......................... 1.0023 1.0016
Boulder, CO
1145 Brazoria, TX.................................. 0.9136 0.9400
Brazoria, TX
1150 Bremerton, WA................................. 1.1007 1.0679
Kitsap, WA
1240 Brownsville-Harlingen-San Benito, TX.......... 0.8699 0.9090
Cameron, TX
1260 Bryan-College Station, TX..................... 0.7040 0.7864
Brazos, TX
1280 *Buffalo-Niagara Falls, NY.................... 0.9266 0.9491
Erie, NY
Niagara, NY
1303 Burlington, VT................................ 1.0098 1.0067
Chittenden, VT
Franklin, VT
Grand Isle, VT
1310 Caguas, PR.................................... 0.4551 0.5833
Caguas, PR
Cayey, PR
Cidra, PR
Gurabo, PR
San Lorenzo, PR
1320 Canton-Massillon, OH.......................... 0.8968 0.9281
[[Page 29973]]
Carroll, OH
Stark, OH
1350 Casper, WY.................................... 0.9019 0.9317
Natrona, WY
1360 Cedar Rapids, IA.............................. 0.8535 0.8972
Linn, IA
1400 Champaign-Urbana, IL.......................... 0.8740 0.9119
Champaign, IL
1440 Charleston-North Charleston, SC............... 0.8739 0.9118
Berkeley, SC
Charleston, SC
Dorchester, SC
1480 Charleston, WV................................ 0.9148 0.9408
Kanawha, WV
Putnam, WV
1520 *Charlotte-Gastonia-Rock Hill, NC-SC.......... 0.9758 0.9834
Cabarrus, NC
Gaston, NC
Lincoln, NC
Mecklenburg, NC
Rowan, NC
Union, NC
York, SC
1540 Charlottesville, VA........................... 0.9065 0.9350
Albemarle, VA
Charlottesville City, VA
Fluvanna, VA
Greene, VA
1560 Chattanooga, TN-GA............................ 0.8664 0.9065
Catoosa, GA
Dade, GA
Walker, GA
Hamilton, TN
Marion, TN
1580 Cheyenne, WY.................................. 0.7560 0.8257
Laramie, WY
1600 *Chicago, IL.................................. 1.0829 1.0561
Cook, IL
DeKalb, IL
DuPage, IL
Grundy, IL
Kane, IL
Kendall, IL
Lake, IL
McHenry, IL
Will, IL
1620 Chico-Paradise, CA............................ 1.0394 1.0268
Butte, CA
1640 *Cincinnati, OH-KY-IN......................... 0.9565 0.9700
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............... 0.7857 0.8478
Christian, KY
Montgomery, TN
1680* Cleveland-Lorain-Elyria, OH.................. 0.9811 0.9870
Ashtabula, OH
Cuyahoga, OH
Geauga, OH
Lake, OH
Lorain, OH
Medina, OH
1720 Colorado Springs, CO.......................... 0.9323 0.9531
El Paso, CO
1740 Columbia, MO.................................. 0.8887 0.9224
Boone, MO
1760 Columbia, SC.................................. 0.9222 0.9460
Lexington, SC
Richland, SC
1800 Columbus, GA-AL............................... 0.8294 0.8798
Russell, AL
Chattahoochee, GA
Harris, GA
Muscogee, GA
1840 *Columbus, OH................................. 0.9800 0.9863
Delaware, OH
Fairfield, OH
Franklin, OH
Licking, OH
Madison, OH
Pickaway, OH
1880 Corpus Christi, TX............................ 0.8951 0.9269
Nueces, TX
San Patricio, TX
1900 Cumberland, MD-WV............................. 0.8829 0.9182
Allegany, MD
Mineral, WV
1920 *Dallas, TX................................... 0.9624 0.9741
Collin, TX
Dallas, TX
Denton, TX
Ellis, TX
Henderson, TX
Hunt, TX
Kaufman, TX
Rockwall, TX
1950 Danville, VA.................................. 0.8152 0.8694
Danville City, VA
Pittsylvania, VA
1960 Davenport-Moline-Rock Island, IA-IL........... 0.8411 0.8883
Scott, IA
Henry, IL
Rock Island, IL
2000 Dayton-Springfield, OH........................ 0.9292 0.9510
Clark, OH
Greene, OH
Miami, OH
Montgomery, OH
2020 Daytona Beach, FL............................. 0.8356 0.8843
Flagler, FL
Volusia, FL
2030 Decatur, AL................................... 0.8292 0.8796
Lawrence, AL
Morgan, AL
2040 Decatur, IL................................... 0.7920 0.8524
Macon, IL
2080 *Denver, CO................................... 1.0299 1.0204
Adams, CO
Arapahoe, CO
Denver, CO
Douglas, CO
Jefferson, CO
2120 Des Moines, IA................................ 0.8718 0.9103
Dallas, IA
Polk, IA
Warren, IA
2160 *Detroit, MI.................................. 1.0844 1.0571
Lapeer, MI
Macomb, MI
Monroe, MI
Oakland, MI
St. Clair, MI
Wayne, MI
2180 Dothan, AL.................................... 0.8076 0.8639
Dale, AL
Houston, AL
2190 Dover, DE..................................... 0.9222 0.9460
Kent, DE
2200 Dubuque, IA................................... 0.8094 0.8652
Dubuque, IA
2240 Duluth-Superior, MN-WI........................
St. Louis, MN 0.9786 0.9853
Douglas, WI
2281 Dutchess County, NY........................... 1.0644 1.0437
Dutchess, NY
2290 Eau Claire, WI................................ 0.8771 0.9141
Chippewa, WI
Eau Claire, WI
2320 El Paso, TX................................... 0.9719 0.9807
El Paso, TX
2330 Elkhart-Goshen, IN............................ 0.9087 0.9365
Elkhart, IN
2335 Elmira, NY.................................... 0.8253 0.8768
Chemung, NY
2340 Enid, OK...................................... 0.7968 0.8559
Garfield, OK
2360 Erie, PA...................................... 0.8869 0.9211
Erie, PA
2400 Eugene-Springfield, OR........................ 1.1700 1.1135
Lane, OR
2440 Evansville-Henderson, IN-KY................... 0.8648 0.9053
Posey, IN
Vanderburgh, IN
Warrick, IN
Henderson, KY
2520 Fargo-Moorhead, ND-MN......................... 0.8844 0.9193
Clay, MN
Cass, ND
[[Page 29974]]
2560 Fayetteville, NC.............................. 0.8740 0.9119
Cumberland, NC
2580 Fayetteville-Springdale-Rogers, AR............ 0.7466 0.8186
Benton, AR
Washington, AR
2620 Flagstaff, AZ-UT.............................. 0.9122 0.9390
Coconino, AZ
Kane, UT
2640 Flint, MI..................................... 1.1191 1.0801
Genesee, MI
2650 Florence, AL.................................. 0.7722 0.8378
Colbert, AL
Lauderdale, AL
2655 Florence, SC.................................. 0.8243 0.8761
Florence, SC
2670 Fort Collins-Loveland, CO..................... 1.0255 1.0174
Larimer, CO
2680 *Ft. Lauderdale, FL........................... 1.0802 1.0543
Broward, FL
2700 Fort Myers-Cape Coral, FL..................... 0.8384 0.8863
Lee, FL
2710 Fort Pierce-Port St. Lucie, FL................ 0.9782 0.9850
Martin, FL
St. Lucie, FL
2720 Fort Smith, AR-OK............................. 0.7775 0.8417
Crawford, AR
Sebastian, AR
Sequoyah, OK
2750 Fort Walton Beach, FL......................... 0.8555 0.8986
Okaloosa, FL
2760 Fort Wayne, IN................................ 0.8907 0.9238
Adams, IN
Allen, IN
De Kalb, IN
Huntington, IN
Wells, IN
Whitley, IN
2800 *Forth Worth-Arlington, TX.................... 0.9691 0.9787
Hood, TX
Johnson, TX
Parker, TX
Tarrant, TX
2840 Fresno, CA.................................... 1.0601 1.0408
Fresno, CA
Madera, CA
2880 Gadsden, AL................................... 0.8821 0.9177
Etowah, AL
2900 Gainesville, FL............................... 0.9603 0.9726
Alachua, FL
2920 Galveston-Texas City, TX...................... 1.0572 1.0388
Galveston, TX
2960 Gary, IN...................................... 0.9276 0.9498
Lake, IN
Porter, IN
2975 Glens Falls, NY............................... 0.8359 0.8845
Warren, NY
Washington, NY
2980 Goldsboro, NC................................. 0.8449 0.8910
Wayne, NC
2985 Grand Forks, ND-MN............................ 0.8853 0.9200
Polk, MN
Grand Forks, ND
2995 Grand Junction, CO............................ 0.8557 0.8988
Mesa, CO
3000 Grand Rapids-Muskegon-Holland, MI............. 1.0154 1.0105
Allegan, MI
Kent, MI
Muskegon, MI
Ottawa, MI
3040 Great Falls, MT............................... 0.9321 0.9530
Cascade, MT
3060 Greeley, CO................................... 1.0104 1.0071
Weld, CO
3080 Green Bay, WI................................. 0.9592 0.9719
Brown, WI
3120 *Greensboro-Winston-Salem-High Point, NC...... 0.9357 0.9555
Alamance, NC
Davidson, NC
Davie, NC
Forsyth, NC
Guilford, NC
Randolph, NC
Stokes, NC
Yadkin, NC
3150 Greenville, NC................................ 0.9071 0.9354
Pitt, NC
3160 Greenville-Spartanburg-Anderson, SC........... 0.9066 0.9351
Anderson, SC
Cherokee, SC
Greenville, SC
Pickens, SC
Spartanburg, SC
3180 Hagerstown, MD................................ 0.9688 0.9785
Washington, MD
3200 Hamilton-Middletown, OH....................... 0.8862 0.9206
Butler, OH
3240 Harrisburg-Lebanon-Carlisle, PA............... 1.0159 1.0109
Cumberland, PA
Dauphin, PA
Lebanon, PA
Perry, PA
3283 *Hartford, CT................................. 1.2572 1.1697
Hartford, CT
Litchfield, CT
Middlesex, CT
Tolland, CT
3285 Hattiesburg, MS............................... 0.7197 0.7983
Forrest, MS
Lamar, MS
3290 Hickory-Morganton-Lenoir, NC.................. 0.8291 0.8796
Alexander, NC
Burke, NC
Caldwell, NC
Catawba, NC
3320 Honolulu, HI.................................. 1.1826 1.1217
Honolulu, HI
3350 Houma, LA..................................... 0.7859 0.8479
Lafourche, LA
Terrebonne, LA
3360 *Houston, TX.................................. 0.9633 0.9747
Chambers, TX
Fort Bend, TX
Harris, TX
Liberty, TX
Montgomery, TX
Waller, TX
3400 Huntington-Ashland, WV-KY-OH.................. 0.9159 0.9416
Boyd, KY
Carter, KY
Greenup, KY
Lawrence, OH
Cabell, WV
Wayne, WV
3440 Huntsville, AL................................ 0.8491 0.8940
Limestone, AL
Madison, AL
3480 *Indianapolis, IN............................. 0.9851 0.9898
Boone, IN
Hamilton, IN
Hancock, IN
Hendricks, IN
Johnson, IN
Madison, IN
Marion, IN
Morgan, IN
Shelby, IN
3500 Iowa City, IA................................. 0.9408 0.9591
Johnson, IA
3520 Jackson, MI................................... 0.9058 0.9345
Jackson, MI
3560 Jackson, MS................................... 0.7799 0.8435
Hinds, MS
Madison, MS
Rankin, MS
3580 Jackson, TN................................... 0.8529 0.8968
Madison, TN
Chester, TN
3600 Jacksonville, FL.............................. 0.8986 0.9294
Clay, FL
Duval, FL
Nassau, FL
St. Johns, FL
3605 Jacksonville, NC.............................. 0.6978 0.7816
Onslow, NC
3610 Jamestown, NY................................. 0.7551 0.8250
Chautauqua, NY
3620 Janesville-Beloit, WI......................... 0.8831 0.9184
Rock, WI
3640 Jersey City, NJ............................... 1.1420 1.0952
Hudson, NJ
3660 Johnson City-Kingsport-Bristol, TN-VA......... 0.9120 0.9389
Carter, TN
Hawkins, TN
Sullivan, TN
Unicoi, TN
Washington, TN
Bristol City, VA
[[Page 29975]]
Scott, VA
Washington, VA
3680 Johnstown, PA................................. 0.8384 0.8863
Cambria, PA
Somerset, PA
3700 Jonesboro, AR................................. 0.7449 0.8174
Craighead, AR
3710 Joplin, MO.................................... 0.7519 0.8226
Jasper, MO
Newton, MO
3720 Kalamazoo-Battlecreek, MI..................... 1.0676 1.0458
Calhoun, MI
Kalamazoo, MI
Van Buren, MI
3740 Kankakee, IL.................................. 0.8655 0.9058
Kankakee, IL
3760 *Kansas City, KS-MO........................... 0.9571 0.9704
Johnson, KS
Leavenworth, KS
Miami, KS
Wyandotte, KS
Cass, MO
Clay, MO
Clinton, MO
Jackson, MO
Lafayette, MO
Platte, MO
Ray, MO
3800 Kenosha, WI................................... 0.9203 0.9447
Kenosha, WI
3810 Killeen-Temple, TX............................ 1.0259 1.0177
Bell, TX
Coryell, TX
3840 Knoxville, TN................................. 0.8837 0.9188
Anderson, TN
Blount, TN
Knox, TN
Loudon, TN
Sevier, TN
Union, TN
3850 Kokomo, IN.................................... 0.8422 0.8890
Howard, IN
Tipton, IN
3870 La Crosse, WI-MN.............................. 0.8755 0.9130
Houston, MN
La Crosse, WI
3880 Lafayette, LA................................. 0.8226 0.8748
Acadia, LA
Lafayette, LA
St. Landry, LA
St. Martin, LA
3920 Lafayette, IN................................. 0.9181 0.9432
Clinton, IN
Tippecanoe, IN
3960 Lake Charles, LA.............................. 0.7781 0.8421
Calcasieu, LA
3980 Lakeland-Winter Haven, FL..................... 0.8812 0.9170
Polk, FL
4000 Lancaster, PA................................. 0.9492 0.9649
Lancaster, PA
4040 Lansing-East Lansing, MI...................... 1.0093 1.0064
Clinton, MI
Eaton, MI
Ingham, MI
4080 Laredo, TX.................................... 0.7330 0.8084
Webb, TX
4100 Las Cruces, NM................................ 0.8664 0.9065
Dona Ana, NM
4120 *Las Vegas, NV-AZ............................. 1.0601 1.0408
Mohave, AZ
Clark, NV
Nye, NV
4150 Lawrence, KS.................................. 0.8615 0.9029
Douglas, KS
4200 Lawton, OK.................................... 0.9052 0.9341
Comanche, OK
4243 Lewiston-Auburn, ME........................... 0.9543 0.9685
Androscoggin, ME
4280 Lexington, KY................................. 0.8422 0.8890
Bourbon, KY
Clark, KY
Fayette, KY
Jessamine, KY
Madison, KY
Scott, KY
Woodford, KY
4320 Lima, OH...................................... 0.9192 0.9439
Allen, OH
Auglaize, OH
4360 Lincoln, NE................................... 0.9093 0.9370
Lancaster, NE
4400 Little Rock-North Little Rock, AR............. 0.8496 0.8944
Faulkner, AR
Lonoke, AR
Pulaski, AR
Saline, AR
4420 Longview-Marshall, TX......................... 0.8611 0.9027
Gregg, TX
Harrison, TX
Upshur, TX
4480 *Los Angeles-Long Beach, CA................... 1.2290 1.1517
Los Angeles, CA
4520 Louisville, KY-IN............................. 0.9498 0.9653
Clark, IN
Floyd, IN
Harrison, IN
Scott, IN
Bullitt, KY
Jefferson, KY
Oldham, KY
4600 Lubbock, TX................................... 0.8345 0.8835
Lubbock, TX
4640 Lynchburg, VA................................. 0.8199 0.8729
Amherst, VA
Bedford, VA
Bedford City, VA
Campbell, VA
Lynchburg City, VA
4680 Macon, GA..................................... 0.9069 0.9353
Bibb, GA
Houston, GA
Jones, GA
Peach, GA
Twiggs, GA
4720 Madison, WI................................... 1.0062 1.0042
Dane, WI
4800 Mansfield, OH................................. 0.8645 0.9051
Crawford, OH
Richland, OH
4840 Mayaguez, PR.................................. 0.4486 0.5776
Anasco, PR
Cabo Rojo, PR
Hormigueros, PR
Mayaguez, PR
Sabana Grande, PR
San German, PR
4880 McAllen-Edinburg-Mission, TX.................. 0.8034 0.8608
Hidalgo, TX
4890 Medford-Ashland, OR........................... 1.0361 1.0246
Jackson, OR
4900 Melbourne-Titusville-Palm Bay, FL............. 0.8825 0.9180
Brevard, Fl
4920 *Memphis, TN-AR-MS............................ 0.8595 0.9015
Crittenden, AR
DeSoto, MS
Fayette, TN
Shelby, TN
Tipton, TN
4940 Merced, CA.................................... 1.0913 1.0617
Merced, CA
5000 *Miami, FL.................................... 0.9301 0.9516
Dade, FL
5015 *Middlesex-Somerset-Hunterdon, NJ............. 1.0883 1.0597
Hunterdon, NJ
Middlesex, NJ
Somerset, NJ
5080 *Milwaukee-Waukesha, WI....................... 0.9826 0.9881
Milwaukee, WI
Ozaukee, WI
Washington, WI
Waukesha, WI
5120 *Minneapolis-St. Paul, MN-WI.................. 1.0739 1.0500
Anoka, MN
Carver, MN
Chisago, MN
Dakota, MN
Hennepin, MN
Isanti, MN
Ramsey, MN
Scott, MN
Sherburne, MN
Washington, MN
Wright, MN
Pierce, WI
St. Croix, WI
5160 Mobile, AL.................................... 0.8458 0.8916
Baldwin, AL
Mobile, AL
5170 Modesto, CA................................... 1.0384 1.0261
Stanislaus, CA
5190 *Monmouth-Ocean, NJ........................... 1.0912 1.0616
[[Page 29976]]
Monmouth, NJ
Ocean, NJ
5200 Monroe, LA.................................... 0.8420 0.8889
Ouachita, LA
5240 Montgomery, AL................................ 0.7818 0.8449
Autauga, AL
Elmore, AL
Montgomery, AL
5280 Muncie, IN.................................... 0.9156 0.9414
Delaware, IN
5330 Myrtle Beach, SC.............................. 0.7978 0.8567
Horry, SC
5345 Naples, FL.................................... 1.0116 1.0079
Collier, FL
5360 *Nashville, TN................................ 0.9189 0.9437
Cheatham, TN
Davidson, TN
Dickson, TN
Robertson, TN
Rutherford TN
Sumner, TN
Williamson, TN
Wilson, TN
5380 *Nassau-Suffolk, NY........................... 1.3276 1.2142
Nassau, NY
Suffolk, NY
5483 *New Haven-Bridgeport-Stamford-Waterbury-
Danbury, CT........................................ 1.2629 1.1733
Fairfield, CT
New Haven, CT
5523 New London-Norwich, CT........................ 1.2266 1.1501
New London, CT
5560 *New Orleans, LA.............................. 0.9566 0.9701
Jefferson, LA
Orleans, LA
Plaquemines, LA
St. Bernard, LA
St. Charles, LA
St. James, LA
St. John The Baptist, LA
St. Tammany, LA
5600 *New York, NY................................. 1.4352 1.2807
Bronx, NY
Kings, NY
New York, NY
Putnam, NY
Queens, NY
Richmond, NY
Rockland, NY
Westchester, NY
5640 *Newark, NJ................................... 1.1101 1.0741
Essex, NJ
Morris, NJ
Sussex, NJ
Union, NJ
Warren, NJ
5660 Newburgh, NY-PA............................... 1.1291 1.0867
Orange, NY
Pike, PA
5720 *Norfolk-Virginia Beach-Newport News, VA-NC... 0.8314 0.8812
Currituck, NC
Chesapeake City, VA
Gloucester, VA
Hampton City, VA
Isle of Wight, VA
James City, VA
Mathews, VA
Newport News City, VA
Norfolk City, VA
Poquoson City, VA
Portsmouth City, VA
Suffolk City, VA
Virginia Beach City, VA
Williamsburg City, VA
York, VA
5775 *Oakland, CA.................................. 1.5239 1.3344
Alameda, CA
Contra Costa, CA
5790 Ocala, FL..................................... 0.9039 0.9332
Marion, FL
5800 Odessa-Midland, TX............................ 0.8666 0.9066
Ector, TX
Midland, TX
5880 *Oklahoma City, OK............................ 0.8487 0.8937
Canadian, OK
Cleveland, OK
Logan, OK
McClain, OK
Oklahoma, OK
Pottawatomie, OK
5910 Olympia, WA................................... 1.0866 1.0585
Thurston, WA
5920 Omaha, NE-IA.................................. 0.9406 0.9589
Pottawattamie, IA
Cass, NE
Douglas, NE
Sarpy, NE
Washington, NE
5945 *Orange County, CA............................ 1.1408 1.0944
Orange, CA
5960 *Orlando, FL.................................. 0.9328 0.9535
Lake, FL
Orange, FL
Osceola, FL
Seminole, FL
5990 Owensboro, KY................................. 0.7486 0.8201
Daviess, KY
6015 Panama City, FL............................... 0.8343 0.8833
Bay, FL
6020 Parkersburg-Marietta, WV-OH................... 0.8052 0.8621
Washington, OH
Wood, WV
6080 Pensacola, FL................................. 0.8199 0.8729
Escambia, FL
Santa Rosa, FL
6120 Peoria-Pekin, IL.............................. 0.8555 0.8986
Peoria, IL
Tazewell, IL
Woodford, IL
6160 *Philadelphia, PA-NJ.......................... 1.1380 1.0926
Burlington, NJ
Camden, NJ
Gloucester, NJ
Salem, NJ
Bucks, PA
Chester, PA
Delaware, PA
Montgomery, PA
Philadelphia, PA
6200 *Phoenix-Mesa, AZ............................. 0.9451 0.9621
Maricopa, AZ
Pinal, AZ
6240 Pine Bluff, AR................................ 0.7832 0.8459
Jefferson, AR
6280 *Pittsburgh, PA............................... 0.9733 0.9816
Allegheny, PA
Beaver, PA
Butler, PA
Fayette, PA
Washington, PA
Westmoreland, PA
6323 Pittsfield, MA................................ 1.0623 1.0423
Berkshire, MA
6340 Pocatello, ID................................. 0.9543 0.9685
Bannock, ID
6360 Ponce, PR..................................... 0.4560 0.5841
Guayanilla, PR
Juana Diaz, PR
Penuelas, PR
Ponce, PR
Villalba, PR
Yauco, PR
6403 Portland, ME.................................. 0.9634 0.9748
Cumberland, ME
Sagadahoc, ME
York, ME
6440 *Portland-Vancouver, OR-WA.................... 1.1352 1.0907
Clackamas, OR
Columbia, OR
Multnomah, OR
Washington, OR
Yamhill, OR
Clark, WA
6483 *Providence-Warwick-Pawtucket, RI............. 1.1062 1.0716
Bristol, RI
Kent, RI
Newport, RI
Providence, RI
Washington, RI
6520 Provo-Orem, UT................................ 1.0080 1.0055
Utah, UT
6560 Pueblo, CO.................................... 0.8166 0.8705
Pueblo, CO
6580 Punta Gorda, FL............................... 0.8587 0.9009
Charlotte, FL
6600 Racine, WI.................................... 0.8941 0.9262
Racine, WI
6640 Raleigh-Durham-Chapel Hill, NC................ 0.9825 0.9880
Chatham, NC
[[Page 29977]]
Durham, NC
Franklin, NC
Johnston, NC
Orange, NC
Wake, NC
6660 Rapid City, SD................................ 0.8351 0.8839
Pennington, SD
6680 Reading, PA................................... 0.9523 0.9671
Berks, PA
6690 Redding, CA................................... 1.1781 1.1188
Shasta, CA
6720 Reno, NV...................................... 1.0776 1.0525
Washoe, NV
6740 Richland-Kennewick-Pasco, WA.................. 0.9925 0.9949
Benton, WA
Franklin, WA
6760 Richmond-Petersburg, VA....................... 0.9175 0.9427
Charles City County, VA
Chesterfield, VA
Colonial Heights City, VA
Dinwiddie, VA
Goochland, VA
Hanover, VA
Henrico, VA
Hopewell City, VA
New Kent, VA
Petersburg City, VA
Powhatan, VA
Prince George, VA
Richmond City, VA
6780 *Riverside-San Bernardino, CA................. 1.1166 1.0785
Riverside, CA
San Bernardino, CA
6800 Roanoke, VA................................... 0.8362 0.8847
Botetourt, VA
Roanoke, VA
Roanoke City, VA
Salem City, VA
6820 Rochester, MN................................. 1.0509 1.0346
Olmsted, MN
6840 *Rochester, NY................................ 0.9498 0.9653
Genesee, NY
Livingston, NY
Monroe, NY
Ontario, NY
Orleans, NY
Wayne, NY
6880 Rockford, IL.................................. 0.9087 0.9365
Boone, IL
Ogle, IL
Winnebago, IL
6895 Rocky Mount, NC............................... 0.9038 0.9331
Edgecombe, NC
Nash, NC
6920 *Sacramento, CA............................... 1.2225 1.1475
El Dorado, CA
Placer, CA
Sacramento, CA
6960 Saginaw-Bay City-Midland, MI.................. 0.9571 0.9704
Bay, MI
Midland, MI
Saginaw, MI
6980 St. Cloud, MN................................. 0.9551 0.9690
Benton, MN
Stearns, MN
7000 St. Joseph, MO................................ 0.8372 0.8854
Andrew, MO
Buchanan, MO
7040 *St. Louis, MO-IL............................. 0.9145 0.9406
Clinton, IL
Jersey, IL
Madison, IL
Monroe, IL
St. Clair, IL
Franklin, MO
Jefferson, MO
Lincoln, MO
St. Charles, MO
St. Louis, MO
St. Louis City, MO
Warren, MO
7080 Salem, OR..................................... 0.9942 0.9960
Marion, OR
Polk, OR
7120 Salinas, CA................................... 1.4523 1.2911
Monterey, CA
7160 *Salt Lake City-Ogden, UT..................... 0.9869 0.9910
Davis, UT
Salt Lake, UT
Weber, UT
7200 San Angelo, TX................................ 0.7504 0.8215
Tom Green, TX
7240 *San Antonio, TX.............................. 0.8225 0.8748
Bexar, TX
Comal, TX
Guadalupe, TX
Wilson, TX
7320 *San Diego, CA................................ 1.2266 1.1501
San Diego, CA
7360 *San Francisco, CA............................ 1.4120 1.2665
Marin, CA
San Francisco, CA
San Mateo, CA
7400 *San Jose, CA................................. 1.4245 1.2742
Santa Clara, CA
7440 *San Juan-Bayamon, PR......................... 0.4704 0.5966
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.... 1.1379 1.0925
San Luis Obispo, CA
7480 Santa Barbara-Santa Maria-Lompoc, CA.......... 1.0696 1.0472
Santa Barbara, CA
7485 Santa Cruz-Watsonville, CA.................... 1.4199 1.2714
Santa Cruz, CA
7490 Santa Fe, NM.................................. 1.0081 1.0055
Los Alamos, NM
Santa Fe, NM
7500 Santa Rosa, CA................................ 1.2609 1.1721
Sonoma, CA
7510 Sarasota-Bradenton, FL........................ 0.9764 0.9838
Manatee, FL
Sarasota, FL
7520 Savannah, GA.................................. 0.8678 0.9075
Bryan, GA
Chatham, GA
Effingham, GA
7560 Scranton-Wilkes-Barre-Hazleton, PA............ 0.8546 0.8980
Columbia, PA
Lackawanna, PA
Luzerne, PA
Wyoming, PA
7600 *Seattle-Bellevue-Everett, WA................. 1.1383 1.0928
Island, WA
King, WA
Snohomish, WA
7610 Sharon, PA.................................... 0.8790 0.9155
Mercer, PA
7620 Sheboygan, WI................................. 0.7868 0.8486
Sheboygan, WI
7640 Sherman-Denison, TX........................... 0.8528 0.8967
Grayson, TX
7680 Shreveport-Bossier City, LA................... 0.9396 0.9582
Bossier, LA
Caddo, LA
Webster, LA
7720 Sioux City, IA-NE............................. 0.8026 0.8602
Woodbury, IA
Dakota, NE
7760 Sioux Falls, SD............................... 0.8718 0.9103
Lincoln, SD
[[Page 29978]]
Minnehaha, SD
7800 South Bend, IN................................ 0.9887 0.9922
St. Joseph, IN
7840 Spokane, WA................................... 1.0491 1.0334
Spokane, WA
7880 Springfield, IL............................... 0.8719 0.9104
Menard, IL
Sangamon, IL
7920 Springfield, MO............................... 0.7969 0.8560
Christian, MO
Greene, MO
Webster, MO
8003 Springfield, MA............................... 1.0661 1.0448
Hampden, MA
Hampshire, MA
8050 State College, PA............................. 0.9642 0.9753
Centre, PA
8080 Steubenville-Weirton, OH-WV................... 0.8652 0.9056
Jefferson, OH
Brooke, WV
Hancock, WV
8120 Stockton-Lodi, CA............................. 1.1527 1.1022
San Joaquin, CA
8140 Sumter, SC.................................... 0.7848 0.8471
Sumter, SC
8160 Syracuse, NY.................................. 0.9464 0.9630
Cayuga, NY
Madison, NY
Onondaga, NY
Oswego, NY
8200 Tacoma, WA.................................... 1.1024 1.0690
Pierce, WA
8240 Tallahassee, FL............................... 0.8338 0.8830
Gadsden, FL
Leon, FL
8280 *Tampa-St. Petersburg-Clearwater, FL.......... 0.9191 0.9439
Hernando, FL
Hillsborough, FL
Pasco, FL
Pinellas, FL
8320 Terre Haute, IN............................... 0.8620 0.9033
Clay, IN
Vermillion, IN
Vigo, IN
8360 Texarkana, AR-Texarkana, TX................... 0.9594 0.9720
Miller, AR
Bowie, TX
8400 Toledo, OH.................................... 1.0147 1.0100
Fulton, OH
Lucas, OH
Wood, OH
8440 Topeka, KS.................................... 0.9365 0.9561
Shawnee, KS
8480 Trenton, NJ................................... 1.0375 1.0255
Mercer, NJ
8520 Tucson, AZ.................................... 0.9187 0.9436
Pima, AZ
8560 Tulsa, OK..................................... 0.8080 0.8642
Creek, OK
Osage, OK
Rogers, OK
Tulsa, OK
Wagoner, OK
8600 Tuscaloosa, AL................................ 0.8134 0.8681
Tuscaloosa, AL
8640 Tyler, TX..................................... 0.9516 0.9666
Smith, TX
8680 Utica-Rome, NY................................ 0.8362 0.8847
Herkimer, NY
Oneida, NY
8720 Vallejo-Fairfield-Napa, CA.................... 1.3442 1.2245
Napa, CA
Solano, CA
8735 Ventura, CA................................... 1.0551 1.0374
Ventura, CA
8750 Victoria, TX.................................. 0.8517 0.8959
Victoria, TX
8760 Vineland-Millville-Bridgeton, NJ.............. 1.0118 1.0081
Cumberland, NJ
8780 Visalia-Tulare-Porterville, CA................ 0.9931 0.9953
Tulare, CA
8800 Waco, TX...................................... 0.7701 0.8362
McLennan, TX
8840 *Washington, DC-MD-VA-WV...................... 1.0786 1.0532
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...................... 0.8649 0.9054
Black Hawk, IA
8940 Wausau, WI.................................... 1.0553 1.0375
Marathon, WI
8960 West Palm Beach-Boca Raton, FL................ 1.0331 1.0226
Palm Beach, FL
9000 Wheeling, OH-WV............................... 0.7712 0.8370
Belmont, OH
Marshall, WV
Ohio, WV
9040 Wichita, KS................................... 0.9369 0.9563
Butler, KS
Harvey, KS
Sedgwick, KS
9080 Wichita Falls, TX............................. 0.7645 0.8320
Archer, TX
Wichita, TX
9140 Williamsport, PA.............................. 0.8554 0.8986
Lycoming, PA
9160 Wilmington-Newark, DE-MD...................... 1.1549 1.1036
New Castle, DE
Cecil, MD
9200 Wilmington, NC................................ 0.9329 0.9535
New Hanover, NC
Brunswick, NC
9260 Yakima, WA.................................... 1.0109 1.0075
Yakima, WA
9270 Yolo, CA...................................... 1.1439 1.0964
Yolo, CA
9280 York, PA...................................... 0.9422 0.9600
York, PA
9320 Youngstown-Warren, OH......................... 0.9944 0.9962
Columbiana, OH
Mahoning, OH
Trumbull, OH
9340 Yuba City, CA................................. 1.0479 1.0326
Sutter, CA
Yuba, CA
9360 Yuma, AZ...................................... 0.9739 0.9821
Yuma, AZ
------------------------------------------------------------------------
* Large Urban Area
Table 4B.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
Rural Areas
------------------------------------------------------------------------
Wage
Nonurban area index GAF
------------------------------------------------------------------------
Alabama............................................. 0.7257 0.8029
Alaska.............................................. 1.2319 1.1535
Arizona............................................. 0.7995 0.8579
Arkansas............................................ 0.7010 0.7841
California.......................................... 1.0005 1.0003
Colorado............................................ 0.8068 0.8633
Connecticut......................................... 1.2626 1.1731
Delaware............................................ 0.8932 0.9256
Florida............................................. 0.8846 0.9195
Georgia............................................. 0.7747 0.8396
Hawaii.............................................. 1.0236 1.0161
Idaho............................................... 0.8209 0.8736
Illinois............................................ 0.7651 0.8325
Indiana............................................. 0.8176 0.8712
Iowa................................................ 0.7387 0.8127
Kansas.............................................. 0.7207 0.7991
Kentucky............................................ 0.7784 0.8424
Louisiana........................................... 0.7400 0.8137
Maine............................................... 0.8474 0.8928
Maryland............................................ 0.8623 0.9035
Massachusetts....................................... 1.0726 1.0492
Michigan............................................ 0.8939 0.9261
Minnesota........................................... 0.8202 0.8731
[[Page 29979]]
Mississippi......................................... 0.6919 0.7771
Missouri............................................ 0.7221 0.8001
Montana............................................. 0.8142 0.8687
Nebraska............................................ 0.7358 0.8105
Nevada.............................................. 0.8922 0.9249
New Hampshire....................................... 0.9730 0.9814
New Jersey \1\...................................... ........ ........
New Mexico.......................................... 0.7893 0.8504
New York............................................ 0.8375 0.8856
North Carolina...................................... 0.7938 0.8537
North Dakota........................................ 0.7347 0.8097
Ohio................................................ 0.8438 0.8902
Oklahoma............................................ 0.7065 0.7883
Oregon.............................................. 0.9988 0.9992
Pennsylvania........................................ 0.8439 0.8903
Puerto Rico......................................... 0.3999 0.5338
Rhode Island \1\.................................... ........ ........
South Carolina...................................... 0.7909 0.8516
South Dakota........................................ 0.6982 0.7819
Tennessee........................................... 0.7357 0.8104
Texas............................................... 0.7322 0.8078
Utah................................................ 0.8932 0.9256
Vermont............................................. 0.9320 0.9529
Virginia............................................ 0.7763 0.8408
Washington.......................................... 1.0223 1.0152
West Virginia....................................... 0.7964 0.8556
Wisconsin........................................... 0.8477 0.8930
Wyoming............................................. 0.8250 0.8766
------------------------------------------------------------------------
\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
Urban area index GAF
------------------------------------------------------------------------
Abilene, TX......................................... 0.8294 0.8798
Albuquerque, NM..................................... 0.9336 0.9540
Alexandria, LA...................................... 0.8275 0.8784
Amarillo, TX........................................ 0.9503 0.9657
Anchorage, AK....................................... 1.3015 1.1978
Asheville, NC....................................... 0.9078 0.9359
Athens, GA.......................................... 0.9093 0.9370
Atlanta, GA......................................... 0.9812 0.9871
Austin-San Marcos, TX............................... 0.8690 0.9083
Bangor, ME.......................................... 0.9485 0.9644
Barnstable-Yarmouth, MA............................. 1.3837 1.2491
Baton Rouge, LA..................................... 0.8416 0.8886
Benton Harbor, MI................................... 0.8640 0.9047
Benton Harbor, MI (Rural Michigan Hosp.)............ 0.8939 0.9261
Bergen-Passaic, NJ.................................. 1.1573 1.1052
Billings, MT........................................ 0.9147 0.9408
Birmingham, AL...................................... 0.8933 0.9256
Bismarck, ND........................................ 0.7874 0.8490
Boise City, ID...................................... 0.8893 0.9228
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH.... 1.1430 1.0958
Caguas, PR.......................................... 0.4551 0.5833
Casper, WY.......................................... 0.9019 0.9317
Champaign-Urbana, IL................................ 0.8740 0.9119
Charlotte-Gastonia-Rock Hill, NC-SC................. 0.9758 0.9834
Charlottesville, VA................................. 0.8897 0.9231
Chattanooga, TN-GA.................................. 0.8664 0.9065
Chicago, IL......................................... 1.0829 1.0561
Cincinnati, OH-KY-IN................................ 0.9565 0.9700
Cleveland-Lorain-Elyria, OH......................... 0.9811 0.9870
Columbia, MO........................................ 0.8685 0.9080
Columbus, OH........................................ 0.9800 0.9863
Dallas, TX.......................................... 0.9624 0.9741
Davenport-Moline-Rock Island, IA-IL................. 0.8411 0.8883
Denver, CO.......................................... 1.0299 1.0204
Des Moines, IA...................................... 0.8718 0.9103
Detroit, MI......................................... 1.0844 1.0571
Duluth-Superior, MN-WI.............................. 0.9786 0.9853
Dutchess County, NY................................. 1.0174 1.0119
Eugene-Springfield, OR.............................. 1.1700 1.1135
Fargo-Moorhead, ND-MN............................... 0.8730 0.9112
Fayetteville, NC.................................... 0.8468 0.8924
Flint, MI........................................... 1.1191 1.0801
Florence, AL........................................ 0.7722 0.8378
Florence, SC........................................ 0.8243 0.8761
Ft. Lauderdale, FL.................................. 1.0802 1.0543
Fort Pierce-Port St. Lucie, FL...................... 0.9782 0.9850
Fort Walton Beach, FL............................... 0.8555 0.8986
Fort Worth-Arlington, TX............................ 0.9691 0.9787
Gadsden, AL......................................... 0.8821 0.9177
Gainesville, FL..................................... 0.9603 0.9726
Gary, IN............................................ 0.9121 0.9389
Grand Forks, ND-MN.................................. 0.8853 0.9200
Grand Junction, CO.................................. 0.8557 0.8988
Great Falls, MT..................................... 0.9321 0.9530
Greeley, CO......................................... 0.9798 0.9861
Green Bay, WI....................................... 0.9592 0.9719
Greensboro-Winston-Salem-High Point, NC............. 0.9357 0.9555
Harrisburg-Lebanon-Carlisle, PA..................... 1.0044 1.0030
Honolulu, HI........................................ 1.1826 1.1217
Houma, LA........................................... 0.7859 0.8479
Houston, TX......................................... 0.9633 0.9747
Huntington-Ashland, WV-KY-OH........................ 0.9159 0.9416
Huntsville, AL...................................... 0.8491 0.8940
Indianapolis, IN.................................... 0.9851 0.9898
Iowa City, IA....................................... 0.9192 0.9439
Jackson, MS......................................... 0.7799 0.8435
Johnson City-Kingsport-Bristol, TN-VA............... 0.9120 0.9389
Jonesboro, AR....................................... 0.7449 0.8174
Joplin, MO.......................................... 0.7519 0.8226
Kalamazoo-Battle Creek, MI.......................... 1.0676 1.0458
Kansas City, KS-MO.................................. 0.9571 0.9704
Knoxville, TN....................................... 0.8837 0.9188
Lafayette, LA....................................... 0.8226 0.8748
Lafayette, IN....................................... 0.9181 0.9432
Lansing-East Lansing, MI............................ 1.0093 1.0064
Las Cruces, NM...................................... 0.8664 0.9065
Las Vegas, NV-AZ.................................... 1.0601 1.0408
Lexington, KY....................................... 0.8422 0.8890
Lima, OH............................................ 0.9192 0.9439
Lincoln, NE......................................... 0.8935 0.9258
Little Rock-North Little Rock, AR................... 0.8496 0.8944
Longview-Marshall, TX............................... 0.8508 0.8953
Los Angeles-Long Beach, CA.......................... 1.2290 1.1517
Louisville, KY-IN................................... 0.9498 0.9653
Macon, GA........................................... 0.9069 0.9353
Madison, WI......................................... 1.0062 1.0042
Mansfield, OH....................................... 0.8645 0.9051
Medford-Ashland, OR................................. 1.0361 1.0246
Memphis, TN-AR-MS................................... 0.8595 0.9015
Milwaukee-Waukesha, WI.............................. 0.9826 0.9881
Minneapolis-St. Paul, MN-WI......................... 1.0739 1.0500
Monroe, LA.......................................... 0.8420 0.8889
Montgomery, AL...................................... 0.7818 0.8449
Nashville, TN....................................... 0.9189 0.9437
New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT. 1.2629 1.1733
New London-Norwich, CT.............................. 1.2266 1.1501
New Orleans, LA..................................... 0.9566 0.9701
New York, NY........................................ 1.4352 1.2807
Newark, NJ.......................................... 1.1101 1.0741
Newburgh, NY-PA..................................... 1.1468 1.0983
Oakland, CA......................................... 1.5239 1.3344
Odessa-Midland, TX.................................. 0.8522 0.8963
Oklahoma City, OK................................... 0.8487 0.8937
Omaha, NE-IA........................................ 0.9406 0.9589
Orange County, CA................................... 1.1408 1.0944
Peoria-Pekin, IL.................................... 0.8555 0.8986
Philadelphia, PA-NJ................................. 1.1380 1.0926
Pittsburgh, PA...................................... 0.9591 0.9718
Pocatello, ID....................................... 0.8987 0.9295
Portland, ME........................................ 0.9634 0.9748
Portland-Vancouver, OR-WA........................... 1.1352 1.0907
Provo-Orem, UT...................................... 1.0080 1.0055
Raleigh-Durham-Chapel Hill, NC...................... 0.9825 0.9880
Rapid City, SD...................................... 0.8351 0.8839
Rochester, MN....................................... 1.0509 1.0346
Rockford, IL........................................ 0.9087 0.9365
Sacramento, CA...................................... 1.2225 1.1475
Saginaw-Bay City-Midland, MI........................ 0.9571 0.9704
St. Cloud, MN....................................... 0.9551 0.9690
St. Louis, MO-IL.................................... 0.9145 0.9406
Salinas, CA......................................... 1.4309 1.2781
Salt Lake City-Ogden, UT............................ 0.9869 0.9910
San Diego, CA....................................... 1.2266 1.1501
San Francisco, CA................................... 1.4120 1.2665
Santa Fe, NM........................................ 0.9818 0.9875
Santa Rosa, CA...................................... 1.2447 1.1617
Seattle-Bellevue-Everett, WA........................ 1.1383 1.0928
Sherman-Denison, TX................................. 0.8345 0.8835
Sioux City, IA-NE................................... 0.8026 0.8602
Sioux Falls, SD..................................... 0.8613 0.9028
South Bend, IN...................................... 0.9887 0.9922
[[Page 29980]]
Spokane, WA......................................... 1.0316 1.0215
Springfield, IL..................................... 0.8617 0.9031
Springfield, MO..................................... 0.7969 0.8560
Stockton-Lodi, CA................................... 1.1527 1.1022
Syracuse, NY........................................ 0.9464 0.9630
Tampa-St. Petersburg-Clearwater, FL................. 0.9191 0.9439
Texarkana, AR-Texarkana, TX......................... 0.9482 0.9642
Topeka, KS.......................................... 0.9240 0.9473
Tucson, AZ.......................................... 0.9187 0.9436
Tulsa, OK........................................... 0.8080 0.8642
Tyler, TX........................................... 0.9379 0.9570
Vallejo-Fairfield-Napa, CA.......................... 1.3442 1.2245
Washington, DC-MD-VA-WV............................. 1.0786 1.0532
Waterloo-Cedar Falls, IA............................ 0.8649 0.9054
Wausau, WI.......................................... 0.9853 0.9899
Wichita, KS......................................... 0.9130 0.9396
Wichita Falls, TX................................... 0.7645 0.8320
Rural Florida....................................... 0.8846 0.9195
Rural Louisiana..................................... 0.7400 0.8137
Rural Minnesota..................................... 0.8202 0.8731
Rural Missouri...................................... 0.7221 0.8001
Rural New Hampshire................................. 0.9730 0.9814
Rural New Mexico.................................... 0.7893 0.8504
Rural North Carolina................................ 0.7938 0.8537
Rural Oregon........................................ 0.9988 0.9992
Rural Washington.................................... 1.0223 1.0152
Rural West Virginia................................. 0.7964 0.8556
Rural Wyoming....................................... 0.8250 0.8766
------------------------------------------------------------------------
Table 4D.--Average Hourly Wage for Urban Areas
------------------------------------------------------------------------
Average
Urban area hourly
wage
------------------------------------------------------------------------
Abilene, TX.................................................. 16.6537
Aguadilla, PR................................................ 8.4161
Akron, OH.................................................... 19.6368
Albany, GA................................................... 15.9028
Albany-Schenectady-Troy, NY.................................. 17.0385
Albuquerque, NM.............................................. 18.7069
Alexandria, LA............................................... 16.4017
Allentown-Bethlehem-Easton, PA............................... 20.2671
Altoona, PA.................................................. 18.3612
Amarillo, TX................................................. 18.9399
Anchorage, AK................................................ 25.8065
Ann Arbor, MI................................................ 23.6829
Anniston, AL................................................. 16.6112
Appleton-Oshkosh-Neenah, WI.................................. 18.0782
Arecibo, PR.................................................. 8.4753
Asheville, NC................................................ 18.2293
Athens, GA................................................... 18.2596
Atlanta, GA.................................................. 19.7032
Atlantic-Cape May, NJ........................................ 22.4152
Augusta-Aiken, GA-SC......................................... 18.7566
Austin-San Marcos, TX........................................ 17.4495
Bakersfield, CA.............................................. 20.1222
Baltimore, MD................................................ 19.4693
Bangor, ME................................................... 19.0467
Barnstable-Yarmouth, MA...................................... 28.7181
Baton Rouge, LA.............................................. 16.9004
Beaumont-Port Arthur, TX..................................... 17.2215
Bellingham, WA............................................... 22.5492
Benton Harbor, MI............................................ 17.3503
Bergen-Passaic, NJ........................................... 24.3291
Billings, MT................................................. 19.5350
Biloxi-Gulfport-Pascagoula, MS............................... 16.9110
Binghamton, NY............................................... 18.2489
Birmingham, AL............................................... 17.9378
Bismarck, ND................................................. 15.4640
Bloomington,IN............................................... 18.3421
Bloomington-Normal, IL....................................... 17.6360
Boise City, ID............................................... 17.7955
Boston-Worcester-Lawrence-Lowell-Brockton, MA-NH............. 22.9698
Boulder-Longmont, CO......................................... 20.1260
Brazoria, TX................................................. 18.7704
Bremerton, WA................................................ 22.1033
Brownsville-Harlingen-San Benito, TX......................... 17.4677
Bryan-College Station, TX.................................... 14.1367
Buffalo-Niagara Falls, NY.................................... 18.6068
Burlington, VT............................................... 20.2766
Caguas, PR................................................... 9.0320
Canton-Massillon, OH......................................... 18.0078
Casper, WY................................................... 18.1110
Cedar Rapids, IA............................................. 17.1383
Champaign-Urbana, IL......................................... 17.5502
Charleston-North Charleston, SC.............................. 17.5483
Charleston, WV............................................... 18.3703
Charlotte-Gastonia-Rock Hill, NC-SC.......................... 19.5947
Charlottesville, VA.......................................... 18.2038
Chattanooga, TN-GA........................................... 17.3976
Cheyenne, WY................................................. 15.1808
Chicago, IL.................................................. 21.7444
Chico-Paradise, CA........................................... 20.8709
Cincinnati, OH-KY-IN......................................... 19.0516
Clarksville-Hopkinsville, TN-KY.............................. 15.7778
Cleveland-Lorain-Elyria, OH.................................. 19.7007
Colorado Springs, CO......................................... 18.7205
Columbia, MO................................................. 17.8452
Columbia, SC................................................. 18.5185
Columbus, GA-AL.............................................. 16.6542
Columbus, OH................................................. 19.6781
Corpus Christi, TX........................................... 17.9745
Cumberland, MD-WV............................................ 17.7280
Dallas, TX................................................... 19.3876
Danville, VA................................................. 16.3692
Davenport-Moline-Rock Island, IA-IL.......................... 16.8903
Dayton-Springfield, OH....................................... 19.3553
Daytona Beach, FL............................................ 16.7797
Decatur, AL.................................................. 16.6503
Decatur, IL.................................................. 15.9047
Denver, CO................................................... 20.6808
Des Moines, IA............................................... 17.5070
Detroit, MI.................................................. 21.7434
Dothan, AL................................................... 16.2160
Dover, DE.................................................... 18.5175
Dubuque, IA.................................................. 16.2530
Duluth-Superior, MN-WI....................................... 19.6500
Dutchess County, NY.......................................... 21.3729
Eau Claire, WI............................................... 17.6122
El Paso, TX.................................................. 19.5169
Elkhart-Goshen, IN........................................... 18.2474
Elmira, NY................................................... 16.5714
Enid, OK..................................................... 16.0002
Erie, PA..................................................... 17.8087
Eugene-Springfield, OR....................................... 23.0592
Evansville, Henderson, IN-KY................................. 17.3648
Fargo-Moorhead, ND-MN........................................ 17.7585
Fayetteville, NC............................................. 17.5510
Fayetteville-Springdale-Rogers, AR........................... 14.9924
Flagstaff, AZ-UT............................................. 18.3168
Flint, MI.................................................... 22.4728
Florence, AL................................................. 15.1732
Florence, SC................................................. 16.5268
Fort Collins-Loveland, CO.................................... 20.5933
Fort Lauderdale, FL.......................................... 20.8970
Fort Myers-Cape Coral, FL.................................... 16.8350
Fort Pierce-Port St. Lucie, FL............................... 19.6424
Fort Smith, AR-OK............................................ 15.6127
Fort Walton Beach, FL........................................ 17.1797
Fort Wayne, IN............................................... 17.8865
Fort Worth-Arlington, TX..................................... 19.3702
Fresno, CA................................................... 21.2867
Gadsden, AL.................................................. 17.7134
Gainesville, FL.............................................. 19.2822
Galveston-Texas City, TX..................................... 21.2286
Gary, IN..................................................... 19.3581
Glens Falls, NY.............................................. 16.7853
Goldsboro, NC................................................ 16.9659
Grand Forks, ND-MN........................................... 17.5737
Grand Junction, CO........................................... 15.6876
Grand Rapids-Muskegon-Holland, MI............................ 20.3894
Great Falls, MT.............................................. 17.9668
Greeley, CO.................................................. 20.2891
Green Bay, WI................................................ 18.2802
Greensboro-Winston-Salem-High Point, NC...................... 18.7901
Greenville, NC............................................... 18.2150
Greenville-Spartanburg-Anderson, SC.......................... 18.2047
Hagerstown, MD............................................... 19.4546
Hamilton-Middletown, OH...................................... 17.7961
Harrisburg-Lebanon-Carlisle, PA.............................. 20.3990
Hartford, CT................................................. 25.2442
Hattiesburg, MS.............................................. 14.4517
Hickory-Morganton-Lenoir, NC................................. 17.4555
Honolulu, HI................................................. 23.7434
Houma, LA.................................................... 15.7820
Houston, TX.................................................. 19.3444
Huntington-Ashland, WV-KY-OH................................. 18.3921
Huntsville, AL............................................... 17.0504
Indianapolis, IN............................................. 19.7810
Iowa City, IA................................................ 18.8914
Jackson, MI.................................................. 18.1893
Jackson, MS.................................................. 15.6018
Jackson, TN.................................................. 17.1259
Jacksonville, FL............................................. 18.0438
Jacksonville, NC............................................. 14.0121
Jamestown, NY................................................ 15.1621
Janesville-Beloit, WI........................................ 17.7327
Jersey City, NJ.............................................. 22.9317
Johnson City-Kingsport-Bristol, TN-VA........................ 18.3136
Johnstown, PA................................................ 16.8349
Jonesboro, AR................................................ 14.9575
Joplin, MO................................................... 15.0332
Kalamazoo-Battlecreek, MI.................................... 21.4383
Kankakee, IL................................................. 17.3802
Kansas City, KS-MO........................................... 19.2182
Kenosha, WI.................................................. 18.4799
Killeen-Temple, TX........................................... 20.6010
Knoxville, TN................................................ 17.7457
[[Page 29981]]
Kokomo, IN................................................... 16.9123
La Crosse, WI-MN............................................. 17.5812
Lafayette, LA................................................ 16.4732
Lafayette, IN................................................ 18.4349
Lake Charles, LA............................................. 15.6250
Lakeland-Winter Haven, FL.................................... 17.6957
Lancaster, PA................................................ 19.0606
Lansing-East Lansing, MI..................................... 20.2670
Laredo, TX................................................... 14.7188
Las Cruces, NM............................................... 17.3739
Las Vegas, NV-AZ............................................. 21.2874
Lawrence, KS................................................. 17.2986
Lawton, OK................................................... 18.1767
Lewiston-Auburn, ME.......................................... 19.1630
Lexington, KY................................................ 16.8603
Lima, OH..................................................... 18.4571
Lincoln, NE.................................................. 18.2595
Little Rock-North Little Rock, AR............................ 17.0606
Longview-Marshall, TX........................................ 17.2912
Los Angeles-Long Beach, CA................................... 24.6067
Louisville, KY-IN............................................ 19.0725
Lubbock, TX.................................................. 16.7563
Lynchburg, VA................................................ 16.4640
Macon, GA.................................................... 18.2107
Madison, WI.................................................. 20.2048
Mansfield, OH................................................ 17.3603
Mayaguez, PR................................................. 9.0075
McAllen-Edinburg-Mission, TX................................. 16.1323
Medford-Ashland, OR.......................................... 20.8059
Melbourne-Titusville-Palm Bay, FL............................ 17.7216
Memphis, TN-AR-MS............................................ 17.2589
Merced, CA................................................... 21.9146
Miami, FL.................................................... 19.8627
Middlesex-Somerset-Hunterdon, NJ............................. 22.0067
Milwaukee-Waukesha, WI....................................... 19.7306
Minneapolis-St. Paul, MN-WI.................................. 21.5643
Mobile, AL................................................... 16.9845
Modesto, CA.................................................. 21.6914
Monmouth-Ocean, NJ........................................... 21.9116
Monroe, LA................................................... 16.9075
Montgomery, AL............................................... 15.4155
Muncie, IN................................................... 18.3854
Myrtle Beach, SC............................................. 16.0211
Naples, FL................................................... 20.3132
Nashville, TN................................................ 18.4518
Nassau-Suffolk, NY........................................... 27.7072
New Haven-Bridgeport-Stamford-Waterbury-Danbury, CT.......... 25.3561
New London-Norwich, CT....................................... 24.1396
New Orleans, LA.............................................. 19.2096
New York, NY................................................. 28.8193
Newark, NJ................................................... 24.0494
Newburgh, NY-PA.............................................. 22.6737
Norfolk-Virginia Beach-Newport News, VA-NC................... 16.6956
Oakland, CA.................................................. 30.4360
Ocala, FL.................................................... 18.1497
Odessa-Midland, TX........................................... 17.4016
Oklahoma City, OK............................................ 17.0417
Olympia, WA.................................................. 21.8203
Omaha, NE-IA................................................. 18.8876
Orange County, CA............................................ 23.0599
Orlando, FL.................................................. 18.7302
Owensboro, KY................................................ 15.0313
Panama City, FL.............................................. 16.7539
Parkersburg-Marietta, WV-OH.................................. 16.1677
Pensacola, FL................................................ 16.4635
Peoria-Pekin, IL............................................. 17.1794
Philadelphia, PA-NJ.......................................... 22.8513
Phoenix-Mesa, AZ............................................. 18.9787
Pine Bluff, AR............................................... 15.7267
Pittsburgh, PA............................................... 19.5446
Pittsfield, MA............................................... 21.3310
Pocatello, ID................................................ 19.1619
Ponce, PR.................................................... 9.1572
Portland, ME................................................. 19.3456
Portland-Vancouver, OR-WA.................................... 22.7959
Providence-Warwick, RI....................................... 22.2138
Provo-Orem, UT............................................... 20.2420
Pueblo, CO................................................... 16.3970
Punta Gorda, FL.............................................. 17.2423
Racine, WI................................................... 17.9536
Raleigh-Durham-Chapel Hill, NC............................... 19.7297
Rapid City, SD............................................... 16.7698
Reading, PA.................................................. 19.1233
Redding, CA.................................................. 23.6558
Reno, NV..................................................... 21.6378
Richland-Kennewick-Pasco, WA................................. 19.9294
Richmond-Petersburg, VA...................................... 18.4237
Riverside-San Bernardino, CA................................. 22.7449
Roanoke, VA.................................................. 16.7913
Rochester, MN................................................ 21.1030
Rochester, NY................................................ 19.0730
Rockford, IL................................................. 18.2476
Rocky Mount, NC.............................................. 18.1482
Sacramento, CA............................................... 24.5491
Saginaw-Bay City-Midland, MI................................. 19.2180
St. Cloud, MN................................................ 19.1778
St. Joseph, MO............................................... 16.8108
St. Louis, MO-IL............................................. 18.3627
Salem, OR.................................................... 19.9649
Salinas, CA.................................................. 29.1634
Salt Lake City-Ogden, UT..................................... 19.8077
San Angelo, TX............................................... 15.0684
San Antonio, TX.............................................. 16.5159
San Diego, CA................................................ 24.5670
San Francisco, CA............................................ 28.5345
San Jose, CA................................................. 28.6049
San Juan-Bayamon, PR......................................... 9.4463
San Luis Obispo-Atascadero-Paso Robles, CA................... 22.8504
Santa Barbara-Santa Maria-Lompoc, CA......................... 21.4774
Santa Cruz-Watsonville, CA................................... 28.5128
Santa Fe, NM................................................. 20.2428
Santa Rosa, CA............................................... 26.2920
Sarasota-Bradenton, FL....................................... 19.6072
Savannah, GA................................................. 17.4249
Scranton-Wilkes Barre-Hazleton, PA........................... 17.1601
Seattle-Bellevue-Everett, WA................................. 22.7858
Sharon, PA................................................... 17.6500
Sheboygan, WI................................................ 15.7984
Sherman-Denison, TX.......................................... 17.1241
Shreveport-Bossier City, LA.................................. 18.8682
Sioux City, IA-NE............................................ 16.1162
Sioux Falls, SD.............................................. 17.5067
South Bend, IN............................................... 19.8290
Spokane, WA.................................................. 21.0664
Springfield, IL.............................................. 17.5080
Springfield, MO.............................................. 15.8980
Springfield, MA.............................................. 21.4074
State College, PA............................................ 19.3613
Steubenville-Weirton, OH-WV.................................. 17.3728
Stockton-Lodi, CA............................................ 23.1020
Sumter, SC................................................... 15.7585
Syracuse, NY................................................. 18.9634
Tacoma, WA................................................... 22.1357
Tallahassee, FL.............................................. 16.7434
Tampa-St. Petersburg-Clearwater, FL.......................... 18.2677
Terre Haute, IN.............................................. 17.3093
Texarkana, AR-Texarkana, TX.................................. 19.2649
Toledo, OH................................................... 20.8792
Topeka, KS................................................... 18.8050
Trenton, NJ.................................................. 20.8336
Tucson, AZ................................................... 18.4477
Tulsa, OK.................................................... 16.2252
Tuscaloosa, AL............................................... 16.3331
Tyler, TX.................................................... 19.1086
Utica-Rome, NY............................................... 16.7919
Vallejo-Fairfield-Napa, CA................................... 27.4125
Ventura, CA.................................................. 21.9959
Victoria, TX................................................. 17.1016
Vineland-Millville-Bridgeton, NJ............................. 20.3170
Visalia-Tulare-Porterville, CA............................... 19.9417
Waco, TX..................................................... 15.4645
Washington, DC-MD-VA-WV...................................... 21.6582
Waterloo-Cedar Falls, IA..................................... 17.3631
Wausau, WI................................................... 21.1907
West Palm Beach-Boca Raton, FL............................... 20.8691
Wheeling, OH-WV.............................................. 15.4868
Wichita, KS.................................................. 18.8137
Wichita Falls, TX............................................ 15.3505
Williamsport, PA............................................. 17.1768
Wilmington-Newark, DE-MD..................................... 23.1911
Wilmington, NC............................................... 18.7325
Yakima, WA................................................... 20.2994
Yolo, CA..................................................... 22.9704
York, PA..................................................... 18.9189
Youngstown-Warren, OH........................................ 19.9688
Yuba City, CA................................................ 21.0423
Yuma, AZ..................................................... 19.5572
------------------------------------------------------------------------
Table 4E.--Average Hourly Wage For Rural Areas
------------------------------------------------------------------------
Average
Nonurban area hourly
wage
------------------------------------------------------------------------
Alabama...................................................... 14.5723
Alaska....................................................... 24.7367
Arizona...................................................... 16.0545
Arkansas..................................................... 14.0756
California................................................... 20.0902
Colorado..................................................... 16.2015
Connecticut.................................................. 25.3532
Delaware..................................................... 17.9354
Florida...................................................... 17.7628
Georgia...................................................... 15.5563
Hawaii....................................................... 20.5550
Idaho........................................................ 16.4839
Illinois..................................................... 15.3631
Indiana...................................................... 16.4180
Iowa......................................................... 14.8337
Kansas....................................................... 14.4720
Kentucky..................................................... 15.6298
Louisiana.................................................... 14.8596
Maine........................................................ 17.0166
Maryland..................................................... 17.3152
Massachusetts................................................ 21.5382
Michigan..................................................... 17.9507
Minnesota.................................................... 16.4669
Mississippi.................................................. 13.8932
[[Page 29982]]
Missouri..................................................... 14.4980
Montana...................................................... 16.3497
Nebraska..................................................... 14.7745
Nevada....................................................... 17.9159
New Hampshire................................................ 19.5250
New Jersey \1\............................................... .........
New Mexico................................................... 15.8297
New York..................................................... 16.8172
North Carolina............................................... 15.9365
North Dakota................................................. 14.7534
Ohio......................................................... 16.9442
Oklahoma..................................................... 14.1874
Oregon....................................................... 20.0517
Pennsylvania................................................. 16.9465
Puerto Rico.................................................. 8.0298
Rhode Island \1\............................................. .........
South Carolina............................................... 15.8812
South Dakota................................................. 14.0203
Tennessee.................................................... 14.7740
Texas........................................................ 14.7038
Utah......................................................... 17.9362
Vermont...................................................... 18.7155
Virginia..................................................... 15.5887
Washington................................................... 20.5277
West Virginia................................................ 15.9342
Wisconsin.................................................... 17.0214
Wyoming...................................................... 16.5656
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban.
Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF)
----------------------------------------------------------------------------------------------------------------
Wage index--
reclass. GAF--
Area Wage index GAF hospitals reclass.
hospitals
----------------------------------------------------------------------------------------------------------------
Aguadilla, PR............................................... 0.9152 0.9411 ........... ...........
Arecibo, PR................................................. 0.9217 0.9457 ........... ...........
Caguas, PR.................................................. 0.9937 0.9957 0.9937 0.9957
Mayaguez, PR................................................ 0.9795 0.9859 ........... ...........
Ponce, PR................................................... 0.9958 0.9971 ........... ...........
San Juan-Bayamon, PR........................................ 1.0273 1.0186 ........... ...........
Rural Puerto Rico........................................... 0.8732 0.9113 ........... ...........
----------------------------------------------------------------------------------------------------------------
Table 5.--List of Diagnosis Related Groups (DRGs), Relative Weighting Factors, Geometric and Arithmetic Mean
Length
----------------------------------------------------------------------------------------------------------------
Relative Geometric Arithmetic
weights mean LOS mean LOS
----------------------------------------------------------------------------------------------------------------
1............... 01 SURG CRANIOTOMY AGE >17 EXCEPT 3.0381 6.9 10.0
FOR TRAUMA.
2............... 01 SURG CRANIOTOMY FOR TRAUMA AGE 3.0527 7.9 10.6
>17.
3............... 01 SURG *CRANIOTOMY AGE 0-17....... 1.9470 12.7 12.7
4............... 01 SURG SPINAL PROCEDURES.......... 2.3738 5.5 8.5
5............... 01 SURG EXTRACRANIAL VASCULAR 1.5019 2.9 3.9
PROCEDURES.
6............... 01 SURG CARPAL TUNNEL RELEASE...... .7573 2.2 3.3
7............... 01 SURG PERIPH & CRANIAL NERVE & 2.4812 7.6 11.6
OTHER NERV SYST PROC W CC.
8............... 01 SURG PERIPH & CRANIAL NERVE & 1.1314 2.5 3.6
OTHER NERV SYST PROC W/O
CC.
9............... 01 MED SPINAL DISORDERS & INJURIES 1.2570 5.1 7.2
10.............. 01 MED NERVOUS SYSTEM NEOPLASMS W 1.2176 5.3 7.4
CC.
11.............. 01 MED NERVOUS SYSTEM NEOPLASMS W/ .7857 3.2 4.3
O CC.
12.............. 01 MED DEGENERATIVE NERVOUS SYSTEM .9357 5.0 6.8
DISORDERS.
13.............. 01 MED MULTIPLE SCLEROSIS & .7809 4.7 5.8
CEREBELLAR ATAXIA.
14.............. 01 MED SPECIFIC CEREBROVASCULAR 1.1904 5.1 6.8
DISORDERS EXCEPT TIA.
15.............. 01 MED TRANSIENT ISCHEMIC ATTACK & .7249 3.2 4.1
PRECEREBRAL OCCLUSIONS.
16.............. 01 MED NONSPECIFIC CEREBROVASCULAR 1.0452 4.6 6.1
DISORDERS W CC.
17.............. 01 MED NONSPECIFIC CEREBROVASCULAR .6176 2.9 3.7
DISORDERS W/O CC.
18.............. 01 MED CRANIAL & PERIPHERAL NERVE .9400 4.5 5.9
DISORDERS W CC.
19.............. 01 MED CRANIAL & PERIPHERAL NERVE .6290 3.2 4.1
DISORDERS W/O CC.
20.............. 01 MED NERVOUS SYSTEM INFECTION 2.5777 8.0 10.8
EXCEPT VIRAL MENINGITIS.
21.............. 01 MED VIRAL MENINGITIS........... 1.4784 5.4 7.1
22.............. 01 MED HYPERTENSIVE ENCEPHALOPATHY .8687 3.7 4.8
23.............. 01 MED NONTRAUMATIC STUPOR & COMA. .7820 3.3 4.6
24.............. 01 MED SEIZURE & HEADACHE AGE >17 .9588 3.9 5.4
W CC.
25.............. 01 MED SEIZURE & HEADACHE AGE >17 .5809 2.8 3.6
W/O CC.
26.............. 01 MED SEIZURE & HEADACHE AGE 0-17 .9598 3.7 5.0
27.............. 01 MED TRAUMATIC STUPOR & COMA, 1.2609 3.4 5.5
COMA >1 HR.
28.............. 01 MED TRAUMATIC STUPOR & COMA, 1.1684 4.4 6.4
COMA <1 hr="" age="">17 W CC.
29.............. 01 MED TRAUMATIC STUPOR & COMA, .6364 2.8 3.8
COMA <1 hr="" age="">17 W/O CC.
30.............. 01 MED *TRAUMATIC STUPOR & COMA, .3292 2.0 2.0
COMA <1 hr="" age="" 0-17.="" 31..............="" 01="" med="" concussion="" age="">17 W CC.... .8364 3.5 4.8
32.............. 01 MED CONCUSSION AGE >17 W/O CC.. .5087 2.2 3.1
33.............. 01 MED *CONCUSSION AGE 0-17....... .2069 1.6 1.6
34.............. 01 MED OTHER DISORDERS OF NERVOUS 1.0365 4.2 5.8
SYSTEM W CC.
35.............. 01 MED OTHER DISORDERS OF NERVOUS .5930 3.0 3.9
SYSTEM W/O CC.
36.............. 02 SURG RETINAL PROCEDURES......... .6246 1.3 1.5
[[Page 29983]]
37.............. 02 SURG ORBITAL PROCEDURES......... .9697 2.6 3.9
38.............. 02 SURG PRIMARY IRIS PROCEDURES.... .4780 1.9 2.7
39.............. 02 SURG LENS PROCEDURES WITH OR .5414 1.5 2.0
WITHOUT VITRECTOMY.
40.............. 02 SURG EXTRAOCULAR PROCEDURES .7386 2.2 3.3
EXCEPT ORBIT AGE >17.
41.............. 02 SURG *EXTRAOCULAR PROCEDURES .3351 1.6 1.6
EXCEPT ORBIT AGE 0-17.
42.............. 02 SURG INTRAOCULAR PROCEDURES .5659 1.5 2.0
EXCEPT RETINA, IRIS & LENS.
43.............. 02 MED HYPHEMA.................... .4123 2.9 4.0
44.............. 02 MED ACUTE MAJOR EYE INFECTIONS. .6026 4.3 5.3
45.............. 02 MED NEUROLOGICAL EYE DISORDERS. .6709 2.9 3.6
46.............. 02 MED OTHER DISORDERS OF THE EYE .7231 3.7 4.9
AGE >17 W CC.
47.............. 02 MED OTHER DISORDERS OF THE EYE .4635 2.7 3.6
AGE >17 W/O CC.
48.............. 02 MED *OTHER DISORDERS OF THE EYE .2953 2.9 2.9
AGE 0-17.
49.............. 03 SURG MAJOR HEAD & NECK 1.7911 3.8 5.3
PROCEDURES.
50.............. 03 SURG SIALOADENECTOMY............ .8117 1.7 2.1
51.............. 03 SURG SALIVARY GLAND PROCEDURES .8380 2.0 2.9
EXCEPT SIALOADENECTOMY.
52.............. 03 SURG CLEFT LIP & PALATE REPAIR.. 1.2445 2.2 3.2
53.............. 03 SURG SINUS & MASTOID PROCEDURES 1.0663 2.3 3.6
AGE >17.
54.............. 03 SURG *SINUS & MASTOID PROCEDURES .4786 3.2 3.2
AGE 0-17.
55.............. 03 SURG MISCELLANEOUS EAR, NOSE, .8318 2.0 2.9
MOUTH & THROAT PROCEDURES.
56.............. 03 SURG RHINOPLASTY................ .8845 2.1 2.8
57.............. 03 SURG T&A PROC, EXCEPT 1.0234 2.8 4.0
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY, AGE
>17.
58.............. 03 SURG *T&A PROC, EXCEPT .2718 1.5 1.5
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY, AGE 0-
17.
59.............. 03 SURG TONSILLECTOMY &/OR .8026 2.2 3.1
ADENOIDECTOMY ONLY, AGE
>17.
60.............. 03 SURG *TONSILLECTOMY &/OR .2070 1.5 1.5
ADENOIDECTOMY ONLY, AGE 0-
17.
61.............. 03 SURG MYRINGOTOMY W TUBE 1.1426 2.8 4.6
INSERTION AGE >17.
62.............. 03 SURG *MYRINGOTOMY W TUBE .2931 1.3 1.3
INSERTION AGE 0-17.
63.............. 03 SURG OTHER EAR, NOSE, MOUTH & 1.2390 3.1 4.6
THROAT O.R. PROCEDURES.
64.............. 03 MED EAR, NOSE, MOUTH & THROAT 1.1531 4.4 6.7
MALIGNANCY.
65.............. 03 MED DYSEQUILIBRIUM............. .5174 2.5 3.2
66.............. 03 MED EPISTAXIS.................. .5588 2.8 3.5
67.............. 03 MED EPIGLOTTITIS............... .7881 3.1 3.8
68.............. 03 MED OTITIS MEDIA & URI AGE >17 .6842 3.5 4.3
W CC.
69.............. 03 MED OTITIS MEDIA & URI AGE >17 .5170 2.9 3.5
W/O CC.
70.............. 03 MED OTITIS MEDIA & URI AGE 0-17 .3837 2.7 3.3
71.............. 03 MED LARYNGOTRACHEITIS.......... .6844 3.0 3.9
72.............. 03 MED NASAL TRAUMA & DEFORMITY... .6277 2.7 3.5
73.............. 03 MED OTHER EAR, NOSE, MOUTH & .7661 3.4 4.7
THROAT DIAGNOSES AGE >17.
74.............. 03 MED *OTHER EAR, NOSE, MOUTH & .3330 2.1 2.1
THROAT DIAGNOSES AGE 0-17.
75.............. 04 SURG MAJOR CHEST PROCEDURES..... 3.1862 8.3 10.5
76.............. 04 SURG OTHER RESP SYSTEM O.R. 2.6396 8.7 11.7
PROCEDURES W CC.
77.............. 04 SURG OTHER RESP SYSTEM O.R. 1.1098 3.6 5.1
PROCEDURES W/O CC.
78.............. 04 MED PULMONARY EMBOLISM......... 1.4278 6.6 7.7
79.............. 04 MED RESPIRATORY INFECTIONS & 1.6310 6.8 8.7
INFLAMMATIONS AGE >17 W CC.
80.............. 04 MED RESPIRATORY INFECTIONS & .9138 4.9 6.0
INFLAMMATIONS AGE >17 W/O
CC.
81.............. 04 MED *RESPIRATORY INFECTIONS & 1.5079 6.1 6.1
INFLAMMATIONS AGE 0-17.
82.............. 04 MED RESPIRATORY NEOPLASMS...... 1.3326 5.4 7.3
83.............. 04 MED MAJOR CHEST TRAUMA W CC.... .9660 4.6 5.9
84.............. 04 MED MAJOR CHEST TRAUMA W/O CC.. .5235 2.8 3.5
85.............. 04 MED PLEURAL EFFUSION W CC...... 1.2226 5.3 6.9
86.............. 04 MED PLEURAL EFFUSION W/O CC.... .6697 3.1 4.1
87.............. 04 MED PULMONARY EDEMA & 1.3668 4.9 6.5
RESPIRATORY FAILURE.
88.............. 04 MED CHRONIC OBSTRUCTIVE .9746 4.6 5.7
PULMONARY DISEASE.
89.............. 04 MED SIMPLE PNEUMONIA & PLEURISY 1.1033 5.4 6.6
AGE >17 W CC.
90.............. 04 MED SIMPLE PNEUMONIA & PLEURISY .6793 4.0 4.7
AGE >17 W/O CC.
91.............. 04 MED SIMPLE PNEUMONIA & PLEURISY .7951 3.7 4.4
AGE 0-17.
92.............. 04 MED INTERSTITIAL LUNG DISEASE W .1929 5.3 6.6
CC.
93.............. 04 MED INTERSTITIAL LUNG DISEASE W/ .7367 3.6 4.6
O CC.
94.............. 04 MED PNEUMOTHORAX W CC.......... 1.1833 5.1 6.7
95.............. 04 MED PNEUMOTHORAX W/O CC........ .5950 3.2 4.0
96.............. 04 MED BRONCHITIS & ASTHMA AGE >17 .8093 4.2 5.1
W CC.
97.............. 04 MED BRONCHITIS & ASTHMA AGE >17 .5990 3.3 4.0
W/O CC.
98.............. 04 MED BRONCHITIS & ASTHMA AGE 0- .6334 2.2 3.8
17.
99.............. 04 MED RESPIRATORY SIGNS & .6716 2.5 3.2
SYMPTOMS W CC.
100............. 04 MED RESPIRATORY SIGNS & .5105 1.8 2.2
SYMPTOMS W/O CC.
101............. 04 MED OTHER RESPIRATORY SYSTEM .8495 3.5 4.7
DIAGNOSES W CC.
102............. 04 MED OTHER RESPIRATORY SYSTEM .5298 2.3 2.9
DIAGNOSES W/O CC.
103............. 05 SURG HEART TRANSPLANT........... 16.1872 31.7 47.3
104............. 05 SURG CARDIAC VALVE PROCEDURES W 7.3312 10.8 13.4
CARDIAC CATH.
[[Page 29984]]
105............. 05 SURG CARDIAC VALVE PROCEDURES W/ 5.6831 8.4 10.2
O CARDIAC CATH.
106............. 05 SURG CORONARY BYPASS W CARDIAC 5.5811 9.8 11.1
CATH.
107............. 05 SURG CORONARY BYPASS W/O CARDIAC 4.0780 7.3 8.3
CATH.
108............. 05 SURG OTHER CARDIOTHORACIC 6.1040 9.5 12.1
PROCEDURES.
109............. ....... .................... NO LONGER VALID............ .0000 .0 .0
110............. 05 SURG MAJOR CARDIOVASCULAR 4.1852 7.7 10.2
PROCEDURES W CC.
111............. 05 SURG MAJOR CARDIOVASCULAR 2.2254 5.4 6.2
PROCEDURES W/O CC.
112............. 05 SURG PERCUTANEOUS CARDIOVASCULAR 1.9997 3.1 4.2
PROCEDURES.
113............. 05 SURG AMPUTATION FOR CIRC SYSTEM 2.6574 9.7 13.1
DISORDERS EXCEPT UPPER
LIMB & TOE.
114............. 05 SURG UPPER LIMB & TOE AMPUTATION 1.5397 6.4 8.8
FOR CIRC SYSTEM DISORDERS.
115............. 05 SURG PERM PACE IMPLNT W AMI,HRT 3.5473 6.7 9.2
FAIL OR SHOCK OR AICD LEAD
OR GEN PROC.
116............. 05 SURG OTH PERM CARDIAC PACEMAKER 2.5183 3.5 4.7
IMPLANT OR PTCA W CORONARY
ART STENT.
117............. 05 SURG CARDIAC PACEMAKER REVISION 1.1922 2.7 4.0
EXCEPT DEVICE REPLACEMENT.
118............. 05 SURG CARDIAC PACEMAKER DEVICE 1.5923 2.0 3.0
REPLACEMENT.
119............. 05 SURG VEIN LIGATION & STRIPPING.. 1.2041 3.1 5.1
120............. 05 SURG OTHER CIRCULATORY SYSTEM 1.9153 5.0 8.5
O.R. PROCEDURES.
121............. 05 MED CIRCULATORY DISORDERS W AMI 1.6563 6.0 7.3
& MAJOR COMP DISCH ALIVE.
122............. 05 MED CIRCULATORY DISORDERS W AMI 1.1474 3.9 4.7
W/O MAJOR COMP DISCH ALIVE.
123............. 05 MED CIRCULATORY DISORDERS W 1.4704 2.7 4.5
AMI, EXPIRED.
124............. 05 MED CIRCULATORY DISORDERS 1.3575 3.6 4.6
EXCEPT AMI, W CARD CATH &
COMPLEX DIAG.
125............. 05 MED CIRCULATORY DISORDERS .9739 2.3 2.9
EXCEPT AMI, W CARD CATH W/
O COMPLEX DIAG.
126............. 05 MED ACUTE & SUBACUTE 2.4892 10.0 13.1
ENDOCARDITIS.
127............. 05 MED HEART FAILURE & SHOCK...... 1.0219 4.5 5.8
128............. 05 MED DEEP VEIN THROMBOPHLEBITIS. .7832 5.6 6.4
129............. 05 MED CARDIAC ARREST, UNEXPLAINED 1.1434 1.9 3.2
130............. 05 MED PERIPHERAL VASCULAR .9409 5.1 6.3
DISORDERS W CC.
131............. 05 MED PERIPHERAL VASCULAR .6042 4.1 4.9
DISORDERS W/O CC.
132............. 05 MED ATHEROSCLEROSIS W CC....... .6763 2.7 3.3
133............. 05 MED ATHEROSCLEROSIS W/O CC..... .5391 2.2 2.7
134............. 05 MED HYPERTENSION............... .5785 2.8 3.6
135............. 05 MED CARDIAC CONGENITAL & .8331 3.4 4.5
VALVULAR DISORDERS AGE >17
W CC.
136............. 05 MED CARDIAC CONGENITAL & .5732 2.4 3.1
VALVULAR DISORDERS AGE >17
W/O CC.
137............. 05 MED *CARDIAC CONGENITAL & .8125 3.3 3.3
VALVULAR DISORDERS AGE 0-
17.
138............. 05 MED CARDIAC ARRHYTHMIA & .7960 3.2 4.2
CONDUCTION DISORDERS W CC.
139............. 05 MED CARDIAC ARRHYTHMIA & .4979 2.2 2.7
CONDUCTION DISORDERS W/O
CC.
140............. 05 MED ANGINA PECTORIS............ .6036 2.6 3.2
141............. 05 MED SYNCOPE & COLLAPSE W CC.... .6998 3.1 4.1
142............. 05 MED SYNCOPE & COLLAPSE W/O CC.. .5220 2.3 2.9
143............. 05 MED CHEST PAIN................. .5193 1.9 2.4
144............. 05 MED OTHER CIRCULATORY SYSTEM 1.0902 3.9 5.4
DIAGNOSES W CC.
145............. 05 MED OTHER CIRCULATORY SYSTEM .6397 2.3 3.0
DIAGNOSES W/O CC.
146............. 06 SURG RECTAL RESECTION W CC...... 2.7395 9.3 10.5
147............. 06 SURG RECTAL RESECTION W/O CC.... 1.5895 6.3 6.9
148............. 06 SURG MAJOR SMALL & LARGE BOWEL 3.3879 10.6 12.6
PROCEDURES W CC.
149............. 06 SURG MAJOR SMALL & LARGE BOWEL 1.5505 6.5 7.1
PROCEDURES W/O CC.
150............. 06 SURG PERITONEAL ADHESIOLYSIS W 2.7137 9.1 11.1
CC.
151............. 06 SURG PERITONEAL ADHESIOLYSIS W/O 1.2634 4.9 6.1
CC.
152............. 06 SURG MINOR SMALL & LARGE BOWEL 1.9120 7.2 8.5
PROCEDURES W CC.
153............. 06 SURG MINOR SMALL & LARGE BOWEL 1.1591 5.2 5.8
PROCEDURES W/O CC.
154............. 06 SURG STOMACH, ESOPHAGEAL & 4.1799 10.8 14.1
DUODENAL PROCEDURES AGE
>17 W CC.
155............. 06 SURG STOMACH, ESOPHAGEAL & 1.3360 3.9 5.0
DUODENAL PROCEDURES AGE
>17 W/O CC.
156............. 06 SURG *STOMACH, ESOPHAGEAL & .8368 6.0 6.0
DUODENAL PROCEDURES AGE 0-
17.
157............. 06 SURG ANAL & STOMAL PROCEDURES W 1.1844 4.0 5.6
CC.
158............. 06 SURG ANAL & STOMAL PROCEDURES W/ .6286 2.2 2.8
O CC.
159............. 06 SURG HERNIA PROCEDURES EXCEPT 1.2556 3.8 5.1
INGUINAL & FEMORAL AGE >17
W CC.
160............. 06 SURG HERNIA PROCEDURES EXCEPT .7189 2.3 2.8
INGUINAL & FEMORAL AGE >17
W/O CC.
161............. 06 SURG INGUINAL & FEMORAL HERNIA 1.0571 3.0 4.2
PROCEDURES AGE >17 W CC.
162............. 06 SURG INGUINAL & FEMORAL HERNIA .5897 1.7 2.1
PROCEDURES AGE >17 W/O CC.
163............. 06 SURG HERNIA PROCEDURES AGE 0-17. .8538 3.1 4.7
164............. 06 SURG APPENDECTOMY W COMPLICATED 2.3460 7.5 8.7
PRINCIPAL DIAG W CC.
165............. 06 SURG APPENDECTOMY W COMPLICATED 1.2284 4.7 5.4
PRINCIPAL DIAG W/O CC.
[[Page 29985]]
166............. 06 SURG APPENDECTOMY W/O 1.4655 4.3 5.4
COMPLICATED PRINCIPAL DIAG
W CC.
167............. 06 SURG APPENDECTOMY W/O .8352 2.5 3.0
COMPLICATED PRINCIPAL DIAG
W/O CC.
168............. 03 SURG MOUTH PROCEDURES W CC...... 1.1152 3.2 4.7
169............. 03 SURG MOUTH PROCEDURES W/O CC.... .6870 2.0 2.5
170............. 06 SURG OTHER DIGESTIVE SYSTEM O.R. 2.7585 8.1 11.8
PROCEDURES W CC.
171............. 06 SURG OTHER DIGESTIVE SYSTEM O.R. 1.1221 3.7 5.1
PROCEDURES W/O CC.
172............. 06 MED DIGESTIVE MALIGNANCY W CC.. 1.2870 5.3 7.4
173............. 06 MED DIGESTIVE MALIGNANCY W/O CC .6749 2.8 3.9
174............. 06 MED G.I. HEMORRHAGE W CC....... .9939 4.1 5.2
175............. 06 MED G.I. HEMORRHAGE W/O CC..... .5383 2.7 3.2
176............. 06 MED COMPLICATED PEPTIC ULCER... 1.1050 4.5 5.8
177............. 06 MED UNCOMPLICATED PEPTIC ULCER .8584 3.8 4.7
W CC.
178............. 06 MED UNCOMPLICATED PEPTIC ULCER .6255 2.8 3.3
W/O CC.
179............. 06 MED INFLAMMATORY BOWEL DISEASE. 1.1142 5.2 6.7
180............. 06 MED G.I. OBSTRUCTION W CC...... .9167 4.4 5.7
181............. 06 MED G.I. OBSTRUCTION W/O CC.... .5208 3.1 3.7
182............. 06 MED ESOPHAGITIS, GASTROENT & .7684 3.5 4.6
MISC DIGEST DISORDERS AGE
>17 W CC.
183............. 06 MED ESOPHAGITIS, GASTROENT & .5513 2.6 3.2
MISC DIGEST DISORDERS AGE
>17 W/O CC.
184............. 06 MED ESOPHAGITIS, GASTROENT & .5679 2.7 3.7
MISC DIGEST DISORDERS AGE
0-17.
185............. 03 MED DENTAL & ORAL DIS EXCEPT .8431 3.5 4.8
EXTRACTIONS &
RESTORATIONS, AGE >17.
186............. 03 MED *DENTAL & ORAL DIS EXCEPT .3190 2.9 2.9
EXTRACTIONS &
RESTORATIONS, AGE 0-17.
187............. 03 MED DENTAL EXTRACTIONS & .7018 3.0 3.9
RESTORATIONS.
188............. 06 MED OTHER DIGESTIVE SYSTEM 1.0732 4.3 5.8
DIAGNOSES AGE >17 W CC.
189............. 06 MED OTHER DIGESTIVE SYSTEM .5484 2.5 3.4
DIAGNOSES AGE >17 W/O CC.
190............. 06 MED OTHER DIGESTIVE SYSTEM .8567 3.2 4.9
DIAGNOSES AGE 0-17.
191............. 07 SURG PANCREAS, LIVER & SHUNT 4.3141 11.1 14.9
PROCEDURES W CC.
192............. 07 SURG PANCREAS, LIVER & SHUNT 1.6937 5.6 7.1
PROCEDURES W/O CC.
193............. 07 SURG BILIARY TRACT PROC EXCEPT 3.2686 10.6 12.9
ONLY CHOLECYST W OR W/O
C.D.E. W CC.
194............. 07 SURG BILIARY TRACT PROC EXCEPT 1.6529 5.9 7.4
ONLY CHOLECYST W OR W/O
C.D.E. W/O CC.
195............. 07 SURG CHOLECYSTECTOMY W C.D.E. W 2.7190 8.2 9.8
CC.
196............. 07 SURG CHOLECYSTECTOMY W C.D.E. W/ 1.6123 5.5 6.3
O CC.
197............. 07 SURG CHOLECYSTECTOMY EXCEPT BY 2.3145 7.2 8.7
LAPAROSCOPE W/O C.D.E. W
CC.
198............. 07 SURG CHOLECYSTECTOMY EXCEPT BY 1.1753 4.1 4.7
LAPAROSCOPE W/O C.D.E. W/O
CC.
199............. 07 SURG HEPATOBILIARY DIAGNOSTIC 2.3537 7.9 10.7
PROCEDURE FOR MALIGNANCY.
200............. 07 SURG HEPATOBILIARY DIAGNOSTIC 3.0792 7.6 11.4
PROCEDURE FOR NON-
MALIGNANCY.
201............. 07 SURG OTHER HEPATOBILIARY OR 3.3934 11.0 15.0
PANCREAS O.R. PROCEDURES.
202............. 07 MED CIRRHOSIS & ALCOHOLIC 1.3281 5.3 7.1
HEPATITIS.
203............. 07 MED MALIGNANCY OF HEPATOBILIARY 1.2603 5.2 7.2
SYSTEM OR PANCREAS.
204............. 07 MED DISORDERS OF PANCREAS 1.2126 4.9 6.4
EXCEPT MALIGNANCY.
205............. 07 MED DISORDERS OF LIVER EXCEPT 1.2165 5.0 6.8
MALIG, CIRR, ALC HEPA W CC.
206............. 07 MED DISORDERS OF LIVER EXCEPT .6588 3.2 4.2
MALIG, CIRR, ALC HEPA W/O
CC.
207............. 07 MED DISORDERS OF THE BILIARY 1.0526 4.1 5.4
TRACT W CC.
208............. 07 MED DISORDERS OF THE BILIARY .6065 2.4 3.0
TRACT W/O CC.
209............. 08 SURG MAJOR JOINT & LIMB 2.2348 5.3 5.9
REATTACHMENT PROCEDURES OF
LOWER EXTREMITY.
210............. 08 SURG HIP & FEMUR PROCEDURES 1.8260 6.5 7.6
EXCEPT MAJOR JOINT AGE >17
W CC.
211............. 08 SURG HIP & FEMUR PROCEDURES 1.2523 5.0 5.6
EXCEPT MAJOR JOINT AGE >17
W/O CC.
212............. 08 SURG *HIP & FEMUR PROCEDURES 1.1668 11.1 11.1
EXCEPT MAJOR JOINT AGE 0-
17.
213............. 08 SURG AMPUTATION FOR 1.6483 6.3 8.7
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 MUSCULOSKELETAL 2.0988 7.4 10.3
SYSTEM & CONNECTIVE TISSUE.
217............. 08 SURG WND DEBRID & SKN GRFT 2.7938 9.2 13.7
EXCEPT HAND, FOR
MUSCSKELET & CONN TISS DIS.
218............. 08 SURG LOWER EXTREM & HUMER PROC 1.4542 4.4 5.6
EXCEPT HIP, FOOT, FEMUR
AGE >17 W CC.
219............. 08 SURG LOWER EXTREM & HUMER PROC .9619 2.9 3.4
EXCEPT HIP, FOOT, FEMUR
AGE >17 W/O CC.
[[Page 29986]]
220............. 08 SURG *LOWER EXTREM & HUMER PROC .5796 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, .9015 2.1 2.7
OR OTHER UPPER EXTREMITY
PROC W CC.
224............. 08 SURG SHOULDER, ELBOW OR FOREARM .7474 1.8 2.1
PROC, EXC MAJOR JOINT
PROC, W/O CC.
225............. 08 SURG FOOT PROCEDURES............ 1.0149 3.1 4.6
226............. 08 SURG SOFT TISSUE PROCEDURES W CC 1.4061 4.1 6.3
227............. 08 SURG SOFT TISSUE PROCEDURES W/O .7715 2.2 2.9
CC.
228............. 08 SURG MAJOR THUMB OR JOINT PROC, .9539 2.3 3.5
OR OTH HAND OR WRIST PROC
W CC.
229............. 08 SURG HAND OR WRIST PROC, EXCEPT .6695 1.8 2.4
MAJOR JOINT PROC, W/O CC.
230............. 08 SURG LOCAL EXCISION & REMOVAL OF 1.1279 3.3 5.0
INT FIX DEVICES OF HIP &
FEMUR.
231............. 08 SURG LOCAL EXCISION & REMOVAL OF 1.2689 3.1 4.8
INT FIX DEVICES EXCEPT HIP
& FEMUR.
232............. 08 SURG ARTHROSCOPY................ 1.0599 2.5 4.2
233............. 08 SURG OTHER MUSCULOSKELET SYS & 2.0155 5.7 8.3
CONN TISS O.R. PROC W CC.
234............. 08 SURG OTHER MUSCULOSKELET SYS & 1.1072 2.9 3.9
CONN TISS O.R. PROC W/O
CC.
235............. 08 MED FRACTURES OF FEMUR......... .7709 4.2 5.9
236............. 08 MED FRACTURES OF HIP & PELVIS.. .7341 4.3 5.7
237............. 08 MED SPRAINS, STRAINS, & .5909 3.2 4.2
DISLOCATIONS OF HIP,
PELVIS & THIGH.
238............. 08 MED OSTEOMYELITIS.............. 1.3362 7.0 9.4
239............. 08 MED PATHOLOGICAL FRACTURES & .9851 5.3 7.0
MUSCULOSKELETAL & CONN
TISS MALIGNANCY.
240............. 08 MED CONNECTIVE TISSUE DISORDERS 1.2071 5.1 7.0
W CC.
241............. 08 MED CONNECTIVE TISSUE DISORDERS .5873 3.3 4.2
W/O CC.
242............. 08 MED SEPTIC ARTHRITIS........... 1.0548 5.5 7.2
243............. 08 MED MEDICAL BACK PROBLEMS...... .7157 4.0 5.1
244............. 08 MED BONE DISEASES & SPECIFIC .7167 4.0 5.4
ARTHROPATHIES W CC.
245............. 08 MED BONE DISEASES & SPECIFIC .5014 3.0 4.0
ARTHROPATHIES W/O CC.
246............. 08 MED NON-SPECIFIC ARTHROPATHIES. .5737 3.4 4.3
247............. 08 MED SIGNS & SYMPTOMS OF .5575 2.8 3.7
MUSCULOSKELETAL SYSTEM &
CONN TISSUE.
248............. 08 MED TENDONITIS, MYOSITIS & .7414 3.7 5.0
BURSITIS.
249............. 08 MED AFTERCARE, MUSCULOSKELETAL .6524 2.7 3.9
SYSTEM & CONNECTIVE TISSUE.
250............. 08 MED FX, SPRN, STRN & DISL OF .6984 3.4 4.7
FOREARM, HAND, FOOT AGE
>17 W CC.
251............. 08 MED FX, SPRN, STRN & DISL OF .4527 2.3 3.0
FOREARM, HAND, FOOT AGE
>17 W/O CC.
252............. 08 MED *FX, SPRN, STRN & DISL OF .2518 1.8 1.8
FOREARM, HAND, FOOT AGE 0-
17.
253............. 08 MED FX, SPRN, STRN & DISL OF .7245 3.9 5.3
UPARM, LOWLEG EX FOOT AGE
>17 W CC.
254............. 08 MED FX, SPRN, STRN & DISL OF .4343 2.8 3.5
UPARM, LOWLEG EX FOOT AGE
>17 W/O CC.
255............. 08 MED *FX, SPRN, STRN & DISL OF .2932 2.9 2.9
UPARM, LOWLEG EX FOOT AGE
0-17.
256............. 08 MED OTHER MUSCULOSKELETAL .7779 3.9 5.7
SYSTEM & CONNECTIVE TISSUE
DIAGNOSES.
257............. 09 SURG TOTAL MASTECTOMY FOR .9273 2.6 3.2
MALIGNANCY W CC.
258............. 09 SURG TOTAL MASTECTOMY FOR .7158 2.0 2.3
MALIGNANCY W/O CC.
259............. 09 SURG SUBTOTAL MASTECTOMY FOR .8870 2.1 3.2
MALIGNANCY W CC.
260............. 09 SURG SUBTOTAL MASTECTOMY FOR .6083 1.4 1.7
MALIGNANCY W/O CC.
261............. 09 SURG BREAST PROC FOR NON- .8980 1.8 2.2
MALIGNANCY EXCEPT BIOPSY &
LOCAL EXCISION.
262............. 09 SURG BREAST BIOPSY & LOCAL .7883 2.6 4.0
EXCISION FOR NON-
MALIGNANCY.
263............. 09 SURG SKIN GRAFT &/OR DEBRID FOR 2.0240 8.9 12.5
SKN ULCER OR CELLULITIS W
CC.
264............. 09 SURG SKIN GRAFT &/OR DEBRID FOR 1.0809 5.4 7.3
SKN ULCER OR CELLULITIS W/
O CC.
265............. 09 SURG SKIN GRAFT &/OR DEBRID 1.4947 4.6 7.1
EXCEPT FOR SKIN ULCER OR
CELLULITIS W CC.
266............. 09 SURG SKIN GRAFT &/OR DEBRID .7880 2.6 3.6
EXCEPT FOR SKIN ULCER OR
CELLULITIS W/O CC.
267............. 09 SURG PERIANAL & PILONIDAL .8551 2.7 4.2
PROCEDURES.
268............. 09 SURG SKIN, SUBCUTANEOUS TISSUE & 1.0173 2.4 3.6
BREAST PLASTIC PROCEDURES.
269............. 09 SURG OTHER SKIN, SUBCUT TISS & 1.5805 5.9 8.5
BREAST PROC W CC.
270............. 09 SURG OTHER SKIN, SUBCUT TISS & .7083 2.2 3.2
BREAST PROC W/O CC.
271............. 09 MED SKIN ULCERS................ 1.0344 6.0 7.7
[[Page 29987]]
272............. 09 MED MAJOR SKIN DISORDERS W CC.. .9940 5.1 6.7
273............. 09 MED MAJOR SKIN DISORDERS W/O CC .6713 4.0 5.4
274............. 09 MED MALIGNANT BREAST DISORDERS 1.1158 4.9 7.2
W CC.
275............. 09 MED MALIGNANT BREAST DISORDERS .5823 2.4 3.8
W/O CC.
276............. 09 MED NON-MALIGANT BREAST .6170 3.8 4.7
DISORDERS.
277............. 09 MED CELLULITIS AGE >17 W CC.... .8374 5.1 6.2
278............. 09 MED CELLULITIS AGE >17 W/O CC.. .5629 4.0 4.8
279............. 09 MED *CELLULITIS AGE 0-17....... .7304 4.2 4.2
280............. 09 MED TRAUMA TO THE SKIN, SUBCUT .6748 3.5 4.7
TISS & BREAST AGE >17 W CC.
281............. 09 MED TRAUMA TO THE SKIN, SUBCUT .4539 2.5 3.4
TISS & BREAST AGE >17 W/O
CC.
282............. 09 MED *TRAUMA TO THE SKIN, SUBCUT .2549 2.2 2.2
TISS & BREAST AGE 0-17.
283............. 09 MED MINOR SKIN DISORDERS W CC.. .6927 3.8 5.0
284............. 09 MED MINOR SKIN DISORDERS W/O CC .4355 2.7 3.5
285............. 10 SURG AMPUTAT OF LOWER LIMB FOR 2.1559 8.8 12.1
ENDOCRINE, NUTRIT, &
METABOL DISORDERS.
286............. 10 SURG ADRENAL & PITUITARY 2.2472 5.7 7.2
PROCEDURES.
287............. 10 SURG SKIN GRAFTS & WOUND DEBRID 1.8821 8.6 12.1
FOR ENDOC, NUTRIT & METAB
DISORDERS.
288............. 10 SURG O.R. PROCEDURES FOR OBESITY 1.9792 4.8 5.9
289............. 10 SURG PARATHYROID PROCEDURES..... .9793 2.4 3.5
290............. 10 SURG THYROID PROCEDURES......... .8990 2.0 2.6
291............. 10 SURG THYROGLOSSAL PROCEDURES.... .7362 1.7 2.2
292............. 10 SURG OTHER ENDOCRINE, NUTRIT & 2.5540 7.6 11.2
METAB O.R. PROC W CC.
293............. 10 SURG OTHER ENDOCRINE, NUTRIT & 1.2228 4.0 5.9
METAB O.R. PROC W/O CC.
294............. 10 MED DIABETES AGE >35........... .7562 4.0 5.3
295............. 10 MED DIABETES AGE 0-35.......... .7347 3.2 4.1
296............. 10 MED NUTRITIONAL & MISC .8655 4.3 5.8
METABOLIC DISORDERS AGE
>17 W CC.
297............. 10 MED NUTRITIONAL & MISC .5200 3.0 3.9
METABOLIC DISORDERS AGE
>17 W/O CC.
298............. 10 MED NUTRITIONAL & MISC .4116 2.0 2.5
METABOLIC DISORDERS AGE 0-
17.
299............. 10 MED INBORN ERRORS OF METABOLISM .8645 3.9 5.5
300............. 10 MED ENDOCRINE DISORDERS W CC... 1.0787 5.1 6.6
301............. 10 MED ENDOCRINE DISORDERS W/O CC. .5928 3.1 4.4
302............. 11 SURG KIDNEY TRANSPLANT.......... 3.7056 9.2 11.0
303............. 11 SURG KIDNEY, URETER & MAJOR 2.6067 7.8 9.5
BLADDER PROCEDURES FOR
NEOPLASM.
304............. 11 SURG KIDNEY, URETER & MAJOR 2.3912 6.9 9.6
BLADDER PROC FOR NON-NEOPL
W CC.
305............. 11 SURG KIDNEY, URETER & MAJOR 1.1690 3.4 4.3
BLADDER PROC FOR NON-NEOPL
W/O CC.
306............. 11 SURG PROSTATECTOMY W CC......... 1.2212 4.0 5.8
307............. 11 SURG PROSTATECTOMY W/O CC....... .6495 2.1 2.5
308............. 11 SURG MINOR BLADDER PROCEDURES W 1.5142 4.3 6.4
CC.
309............. 11 SURG MINOR BLADDER PROCEDURES W/ .8733 2.1 2.6
O CC.
310............. 11 SURG TRANSURETHRAL PROCEDURES W 1.0253 3.0 4.3
CC.
311............. 11 SURG TRANSURETHRAL PROCEDURES W/ .5867 1.7 2.1
O CC.
312............. 11 SURG URETHRAL PROCEDURES, AGE .9770 3.1 4.7
>17 W CC.
313............. 11 SURG URETHRAL PROCEDURES, AGE .5799 1.8 2.3
>17 W/O CC.
314............. 11 SURG *URETHRAL PROCEDURES, AGE 0- .4912 2.3 2.3
17.
315............. 11 SURG OTHER KIDNEY & URINARY 2.0639 4.9 8.6
TRACT O.R. PROCEDURES.
316............. 11 MED RENAL FAILURE.............. 1.3100 5.1 7.1
317............. 11 MED ADMIT FOR RENAL DIALYSIS... .5551 2.0 2.9
318............. 11 MED KIDNEY & URINARY TRACT 1.1589 4.7 6.7
NEOPLASMS W CC.
319............. 11 MED KIDNEY & URINARY TRACT .5851 2.0 2.8
NEOPLASMS W/O CC.
320............. 11 MED KIDNEY & URINARY TRACT .8796 4.7 5.9
INFECTIONS AGE >17 W CC.
321............. 11 MED KIDNEY & URINARY TRACT .5864 3.6 4.3
INFECTIONS AGE >17 W/O CC.
322............. 11 MED KIDNEY & URINARY TRACT .5236 3.3 4.1
INFECTIONS AGE 0-17.
323............. 11 MED URINARY STONES W CC, &/OR .7559 2.5 3.4
ESW LITHOTRIPSY.
324............. 11 MED URINARY STONES W/O CC...... .4306 1.7 2.0
325............. 11 MED KIDNEY & URINARY TRACT .6224 3.1 4.2
SIGNS & SYMPTOMS AGE >17 W
CC.
326............. 11 MED KIDNEY & URINARY TRACT .4206 2.3 2.9
SIGNS & SYMPTOMS AGE >17 W/
O CC.
327............. 11 MED KIDNEY & URINARY TRACT .3394 2.3 3.5
SIGNS & SYMPTOMS AGE 0-17.
328............. 11 MED URETHRAL STRICTURE AGE >17 .6891 2.9 3.9
W CC.
329............. 11 MED URETHRAL STRICTURE AGE >17 .5050 1.9 2.3
W/O CC.
330............. 11 MED *URETHRAL STRICTURE AGE 0- .3164 1.6 1.6
17.
331............. 11 MED OTHER KIDNEY & URINARY .9985 4.4 5.9
TRACT DIAGNOSES AGE >17 W
CC.
332............. 11 MED OTHER KIDNEY & URINARY .5845 2.6 3.5
TRACT DIAGNOSES AGE >17 W/
O CC.
333............. 11 MED OTHER KIDNEY & URINARY .8999 4.0 5.7
TRACT DIAGNOSES AGE 0-17.
334............. 12 SURG MAJOR MALE PELVIC 1.6387 4.8 5.4
PROCEDURES W CC.
335............. 12 SURG MAJOR MALE PELVIC 1.2197 3.7 4.1
PROCEDURES W/O CC.
336............. 12 SURG TRANSURETHRAL PROSTATECTOMY .8893 2.9 3.8
W CC.
[[Page 29988]]
337............. 12 SURG TRANSURETHRAL PROSTATECTOMY .6159 2.1 2.4
W/O CC.
338............. 12 SURG TESTES PROCEDURES, FOR 1.0997 3.3 5.1
MALIGNANCY.
339............. 12 SURG TESTES PROCEDURES, NON- 1.0073 3.1 4.6
MALIGNANCY AGE >17.
340............. 12 SURG *TESTES PROCEDURES, NON- .2813 2.4 2.4
MALIGNANCY AGE 0-17.
341............. 12 SURG PENIS PROCEDURES........... 1.1129 2.2 3.1
342............. 12 SURG CIRCUMCISION AGE >17....... .8680 3.0 4.2
343............. 12 SURG *CIRCUMCISION AGE 0-17..... .1528 1.7 1.7
344............. 12 SURG OTHER MALE REPRODUCTIVE 1.0265 2.1 3.1
SYSTEM O.R. PROCEDURES FOR
MALIGNANCY.
345............. 12 SURG OTHER MALE REPRODUCTIVE .8547 2.7 3.8
SYSTEM O.R. PROC EXCEPT
FOR MALIGNANCY.
346............. 12 MED MALIGNANCY, MALE .9554 4.5 6.3
REPRODUCTIVE SYSTEM, W CC.
347............. 12 MED MALIGNANCY, MALE .4682 2.2 3.0
REPRODUCTIVE SYSTEM, W/O
CC.
348............. 12 MED BENIGN PROSTATIC .6954 3.3 4.5
HYPERTROPHY W CC.
349............. 12 MED BENIGN PROSTATIC .4196 2.1 2.7
HYPERTROPHY W/O CC.
350............. 12 MED INFLAMMATION OF THE MALE .6801 3.8 4.6
REPRODUCTIVE SYSTEM.
351............. 12 MED *STERILIZATION, MALE....... .2345 1.3 1.3
352............. 12 MED OTHER MALE REPRODUCTIVE .6210 2.8 3.9
SYSTEM DIAGNOSES.
353............. 13 SURG PELVIC EVISCERATION, 2.1041 6.4 8.3
RADICAL HYSTERECTOMY &
RADICAL VULVECTOMY.
354............. 13 SURG UTERINE, ADNEXA PROC FOR 1.4944 5.0 6.0
NON-OVARIAN/ADNEXAL MALIG
W CC.
355............. 13 SURG UTERINE, ADNEXA PROC FOR .9167 3.4 3.6
NON-OVARIAN/ADNEXAL MALIG
W/O CC.
356............. 13 SURG FEMALE REPRODUCTIVE SYSTEM .7715 2.5 2.8
RECONSTRUCTIVE PROCEDURES.
357............. 13 SURG UTERINE & ADNEXA PROC FOR 2.4197 7.6 9.3
OVARIAN OR ADNEXAL
MALIGNANCY.
358............. 13 SURG UTERINE & ADNEXA PROC FOR 1.2028 3.8 4.5
NON-MALIGNANCY W CC.
359............. 13 SURG UTERINE & ADNEXA PROC FOR .8469 2.9 3.1
NON-MALIGNANCY W/O CC.
360............. 13 SURG VAGINA, CERVIX & VULVA .8713 2.7 3.3
PROCEDURES.
361............. 13 SURG LAPAROSCOPY & INCISIONAL 1.1804 2.6 3.7
TUBAL INTERRUPTION.
362............. 13 SURG *ENDOSCOPIC TUBAL .2998 1.4 1.4
INTERRUPTION.
363............. 13 SURG D&C, CONIZATION & RADIO- .7470 2.6 3.5
IMPLANT, FOR MALIGNANCY.
364............. 13 SURG D&C, CONIZATION EXCEPT FOR .7020 2.5 3.5
MALIGNANCY.
365............. 13 SURG OTHER FEMALE REPRODUCTIVE 1.7123 4.7 7.2
SYSTEM O.R. PROCEDURES.
366............. 13 MED MALIGNANCY, FEMALE 1.1898 4.9 7.1
REPRODUCTIVE SYSTEM W CC.
367............. 13 MED MALIGNANCY, FEMALE .5347 2.1 2.9
REPRODUCTIVE SYSTEM W/O CC.
368............. 13 MED INFECTIONS, FEMALE .9733 5.0 6.3
REPRODUCTIVE SYSTEM.
369............. 13 MED MENSTRUAL & OTHER FEMALE .5386 2.5 3.4
REPRODUCTIVE SYSTEM
DISORDERS.
370............. 14 SURG CESAREAN SECTION W CC...... 1.0660 4.3 5.6
371............. 14 SURG CESAREAN SECTION W/O CC.... .7057 3.3 3.6
372............. 14 MED VAGINAL DELIVERY W .5552 2.4 3.1
COMPLICATING DIAGNOSES.
373............. 14 MED VAGINAL DELIVERY W/O .3954 1.7 2.0
COMPLICATING DIAGNOSES.
374............. 14 SURG VAGINAL DELIVERY W .7814 2.3 2.9
STERILIZATION &/OR D&C.
375............. 14 SURG *VAGINAL DELIVERY W O.R. .6804 4.4 4.4
PROC EXCEPT STERIL &/OR
D&C.
376............. 14 MED POSTPARTUM & POST ABORTION .4882 2.4 3.3
DIAGNOSES W/O O.R.
PROCEDURE.
377............. 14 SURG POSTPARTUM & POST ABORTION 1.0654 2.6 4.1
DIAGNOSES W O.R. PROCEDURE.
378............. 14 MED ECTOPIC PREGNANCY.......... .8186 2.3 2.7
379............. 14 MED THREATENED ABORTION........ .4021 2.1 3.0
380............. 14 MED ABORTION W/O D&C........... .3424 1.5 1.8
381............. 14 SURG ABORTION W D&C, ASPIRATION .4595 1.6 2.2
CURETTAGE OR HYSTEROTOMY.
382............. 14 MED FALSE LABOR................ .2107 1.2 1.3
383............. 14 MED OTHER ANTEPARTUM DIAGNOSES .4596 2.8 3.8
W MEDICAL COMPLICATIONS.
384............. 14 MED OTHER ANTEPARTUM DIAGNOSES .3659 2.0 2.9
W/O MEDICAL COMPLICATIONS.
385............. 15 .................... *NEONATES, DIED OR 1.3655 1.8 1.8
TRANSFERRED TO ANOTHER
ACUTE CARE FACILITY.
386............. 15 .................... *EXTREME IMMATURITY OR 4.5029 17.9 17.9
RESPIRATORY DISTRESS
SYNDROME, NEONATE.
387............. 15 .................... *PREMATURITY W MAJOR 3.0754 13.3 13.3
PROBLEMS.
388............. 15 .................... *PREMATURITY W/O MAJOR 1.8556 8.6 8.6
PROBLEMS.
389............. 15 .................... FULL TERM NEONATE W MAJOR 1.4625 5.1 6.3
PROBLEMS.
390............. 15 .................... *NEONATE W OTHER 1.3048 3.4 3.4
SIGNIFICANT PROBLEMS.
391............. 15 .................... * NORMAL NEWBORN........... .1514 3.1 3.1
392............. 16 SURG SPLENECTOMY AGE >17........ 3.1584 8.1 10.6
393............. 16 SURG *SPLENECTOMY AGE 0-17...... 1.3376 9.1 9.1
[[Page 29989]]
394............. 16 SURG OTHER O.R. PROCEDURES OF 1.6297 4.5 7.4
THE BLOOD AND BLOOD
FORMING ORGANS.
395............. 16 MED RED BLOOD CELL DISORDERS .8191 3.6 5.0
AGE >17.
396............. 16 MED RED BLOOD CELL DISORDERS .6302 2.7 4.1
AGE 0-17.
397............. 16 MED COAGULATION DISORDERS...... 1.2694 4.2 5.8
398............. 16 MED RETICULOENDOTHELIAL & 1.2233 4.9 6.3
IMMUNITY DISORDERS W CC.
399............. 16 MED RETICULOENDOTHELIAL & .6859 3.2 4.0
IMMUNITY DISORDERS W/O CC.
400............. 17 SURG LYMPHOMA & LEUKEMIA W MAJOR 2.6206 6.3 9.7
O.R. PROCEDURE.
401............. 17 SURG LYMPHOMA & NON-ACUTE 2.5614 8.1 11.7
LEUKEMIA W OTHER O.R. PROC
W CC.
402............. 17 SURG LYMPHOMA & NON-ACUTE 1.0130 2.9 4.2
LEUKEMIA W OTHER O.R. PROC
W/O CC.
403............. 17 MED LYMPHOMA & NON-ACUTE 1.6930 6.0 8.6
LEUKEMIA W CC.
404............. 17 MED LYMPHOMA & NON-ACUTE .7928 3.3 4.6
LEUKEMIA W/O CC.
405............. 17 .................... *ACUTE LEUKEMIA W/O MAJOR 1.8964 4.9 4.9
O.R. PROCEDURE AGE 0-17.
406............. 17 SURG MYELOPROLIF DISORD OR 2.5952 7.2 10.0
POORLY DIFF NEOPL W MAJ
O.R. PROC W CC.
407............. 17 SURG MYELOPROLIF DISORD OR 1.1430 3.5 4.4
POORLY DIFF NEOPL W MAJ
O.R. PROC W/O CC.
408............. 17 SURG MYELOPROLIF DISORD OR 1.7314 4.8 7.7
POORLY DIFF NEOPL W OTHER
O.R. PROC.
409............. 17 MED RADIOTHERAPY............... .9545 4.3 5.9
410............. 17 MED CHEMOTHERAPY W/O ACUTE .7957 2.6 3.4
LEUKEMIA AS SECONDARY
DIAGNOSIS.
411............. 17 MED HISTORY OF MALIGNANCY W/O .4403 1.8 2.3
ENDOSCOPY.
412............. 17 MED HISTORY OF MALIGNANCY W .5176 2.4 3.4
ENDOSCOPY.
413............. 17 MED OTHER MYELOPROLIF DIS OR 1.3771 5.7 8.0
POORLY DIFF NEOPL DIAG W
CC.
414............. 17 MED OTHER MYELOPROLIF DIS OR .7072 3.2 4.6
POORLY DIFF NEOPL DIAG W/O
CC.
415............. 18 SURG O.R. PROCEDURE FOR 3.5212 10.9 14.9
INFECTIOUS & PARASITIC
DISEASES.
416............. 18 MED SEPTICEMIA AGE >17......... 1.4832 5.8 7.7
417............. 18 MED SEPTICEMIA AGE 0-17........ .7530 3.3 4.4
418............. 18 MED POSTOPERATIVE & POST- .9666 5.0 6.3
TRAUMATIC INFECTIONS.
419............. 18 MED FEVER OF UNKNOWN ORIGIN AGE .8810 4.1 5.3
>17 W CC.
420............. 18 MED FEVER OF UNKNOWN ORIGIN AGE .6040 3.2 4.0
>17 W/O CC.
421............. 18 MED VIRAL ILLNESS AGE >17...... .7063 3.3 4.2
422............. 18 MED VIRAL ILLNESS & FEVER OF .5308 2.7 3.9
UNKNOWN ORIGIN AGE 0-17.
423............. 18 MED OTHER INFECTIOUS & 1.5656 5.8 7.9
PARASITIC DISEASES
DIAGNOSES.
424............. 19 SURG O.R. PROCEDURE W PRINCIPAL 2.4655 9.9 16.9
DIAGNOSES OF MENTAL
ILLNESS.
425............. 19 MED ACUTE ADJUST REACT & .6861 3.2 4.4
DISTURBANCES OF
PSYCHOSOCIAL DYSFUNCTION.
426............. 19 MED DEPRESSIVE NEUROSES........ .5648 3.7 5.2
427............. 19 MED NEUROSES EXCEPT DEPRESSIVE. .5805 3.6 5.3
428............. 19 MED DISORDERS OF PERSONALITY & .6946 4.9 7.6
IMPULSE CONTROL.
429............. 19 MED ORGANIC DISTURBANCES & .8713 5.4 7.9
MENTAL RETARDATION.
430............. 19 MED PSYCHOSES.................. .8101 6.5 9.1
431............. 19 MED CHILDHOOD MENTAL DISORDERS. .8425 5.5 8.9
432............. 19 MED OTHER MENTAL DISORDER .7654 3.7 5.8
DIAGNOSES.
433............. 20 .................... ALCOHOL/DRUG ABUSE OR .3037 2.4 3.3
DEPENDENCE, LEFT AMA.
434............. 20 .................... ALC/DRUG ABUSE OR DEPEND, .6852 4.0 5.3
DETOX OR OTH SYMPT TREAT W
CC.
435............. 20 .................... ALC/DRUG ABUSE OR DEPEND, .3987 3.6 4.5
DETOX OR OTH SYMPT TREAT W/
O CC.
436............. 20 .................... ALC/DRUG DEPENDENCE W .8107 11.5 14.0
REHABILITATION THERAPY.
437............. 20 .................... ALC/DRUG DEPENDENCE, .7364 8.3 9.9
COMBINED REHAB & DETOX
THERAPY.
438............. ....... .................... NO LONGER VALID............ .0000 .0 .0
439............. 21 SURG SKIN GRAFTS FOR INJURIES... 1.6308 5.4 8.5
440............. 21 SURG WOUND DEBRIDEMENTS FOR 1.8261 6.0 9.5
INJURIES.
441............. 21 SURG HAND PROCEDURES FOR .9319 2.2 3.5
INJURIES.
442............. 21 SURG OTHER O.R. PROCEDURES FOR 2.1794 5.4 8.3
INJURIES W CC.
443............. 21 SURG OTHER O.R. PROCEDURES FOR .9109 2.5 3.4
INJURIES W/O CC.
444............. 21 MED TRAUMATIC INJURY AGE >17 W .6988 3.7 4.8
CC.
445............. 21 MED TRAUMATIC INJURY AGE >17 W/ .4849 2.6 3.7
O CC.
446............. 21 MED *TRAUMATIC INJURY AGE 0-17. .2940 2.4 2.4
447............. 21 MED ALLERGIC REACTIONS AGE >17. .4932 2.0 2.6
448............. 21 MED ALLERGIC REACTIONS AGE 0-17 .0952 1.0 1.0
449............. 21 MED POISONING & TOXIC EFFECTS .7859 2.8 4.0
OF DRUGS AGE >17 W CC.
450............. 21 MED POISONING & TOXIC EFFECTS .4416 1.7 2.3
OF DRUGS AGE >17 W/O CC.
451............. 21 MED *POISONING & TOXIC EFFECTS .2611 2.1 2.1
OF DRUGS AGE 0-17.
452............. 21 MED COMPLICATIONS OF TREATMENT .9475 3.7 5.2
W CC.
453............. 21 MED COMPLICATIONS OF TREATMENT .4946 2.3 3.1
W/O CC.
454............. 21 MED OTHER INJURY, POISONING & .9026 3.3 5.2
TOXIC EFFECT DIAG W CC.
[[Page 29990]]
455............. 21 MED OTHER INJURY, POISONING & .4431 2.0 2.8
TOXIC EFFECT DIAG W/O CC.
456............. 22 .................... BURNS, TRANSFERRED TO 1.7408 3.7 7.3
ANOTHER ACUTE CARE
FACILITY.
457............. 22 MED EXTENSIVE BURNS W/O O.R. 1.5647 2.5 4.9
PROCEDURE.
458............. 22 SURG NON-EXTENSIVE BURNS W SKIN 3.5516 11.1 16.0
GRAFT.
459............. 22 SURG NON-EXTENSIVE BURNS W WOUND 1.5555 6.5 9.3
DEBRIDEMENT OR OTHER O.R.
PROC.
460............. 22 MED NON-EXTENSIVE BURNS W/O .9464 4.4 6.3
O.R. PROCEDURE.
461............. 23 SURG O.R. PROC W DIAGNOSES OF 1.0082 2.5 4.6
OTHER CONTACT W HEALTH
SERVICES.
462............. 23 MED REHABILITATION............. 1.3997 10.5 13.1
463............. 23 MED SIGNS & SYMPTOMS W CC...... .6904 3.6 4.8
464............. 23 MED SIGNS & SYMPTOMS W/O CC.... .4855 2.7 3.4
465............. 23 MED AFTERCARE W HISTORY OF .5882 2.2 3.8
MALIGNANCY AS SECONDARY
DIAGNOSIS.
466............. 23 MED AFTERCARE W/O HISTORY OF .6265 2.6 4.7
MALIGNANCY AS SECONDARY
DIAGNOSIS.
467............. 23 MED OTHER FACTORS INFLUENCING .4641 2.3 4.2
HEALTH STATUS.
468............. ....... .................... EXTENSIVE O.R. PROCEDURE 3.6128 9.9 14.1
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 MAJOR 3.4694 5.8 6.7
JOINT PROCS OF LOWER
EXTREMITY.
472............. 22 SURG EXTENSIVE BURNS W O.R. 10.2511 11.7 23.9
PROCEDURE.
473............. 17 .................... ACUTE LEUKEMIA W/O MAJOR 3.4633 7.9 13.6
O.R. PROCEDURE AGE >17.
474............. ....... .................... NO LONGER VALID............ 0000 .0 .0
475............. 04 MED RESPIRATORY SYSTEM 3.7349 8.2 11.6
DIAGNOSIS WITH VENTILATOR
SUPPORT.
476............. ....... SURG PROSTATIC O.R. PROCEDURE 2.2284 9.5 12.6
UNRELATED TO PRINCIPAL
DIAGNOSIS.
477............. ....... SURG NON-EXTENSIVE O.R. 1.7434 5.5 8.6
PROCEDURE UNRELATED TO
PRINCIPAL DIAGNOSIS.
478............. 05 SURG OTHER VASCULAR PROCEDURES W 2.3179 5.2 7.7
CC.
479............. 05 SURG OTHER VASCULAR PROCEDURES W/ 1.4148 3.2 4.2
O CC.
480............. ....... SURG LIVER TRANSPLANT........... 10.6265 18.7 24.2
481............. ....... SURG BONE MARROW TRANSPLANT..... 11.1194 26.3 29.9
482............. ....... SURG TRACHEOSTOMY FOR FACE, 3.5738 10.5 13.5
MOUTH & NECK DIAGNOSES.
483............. ....... SURG TRACHEOSTOMY EXCEPT FOR 15.9340 33.7 43.3
FACE, MOUTH & NECK
DIAGNOSES.
484............. 24 SURG CRANIOTOMY FOR MULTIPLE 5.7304 10.6 15.3
SIGNIFICANT TRAUMA.
485............. 24 SURG LIMB REATTACHMENT, HIP AND 3.0798 8.2 10.4
FEMUR PROC FOR MULTIPLE
SIGNIFICANT TR.
486............. 24 SURG OTHER O.R. PROCEDURES FOR 4.8508 8.8 13.4
MULTIPLE SIGNIFICANT
TRAUMA.
487............. 24 MED OTHER MULTIPLE SIGNIFICANT 2.0089 5.9 8.3
TRAUMA.
488............. 25 SURG HIV W EXTENSIVE O.R. 4.4739 12.0 17.8
PROCEDURE.
489............. 25 MED HIV W MAJOR RELATED 1.7916 6.7 9.8
CONDITION.
490............. 25 MED HIV W OR W/O OTHER RELATED .9930 4.2 6.0
CONDITION.
491............. 08 SURG MAJOR JOINT & LIMB 1.6585 3.3 3.9
REATTACHMENT PROCEDURES OF
UPPER EXTREMITY.
492............. 17 MED CHEMOTHERAPY W ACUTE 4.6072 11.8 17.9
LEUKEMIA AS SECONDARY
DIAGNOSIS.
493............. 07 SURG LAPAROSCOPIC 1.7593 4.1 5.7
CHOLECYSTECTOMY W/O C.D.E.
W CC.
494............. 07 SURG LAPAROSCOPIC .9434 1.8 2.4
CHOLECYSTECTOMY W/O C.D.E.
W/O CC.
495............. ....... SURG LUNG TRANSPLANT............ 9.0199 14.4 17.4
496............. 08 SURG COMBINED ANTERIOR/POSTERIOR 5.4752 9.2 11.5
SPINAL FUSION.
497............. 08 SURG SPINAL FUSION W CC......... 2.7641 5.3 6.8
498............. 08 SURG SPINAL FUSION W/O CC....... 1.6140 3.1 3.7
499............. 08 SURG BACK & NECK PROCS EXCEPT 1.4825 4.1 5.3
SPINAL FUSION W CC.
500............. 08 SURG BACK & NECK PROCS EXCEPT .9704 2.6 3.1
SPINAL FUSION W/O CC.
501............. 08 SURG KNEE PROC W PRINCIPAL 2.3780 8.1 10.4
DIAGNOSIS OF INFECTION W
CC.
502............. 08 SURG KNEE PROC W PRINCIPAL 1.4616 4.1 5.3
DIAGNOSIS OF INFECTION W/O
CC.
503............. 08 SURG KNEE PROCEDURES W/O .9891 2.7 3.4
PRINCIPAL DIAGNOSIS OF
INFECTION.
----------------------------------------------------------------------------------------------------------------
*Medicare data have been supplemented by data from 19 states for low volume DRGs.
**DRGS 469 and 470 contain cases which could not be assigned to valid DRGs.
Note: Geometric mean is used only to determine payment for transfer cases.
Note: Arithmetic mean is used only to determine payment for outlier cases.
Note: Relative weights are based on Medicare patient data and may not be appropriate for other patients.
[[Page 29991]]
Table 6A.--New Diagnosis Codes
----------------------------------------------------------------------------------------------------------------
Diagnosis
code Description CC MDC DRG
----------------------------------------------------------------------------------------------------------------
007.4....... Other protozoal intestinal N 6 182, 183, 184
diseases,
cryptosporidiosis.
031.2....... Disease due to N 18 423
disseminated 25 489 1
mycobacterium avium-
intracellulare complex
(DMAC).
038.10...... Staphylococcal septicemia, Y 15 387, 389 2
unspecified. 18 416, 417
25 4891
038.11...... Staphylococcus aureus Y 15 387, 389 2
septicemia. 18 416, 417
25 4891
038.19...... Other staphylococcal Y 15 387, 389 2
septicemia. 18 416,417
25 4891
275.40...... Unspecified disorder of N 10 296, 297, 298
calcium metabolism.
275.41...... Hypocalcemia.............. N 10 296, 297, 298
275.42...... Hypercalcemia............. N 10 296, 297, 298
275.49...... Other disorder of calcium N 10 296, 297, 298
metabolism.
438.0....... Late effect of N 1 12
cerebrovascular disease,
cognitive deficits.
438.10...... Late effect of N 1 12
cerebrovascular disease,
speech and language
deficits, unspecified..
438.11...... Late effect of N 1 12
cerebrovascular disease,
speech and language
deficits, aphasia.
438.12...... Late effect of N 1 12
cerebrovascular disease,
speech and language
deficits, dysphasia.
438.19...... Late effect of N 1 12
cerebrovascular disease,
other speech and language
deficits.
438.20...... Late effect of N 1 12
cerebrovascular disease,
hemiplegia affecting
unspecified side.
438.21...... Late effect of N 1 12
cerebrovascular disease,
hemiplegia affecting
dominant side.
438.22...... Late effect of N 1 12
cerebrovascular disease,
hemiplegia affecting
nondominant side.
438.30...... Late effect of N 1 12
cerebrovascular disease,
monoplegia of upper limb
affecting unspecified
side.
438.31...... Late effect of N 1 12
cerebrovascular disease,
monoplegia of upper limb
affecting dominant side.
438.32...... Late effect of N 1 12
cerebrovascular disease,
monoplegia of upper limb
affecting nondominant
side.
438.40...... Late effect of N 1 12
cerebrovascular disease,
monoplegia of lower limb
affecting unspecified
side.
438.41...... Late effect of N 1 12
cerebrovascular disease,
monoplegia of lower limb
affecting dominant side.
438.42...... Late effect of N 1 12
cerebrovascular disease,
monoplegia of lower limb
affecting nondominant
side.
438.50...... Late effect of N 1 12
cerebrovascular disease,
other paralytic syndrome
affecting unspecified
side.
438.51...... Late effect of N 1 12
cerebrovascular disease,
other paralytic syndrome
affecting dominant side.
438.52...... Late effect of N 1 12
cerebrovascular disease,
other paralytic syndrome
affecting nondominant
side.
438.81...... Other late effect of N 1 12
cerebrovascular disease,
apraxia.
438.82...... Other late effect of N 1 12
cerebrovascular disease,
dysphagia.
438.89...... Other late effects of N 1 12
cerebrovascular disease.
438.9....... Unspecified late effects N 1 12
of cerebrovascular
disease.
458.8....... Other specified N 5 144, 145
hypotension. 1213
474.00...... Chronic tonsillitis....... N pre 482
3 68, 69, 70
474.01...... Chronic adenoiditis....... N pre 482
3 68, 69, 70
474.02...... Chronic tonsillitis and N pre 482
adenoiditis. 3 68, 69, 70
482.84...... Legionnaires' disease..... Y 4 79, 80, 81
518.6....... Allergic bronchopulmonary Y 4 92, 93
aspergillosis.
655.70...... Decreased fetal movements N 14 469
unspecified as to episode
of care or not applicable.
655.71...... Decreased fetal movements N 14 370, 371, 372, 373, 374, 375
delivered, with or
without mention of
antepartum condition.
655.73...... Decreased fetal movements N 14 383, 384
antepartum condition or
complication.
686.00...... Other local infection of N 9 277, 278, 279
skin and subcutaneous
tissue, pyoderma,
unspecified.
[[Page 29992]]
686.01...... Other local infection of N 9 277, 278, 279
skin and subcutaneous
tissue, pyoderma
gangrenosum.
686.09...... Other local infection of N 9 277, 278, 279
skin and subcutaneous
tissue, other pyoderma.
756.70...... Congenital anomaly of N 6 188, 189, 190
abdominal wall,
unspecified.
756.71...... Congenital anomaly of N 6 188, 189, 190
abdominal wall, prune
belly syndrome.
756.79...... Other congenital anomalies N 6 188, 189, 190
of abdominal wall.
780.31...... Febrile convulsions....... Y 1 24, 25, 26
15 387, 389 2
780.39...... Other convulsions......... Y 1 24, 25, 26
15 387, 389 2
790.94...... Other nonspecific findings N 23 463, 464
on examination of blood,
euthyroid sick syndrome.
796.5....... Abnormal findings on N 14 383, 384
antenatal screening.
959.01...... Head injury, unspecified.. N pre 482
21 444, 445, 446
24 significant trauma list
959.09...... Injury of face and neck... N pre 482
21 444, 445, 446
24 significant trauma list
V02.60...... Viral hepatitis carrier, N 7 205, 206
unspecified.
V02.61...... Hepatitis B carrier....... N 7 205, 206
V02.62...... Hepatitis C carrier....... N 7 205, 206
V02.69...... Other viral hepatitis N 7 205, 206
carrier.
V12.40...... Personal history of N 23 467
unspecified disorder of
nervous system and sense
organs.
V12.41...... Personal history of benign N 23 467
neoplasm of the brain.
V12.49...... Personal history of other N 23 467
disorder of nervous
system and sense organs.
V16.40...... Family history of N 23 467
malignant neoplasm of
genital organ,
unspecified.
V16.41...... Family history of N 23 467
malignant neoplasm of
ovary.
V16.42...... Family history of N 23 467
malignant neoplasm of
prostate.
V16.43...... Family history of N 23 467
malignant neoplasm of
testis.
V16.49...... Family history of other N 23 467
malignant neoplasm.
V28.6....... Antenatal screening for N 23 467
streptococcus B.
V42.81...... Organ or tissue replaced Y 16 398, 399
by transplant, bone
marrow.
V42.82...... Organ or tissue replaced Y 16 398, 399
by transplant, peripheral
stem cells.
V42.83...... Organ or tissue replaced Y 7 467
by transplant, pancreas.
V42.89...... Other organ or tissue Y 23 467
replaced by transplant.
V45.61...... Cataract extraction status N 23 467
V45.69...... Other states following N 23 467
surgery of eye and adnexa.
V45.71...... Acquired absence of breast N 23 467
V45.72...... Acquired absence of N 23 467
intestine (large (small).
V45.73...... Acquired absence of kidney N 23 467
V53.01...... Fitting and adjustment of N 23 467
cerebral ventricular
(communicating) shunt.
V53.02...... Fitting and adjustment of N 23 467
neuropacemaker (brain)
(peripheral nerve)(Spinal
cord).
V53.09...... Fitting and adjustment of N 23 467
other devices related to
nervous system and
special senses.
V64.4....... Laparoscopic surgical N 23 467
procedure converted to
open procedure.
V76.10...... Screening for malignant N 23 467
neoplasm, breast
screening, unspecified.
V76.11...... Screening mammogram for N 23 467
high-risk patient,
malignant neoplasm of
breast.
V76.12...... Other screening mammogram N 23 467
for malignant neoplasm of
breast.
V76.19...... Other screening breast N 23 467
examination for malignant
neoplasm.
----------------------------------------------------------------------------------------------------------------
\1\ HIV major related condition in this DRG.
\2\ Classified as a ``major problem'' in these DRGs.
\3\ Classified as a ``major complication'' in this DRG.
Table 6B.--New Procedure Codes
----------------------------------------------------------------------------------------------------------------
Procedure
code Description OR MDC DRG
----------------------------------------------------------------------------------------------------------------
37.35....... Partial ventriculectomy... Y 5 108
41.05....... Allogeneic hematopoietic Y pre 481
stem cell transplant.
41.06....... Cord blood stem cell Y pre 481
transplant.
----------------------------------------------------------------------------------------------------------------
[[Page 29993]]
Table 6C.--Invalid Diagnosis Codes
----------------------------------------------------------------------------------------------------------------
Diagnosis
code Description CC MDC DRG
----------------------------------------------------------------------------------------------------------------
038.1....... Staphylococcal septicemia. Y 15 387, 389 1
18 416, 417
25 489 2
275.4....... Disorders of calcium N 10 296, 297, 298
metabolism.
438......... Late effects of N 1 12
cerebrovascular disease.
474.0....... Chronic tonsillitis and N pre 482
adenoiditis. 3 68, 69, 70
686.0....... Other local infections of N 9 277, 278, 279
skin and subcutaneous
tissue, pyoderma.
756.7....... Other congenital anomalies N 6 188, 189, 190
of abdominal wall.
780.3....... Convulsions............... Y 1 24, 25, 26
15 387, 389 1
959.0....... Injury, other and N pre 482
unspecified of head, 21 444, 445, 446
face, and neck. 24 significant trauma list
V02.6....... Carrier or suspected N 7 205, 206
carrier of viral
hepatitis.
V12.4....... Personal history of N 23 467
disorders of nervous
system and sense organs.
V16.4....... Family history of N 23 467
malignant neoplasm of
genital organs.
V42.8....... Unspecified organ or Y 7 205, 206
tissue replaced by
transplant.
V45.6....... Other postsurgical state N 23 467
following surgery of eye
and adnexa.
V53.0....... Fitting and adjustment of N 23 467
devices related to
nervous system and
special senses.
V76.1....... Special screening for N 23 467
malignant neoplasm of the
breast.
----------------------------------------------------------------------------------------------------------------
\1\ Classified as a ``major problem'' in these DRGs.
\2\ HIV major related condition in this DRG.
Table 6D.--Revised Diagnosis Code Titles
----------------------------------------------------------------------------------------------------------------
Diagnosis
code Description CC MDC DRG
----------------------------------------------------------------------------------------------------------------
041.04...... Streptococcus infection in N 18 423
conditions classified
elsewhere and of
unspecified site, Group D
[Enterococcus].
474.0....... Chronic tonsillitis and N 3 68, 69, 70
adenoiditis.
959.0....... Injury, other and N pre 482
unspecified of head, 21 444, 445, 446
face, and neck. 24 significant trauma list
----------------------------------------------------------------------------------------------------------------
[[Page 29994]]
Table 6E.--Additions to the CC Exclusions List
Page 1 of 5 Pages
CCs that are added to the list are in Table 6E--Additions to the CC
Exclusions List. Each of the principal diagnoses is shown with an
asterisk, and the revisions to the CC Exclusions List are provided in an
indented column immediately following the affected principal diagnosis.
------------------------------------------------------------------------
------------------------------------------------------------------------
*0031 48284 48284 48284 01176 01354 01643 01771
03810 *01140 *01186 *01795 01180 01355 01644 01772
03811 48284 48284 48284 01181 01356 01645 01773
03819 *01141 *01190 *01796 01182 01360 01646 01774
*0074 48284 48284 48284 01183 01361 01650 01775
00841 *01142 *01191 *0202 01184 01362 01651 01776
00842 48284 48284 03810 01185 01363 01652 01780
00843 *01143 *01192 03811 01186 01364 01653 01781
00844 48284 48284 03819 01190 01365 01654 01782
00845 *01144 *01193 *0212 01191 01366 01655 01783
00846 48284 48284 48284 01192 01380 01656 01784
00847 *01145 *01194 *0310 01193 01381 01660 01785
00849 48284 48284 48284 01194 01382 01661 01786
*01100 *01146 *01195 *0312 01195 01383 01662 01790
48284 48284 48284 01100 01196 01384 01663 01791
*01101 *01150 *01196 01101 01200 01385 01664 01792
48284 48284 48284 01102 01201 01386 01665 01793
*01102 *01151 *01200 01103 01202 01390 01666 01794
48284 48284 48284 01104 01203 01391 01670 01795
*01103 *01152 *01201 01105 01204 01392 01671 01796
48284 48284 48284 01106 01205 01393 01672 01800
*01104 *01153 *01202 01110 01206 01394 01673 01801
48284 48284 48284 01111 01210 01395 01674 01802
*01105 *01154 *01203 01112 01211 01396 01675 01803
48284 48284 48284 01113 01212 01400 01676 01804
*01106 *01155 *01204 01114 01213 01401 01690 01805
48284 48284 48284 01115 01214 01402 01691 01806
*01110 *01156 *01205 01116 01215 01403 01692 01880
48284 48284 48284 01120 01216 01404 01693 01881
*01111 *01160 *01206 01121 01300 01405 01694 01882
48284 48284 48284 01122 01301 01406 01695 01883
*01112 *01161 *01210 01123 01302 01480 01696 01884
48284 48284 48284 01124 01303 01482 01720 01885
*01113 *01162 *01211 01125 01304 01483 01721 01886
48284 48284 48284 01126 01305 01484 01722 01890
*01114 *01163 *01212 01130 01306 01485 01723 01891
48284 48284 48284 01131 01310 01486 01724 01892
*01115 *01164 *01213 01132 01311 01600 01725 01893
48284 48284 48284 01133 01312 01601 01726 01894
*01116 *01165 *01214 01134 01313 01602 01730 01895
48284 48284 48284 01135 01314 01603 01731 01896
*01120 *01166 *01215 01136 01315 01604 01732 0310
48284 48284 48284 01140 01316 01605 01733 *0362
*01121 *01170 *01216 01141 01320 01606 01734 03810
48284 48284 48284 01142 01321 01610 01735 03811
*01122 *01171 *01280 01143 01322 01611 01736 03819
48284 48284 48284 01144 01323 01612 01740 *0380
*01123 *01172 *01281 01145 01324 01613 01741 03810
48284 48284 48284 01146 01325 01614 01742 03811
*01124 *01173 *01282 01150 01326 01615 01743 03819
48284 48284 48284 01151 01330 01616 01744 *03810
*01125 *01174 *01283 01152 01331 01620 01745 0362
48284 48284 48284 01153 01332 01621 01746 0380
*01126 *01175 *01284 01154 01333 01622 01750 03810
48284 48284 48284 01155 01334 01623 01751 03811
*01130 *01176 *01285 01156 01335 01624 01752 03819
48284 48284 48284 01160 01336 01625 01753 0382
*01131 *01180 *01286 01161 01340 01626 01754 0383
48284 48284 48284 01162 01341 01630 01755 03840
*01132 *01181 *01790 01163 01342 01631 01756 03841
48284 48284 48284 01164 01343 01632 01760 03842
*01133 *01182 *01791 01165 01344 01633 01761 03843
48284 48284 48284 01170 01345 01634 01762 03844
*01134 *01183 *01792 01171 01346 01635 01763 03849
48284 48284 48284 01172 01350 01636 01764 0388
*01135 *01184 *01793 01173 01351 01640 01765 0389
48284 48284 48284 01174 01352 01641 01766 0545
*01136 *01185 *01794 01175 01353 01642 01770 *03811
------------------------------------------------------------------------
[[Page 29995]]
Page 2 of 5 Pages
------------------------------------------------------------------------
------------------------------------------------------------------------
0362 *0391 03819 *34550 48284 01196 *4838 48284
0380 48284 *04182 78031 *48283 01200 48284 *5078
03810 *04089 03810 78039 48284 01201 *4841 48284
03811 03810 03811 *34551 *48284 01202 48284 *5080
03819 03811 03819 78031 01100 01203 *4843 48284
0382 03819 *04183 78039 01101 01204 48284 *5081
0383 *04100 03810 *34560 01102 01205 *4845 48284
03840 03810 03811 78031 01103 01206 48284 *5088
03841 03811 03819 78039 01104 01210 *4846 48284
03842 03819 *04184 *34561 01105 01211 48284 *5089
03843 *04101 03810 78031 01106 01212 *4847 48284
03844 03810 03811 78039 01110 01213 48284 *5171
03849 03811 03819 *34570 01111 01214 *4848 48284
0388 03819 *04185 78031 01112 01215 48284 *5178
0389 *04102 03810 78039 01113 01216 *485 48284
0545 03810 03811 *34571 01114 0310 48284 *5186
*03819 03811 03819 78031 01115 11505 *486 5186
0362 03819 *04186 78039 01116 11515 48284 *51889
0380 *04103 03810 *34580 01120 1304 *4870 48284
03810 03810 03811 78031 01121 1363 48284 *5198
03811 03811 03819 78039 01122 481 *4871 48284
03819 03819 *04189 *34581 01123 4820 48284 5186
0382 *04104 03810 78031 01124 4821 *494 *5199
0383 03810 03811 78039 01125 4822 48284 48284
03840 03811 03819 *34590 01126 48230 *4950 5186
03841 03819 *0419 78031 01130 48231 48284 *5990
03842 *04105 03810 78039 01131 48232 *4951 99664
03843 03810 03811 *34591 01132 48239 48284 *65570
03844 03811 03819 78031 01133 4824 *4952 66500
03849 03819 *0545 78039 01134 48281 48284 66501
0388 *04109 03810 *3488 01135 48282 *4953 66503
0389 03810 03811 78031 01136 48283 48284 66510
0545 03811 03819 78039 01140 48284 *4954 66511
*0382 03819 *11505 *3489 01141 48289 48284 *65571
03810 *04110 48284 78031 01142 4829 *4955 66500
03811 03810 *11515 78039 01143 4830 48284 66501
03819 03811 48284 *34989 01144 4831 *4956 66503
*0383 03819 *11595 78031 01145 4838 48284 66510
03810 *04111 48284 78039 01146 4841 *4957 66511
03811 03810 *1221 *3499 01150 4843 48284 *65573
03819 03811 48284 78031 01151 4845 *4958 66500
*03840 03819 *1304 78039 01152 4846 48284 66501
03810 *04119 48284 *4800 01153 4847 *4959 66503
03811 03810 *1363 48284 01154 4848 48284 66510
03819 03811 48284 *4801 01155 485 *496 66511
*03841 03819 *1398 48284 01156 486 48284 *68600
03810 *0412 03810 *4802 01160 4870 *500 6800
03811 03810 03811 48284 01161 4950 48284 6801
03819 03811 03819 *4808 01162 4951 *501 6802
*03842 03819 *34500 48284 01163 4952 48284 6803
03810 *0413 78031 *4809 01164 4953 *502 6804
03811 03810 78039 48284 01165 4954 48284 6805
03819 03811 *34501 *481 01166 4955 *503 6806
*03843 03819 78031 48284 01170 4956 48284 6807
03810 *0414 78039 *4820 01171 4957 *504 6808
03811 03810 *34510 48284 01172 4958 48284 6809
03819 03811 78031 *4821 01173 4959 *505 6820
*03844 03819 78039 48284 01174 5060 48284 6821
03810 *0415 *34511 *4822 01175 5061 *5060 6822
03811 03810 78031 48284 01176 5070 48284 6823
03819 03811 78039 *48230 01180 5071 *5061 6825
*03849 03819 *3452 48284 01181 5078 48284 6826
03810 *0416 78031 *48231 01182 5080 *5062 6827
03811 03810 78039 48284 01183 5081 48284 6828
03819 03811 *3453 *48232 01184 5171 *5063 6829
*0388 03819 78031 48284 01185 *48289 48284 684
03810 *0417 78039 *48239 01186 48284 *5064 *68601
03811 03810 *34540 48284 01190 *4829 48284 6800
03819 03811 78031 *4824 01191 48284 *5069 6801
*0389 03819 78039 48284 01192 *4830 48284 6802
03810 *04181 *34541 *48281 01193 48284 *5070 6803
03811 03810 78031 48284 01194 *4831 48284 6804
03819 03811 78039 *48282 01195 48284 *5071 6805
------------------------------------------------------------------------
[[Page 29996]]
Page 3 of 5 Pages
------------------------------------------------------------------------
------------------------------------------------------------------------
6806 80019 80110 80220 80359 80450 85132 85223
6807 80020 80111 80221 80360 80451 85133 85224
6808 80021 80112 80222 80361 80452 85134 85225
6809 80022 80113 80223 80362 80453 85135 85226
6820 80023 80114 80224 80363 80454 85136 85229
6821 80024 80115 80225 80364 80455 85139 85230
6822 80025 80116 80226 80365 80456 85140 85231
6823 80026 80119 80227 80366 80459 85141 85232
6825 80029 80120 80228 80369 80460 85142 85233
6826 80030 80121 80229 80370 80461 85143 85234
6827 80031 80122 80230 80371 80462 85144 85235
6828 80032 80123 80231 80372 80463 85145 85236
6829 80033 80124 80232 80373 80464 85146 85239
684 80034 80125 80233 80374 80465 85149 85240
*68609 80035 80126 80234 80375 80466 85150 85241
6800 80036 80129 80235 80376 80469 85151 85242
6801 80039 80130 80236 80379 80470 85152 85243
6802 80040 80131 80237 80380 80471 85153 85244
6803 80041 80132 80238 80381 80472 85154 85245
6804 80042 80133 80239 80382 80473 85155 85246
6805 80043 80134 8024 80383 80474 85156 85249
6806 80044 80135 8025 80384 80475 85159 85250
6807 80045 80136 8026 80385 80476 85160 85251
6808 80046 80139 8027 80386 80479 85161 85252
6809 80049 80140 8028 80389 80480 85162 85253
6820 80050 80141 8029 80390 80481 85163 85254
6821 80051 80142 80300 80391 80482 85164 85255
6822 80052 80143 80301 80392 80483 85165 85256
6823 80053 80144 80302 80393 80484 85166 85259
6825 80054 80145 80303 80394 80485 85169 85300
6826 80055 80146 80304 80395 80486 85170 85301
6827 80056 80149 80305 80396 80489 85171 85302
6828 80059 80150 80306 80399 80490 85172 85303
6829 80060 80151 80309 80400 80491 85173 85304
684 80061 80152 80310 80401 80492 85174 85305
*74861 80062 80153 80311 80402 80493 85175 85306
48284 80063 80154 80312 80403 80494 85176 85309
*7790 80064 80155 80313 80404 80495 85179 85310
78031 80065 80156 80314 80405 80496 85180 85311
78039 80066 80159 80315 80406 80499 85181 85312
*7791 80069 80160 80316 80409 8500 85182 85313
78031 80070 80161 80319 80410 8501 85183 85314
78039 80071 80162 80320 80411 8502 85184 85315
*78031 80072 80163 80321 80412 8503 85185 85316
78031 80073 80164 80322 80413 8504 85186 85319
78039 80074 80165 80323 80414 8505 85189 85400
*78039 80075 80166 80324 80415 8509 85190 85401
78031 80076 80169 80325 80416 85100 85191 85402
78039 80079 80170 80326 80419 85101 85192 85403
*7809 80080 80171 80329 80420 85102 85193 85404
78031 80081 80172 80330 80421 85103 85194 85405
78039 80082 80173 80331 80422 85104 85195 85406
*79094 80083 80174 80332 80423 85105 85196 85409
7907 80084 80175 80333 80424 85106 85199 85410
*7998 80085 80176 80334 80425 85109 85200 85411
78031 80086 80179 80335 80426 85110 85201 85412
78039 80089 80180 80336 80429 85111 85202 85413
*95901 80090 80181 80339 80430 85112 85203 85414
80000 80091 80182 80340 80431 85113 85204 85415
80001 80092 80183 80341 80432 85114 85205 85416
80002 80093 80184 80342 80433 85115 85206 85419
80003 80094 80185 80343 80434 85116 85209 9251
80004 80095 80186 80344 80435 85119 85210 9252
80005 80096 80189 80345 80436 85120 85211 *95909
80006 80099 80190 80346 80439 85121 85212 80000
80009 80100 80191 80349 80440 85122 85213 80001
80010 80101 80192 80350 80441 85123 85214 80002
80011 80102 80193 80351 80442 85124 85215 80003
80012 80103 80194 80352 80443 85125 85216 80004
80013 80104 80195 80353 80444 85126 85219 80005
80014 80105 80196 80354 80445 85129 85220 80006
80015 80106 80199 80355 80446 85130 85221 80009
80016 80109 8021 80356 80449 85131 85222 80010
------------------------------------------------------------------------
[[Page 29997]]
Page 4 of 5 Pages
------------------------------------------------------------------------
------------------------------------------------------------------------
80011 80102 80193 80351 80442 85124 85215 V4282
80012 80103 80194 80352 80443 85125 85216 V4283
80013 80104 80195 80353 80444 85126 85219 V4289
80014 80105 80196 80354 80445 85129 85220 *99685
80015 80106 80199 80355 80446 85130 85221 V4281
80016 80109 8021 80356 80449 85131 85222 *99686
80019 80110 80220 80359 80450 85132 85223 V4283
80020 80111 80221 80360 80451 85133 85224 *99689
80021 80112 80222 80361 80452 85134 85225 V4289
80022 80113 80223 80362 80453 85135 85226 *V090
80023 80114 80224 80363 80454 85136 85229 03810
80024 80115 80225 80364 80455 85139 85230 03811
80025 80116 80226 80365 80456 85140 85231 03819
80026 80119 80227 80366 80459 85141 85232 *V091
80029 80120 80228 80369 80460 85142 85233 03810
80030 80121 80229 80370 80461 85143 85234 03811
80031 80122 80230 80371 80462 85144 85235 03819
80032 80123 80231 80372 80463 85145 85236 *V092
80033 80124 80232 80373 80464 85146 85239 03810
80034 80125 80233 80374 80465 85149 85240 03811
80035 80126 80234 80375 80466 85150 85241 03819
80036 80129 80235 80376 80469 85151 85242 *V093
80039 80130 80236 80379 80470 85152 85243 03810
80040 80131 80237 80380 80471 85153 85244 03811
80041 80132 80238 80381 80472 85154 85245 03819
80042 80133 80239 80382 80473 85155 85246 *V094
80043 80134 8024 80383 80474 85156 85249 03810
80044 80135 8025 80384 80475 85159 85250 03811
80045 80136 8026 80385 80476 85160 85251 03819
80046 80139 8027 80386 80479 85161 85252 *V0950
80049 80140 8028 80389 80480 85162 85253 03810
80050 80141 8029 80390 80481 85163 85254 03811
80051 80142 80300 80391 80482 85164 85255 03819
80052 80143 80301 80392 80483 85165 85256 *V0951
80053 80144 80302 80393 80484 85166 85259 03810
80054 80145 80303 80394 80485 85169 85300 03811
80055 80146 80304 80395 80486 85170 85301 03819
80056 80149 80305 80396 80489 85171 85302 *V096
80059 80150 80306 80399 80490 85172 85303 03810
80060 80151 80309 80400 80491 85173 85304 03811
80061 80152 80310 80401 80492 85174 85305 03819
80062 80153 80311 80402 80493 85175 85306 *V0970
80063 80154 80312 80403 80494 85176 85309 03810
80064 80155 80313 80404 80495 85179 85310 03811
80065 80156 80314 80405 80496 85180 85311 03819
80066 80159 80315 80406 80499 85181 85312 *V0971
80069 80160 80316 80409 8500 85182 85313 03810
80070 80161 80319 80410 8501 85183 85314 03811
80071 80162 80320 80411 8502 85184 85315 03819
80072 80163 80321 80412 8503 85185 85316 *V0980
80073 80164 80322 80413 8504 85186 85319 03810
80074 80165 80323 80414 8505 85189 85400 03811
80075 80166 80324 80415 8509 85190 85401 03819
80076 80169 80325 80416 85100 85191 85402 *V0981
80079 80170 80326 80419 85101 85192 85403 03810
80080 80171 80329 80420 85102 85193 85404 03811
80081 80172 80330 80421 85103 85194 85405 03819
80082 80173 80331 80422 85104 85195 85406 *V0990
80083 80174 80332 80423 85105 85196 85409 03810
80084 80175 80333 80424 85106 85199 85410 03811
80085 80176 80334 80425 85109 85200 85411 03819
80086 80179 80335 80426 85110 85201 85412 *V0991
80089 80180 80336 80429 85111 85202 85413 03810
80090 80181 80339 80430 85112 85203 85414 03811
80091 80182 80340 80431 85113 85204 85415 03819
80092 80183 80341 80432 85114 85205 85416 *V4283
80093 80184 80342 80433 85115 85206 85419 V4283
80094 80185 80343 80434 85116 85209 9251 *V4289
80095 80186 80344 80435 85119 85210 9252 V420
80096 80189 80345 80436 85120 85211 *99664 V421
80099 80190 80346 80439 85121 85212 5990 V422
80100 80191 80349 80440 85122 85213 *99680 V426
80101 80192 80350 80441 85123 85214 V4281 V427
------------------------------------------------------------------------
[[Page 29998]]
Page 5 of 5 Pages
------------------------------------------------------------------------
------------------------------------------------------------------------
V4289
*V429
V4281
V4282
V4283
V4289
------------------------------------------------------------------------
[[Page 29999]]
Table 6F.--Deletions to the CC Exclusions List
Page 1 of 2 Pages
CCs that are deleted from the list are in Table 6G--Deletions to the CC
Exclusions List. Each of the principal diagnoses is shown with an
asterisk, and the revisions to the CC Exclusions List are provided in an
indented column immediately following the affected principal diagnosis.
------------------------------------------------------------------------
------------------------------------------------------------------------
*0031 0381 7803 80039 80123 80226 80360 80444
0381 *0414 *34989 80040 80124 80227 80361 80445
*0202 0381 7803 80041 80125 80228 80362 80446
0381 *0415 *3499 80042 80126 80229 80363 80449
*0362 0381 7803 80043 80129 80230 80364 80450
0381 *0416 *6860 80044 80130 80231 80365 80451
*0380 0381 6800 80045 80131 80232 80366 80452
0381 *0417 6801 80046 80132 80233 80369 80453
*0381 0381 6802 80049 80133 80234 80370 80454
0362 *04181 6803 80050 80134 80235 80371 80455
0380 0381 6804 80051 80135 80236 80372 80456
0381 *04182 6805 80052 80136 80237 80373 80459
0382 0381 6806 80053 80139 80238 80374 80460
0383 *04183 6807 80054 80140 80239 80375 80461
03840 0381 6808 80055 80141 8024 80376 80462
03841 *04184 6809 80056 80142 8025 80379 80463
03842 0381 6820 80059 80143 8026 80380 80464
03843 *04185 6821 80060 80144 8027 80381 80465
03844 0381 6822 80061 80145 8028 80382 80466
03849 *04186 6823 80062 80146 8029 80383 80469
0388 0381 6825 80063 80149 80300 80384 80470
0389 *04189 6826 80064 80150 80301 80385 80471
0545 0381 6827 80065 80151 80302 80386 80472
*0382 *0419 6828 80066 80152 80303 80389 80473
0381 0381 6829 80069 80153 80304 80390 80474
*0383 *0545 684 80070 80154 80305 80391 80475
0381 0381 *7790 80071 80155 80306 80392 80476
*03840 *1398 7803 80072 80156 80309 80393 80479
0381 0381 *7791 80073 80159 80310 80394 80480
*03841 *34500 7803 80074 80160 80311 80395 80481
0381 7803 *7803 80075 80161 80312 80396 80482
*03842 *34501 7803 80076 80162 80313 80399 80483
0381 7803 *7809 80079 80163 80314 80400 80484
*03843 *34510 7803 80080 80164 80315 80401 80485
0381 7803 *7998 80081 80165 80316 80402 80486
*03844 *34511 7803 80082 80166 80319 80403 80489
0381 7803 *9590 80083 80169 80320 80404 80490
*03849 *3452 80000 80084 80170 80321 80405 80491
0381 7803 80001 80085 80171 80322 80406 80492
*0388 *3453 80002 80086 80172 80323 80409 80493
0381 7803 80003 80089 80173 80324 80410 80494
*0389 *34540 80004 80090 80174 80325 80411 80495
0381 7803 80005 80091 80175 80326 80412 80496
*04089 *34541 80006 80092 80176 80329 80413 80499
0381 7803 80009 80093 80179 80330 80414 8500
*04100 *34550 80010 80094 80180 80331 80415 8501
0381 7803 80011 80095 80181 80332 80416 8502
*04101 *34551 80012 80096 80182 80333 80419 8503
0381 7803 80013 80099 80183 80334 80420 8504
*04102 *34560 80014 80100 80184 80335 80421 8505
0381 7803 80015 80101 80185 80336 80422 8509
*04103 *34561 80016 80102 80186 80339 80423 85100
0381 7803 80019 80103 80189 80340 80424 85101
*04104 *34570 80020 80104 80190 80341 80425 85102
0381 7803 80021 80105 80191 80342 80426 85103
*04105 *34571 80022 80106 80192 80343 80429 85104
0381 7803 80023 80109 80193 80344 80430 85105
*04109 *34580 80024 80110 80194 80345 80431 85106
0381 7803 80025 80111 80195 80346 80432 85109
*04110 *34581 80026 80112 80196 80349 80433 85110
0381 7803 80029 80113 80199 80350 80434 85111
*04111 *34590 80030 80114 8021 80351 80435 85112
0381 7803 80031 80115 80220 80352 80436 85113
*04119 *34591 80032 80116 80221 80353 80439 85114
0381 7803 80033 80119 80222 80354 80440 85115
*0412 *3488 80034 80120 80223 80355 80441 85116
0381 7803 80035 80121 80224 80356 80442 85119
*0413 *3489 80036 80122 80225 80359 80443 85120
------------------------------------------------------------------------
[[Page 30000]]
Page 2 of 2 Pages
------------------------------------------------------------------------
------------------------------------------------------------------------
85121 85212 V428
85122 85213 *99686
85123 85214 V428
85124 85215 *99689
85125 85216 V428
85126 85219 *V090
85129 85220 0381
85130 85221 *V091
85131 85222 0381
85132 85223 *V092
85133 85224 0381
85134 85225 *V093
85135 85226 0381
85136 85229 *V094
85139 85230 0381
85140 85231 *V0950
85141 85232 0381
85142 85233 *V0951
85143 85234 0381
85144 85235 *V096
85145 85236 0381
85146 85239 *V0970
85149 85240 0381
85150 85241 *V0971
85151 85242 0381
85152 85243 *V0980
85153 85244 0381
85154 85245 *V0981
85155 85246 0381
85156 85249 *V0990
85159 85250 0381
85160 85251 *V0991
85161 85252 0381
85162 85253 *V428
85163 85254 V420
85164 85255 V421
85165 85256 V422
85166 85259 V426
85169 85300 V427
85170 85301 V428
85171 85302 *V429
85172 85303 V428
85173 85304
85174 85305
85175 85306
85176 85309
85179 85310
85180 85311
85181 85312
85182 85313
85183 85314
85184 85315
85185 85316
85186 85319
85189 85400
85190 85401
85191 85402
85192 85403
85193 85404
85194 85405
85195 85406
85196 85409
85199 85410
85200 85411
85201 85412
85202 85413
85203 85414
85204 85415
85205 85416
85206 85419
85209 9251
85210 9252
85211 *99680
------------------------------------------------------------------------
[[Page 30001]]
Table 7A.--Medicare Prospective Payment System; Selected Percentile Lengths of Stay
[FY96 MEDPAR Update 12/96 Grouper V14.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number Arithmetic 10th 25th 50th 75th 90th
DRG discharges mean LOS percentile percentile percentile percentile percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1....................................... 36587 10.0378 2 4 7 13 21
2....................................... 6771 10.5860 3 5 8 13 21
3....................................... 1 1.0000 1 1 1 1 1
4....................................... 6231 8.4710 2 3 6 10 18
5....................................... 102519 3.9306 1 2 3 4 8
6....................................... 417 3.2590 1 1 2 4 7
7....................................... 11911 11.6376 3 5 8 13 22
8....................................... 2088 3.8410 1 1 3 5 8
9....................................... 1712 7.0596 1 3 5 9 14
10...................................... 20092 7.2703 2 3 5 9 15
11...................................... 2933 4.2636 1 2 3 6 9
12...................................... 25964 6.8386 2 3 5 8 13
13...................................... 6323 5.7745 2 3 5 7 10
14...................................... 374831 6.7444 2 3 5 8 13
15...................................... 145009 4.0646 1 2 3 5 7
16...................................... 13995 6.0974 2 3 5 7 11
17...................................... 3084 3.7036 1 2 3 5 7
18...................................... 24039 5.7935 2 3 4 7 11
19...................................... 6542 4.0880 1 2 3 5 8
20...................................... 8163 9.4084 2 4 7 12 19
21...................................... 1177 7.0935 2 3 5 9 14
22...................................... 2887 4.7645 2 2 4 6 9
23...................................... 6025 4.5610 1 2 3 6 9
24...................................... 57698 5.3362 1 2 4 6 10
25...................................... 22091 3.6103 1 2 3 4 7
26...................................... 40 5.2500 1 2 4 7 11
27...................................... 3743 5.5060 1 1 3 7 13
28...................................... 12494 6.3374 1 3 4 8 13
29...................................... 3906 3.7384 1 2 3 5 7
30...................................... 1 4.0000 4 4 4 4 4
31...................................... 3008 4.7822 1 2 3 6 9
32...................................... 1389 3.0756 1 1 2 3 6
34...................................... 18440 5.8049 1 3 4 7 11
35...................................... 3698 3.9227 1 2 3 5 7
36...................................... 6706 1.5406 1 1 1 2 2
37...................................... 1756 3.9169 1 1 3 4 8
38...................................... 195 2.7077 1 1 2 3 5
39...................................... 2545 2.0000 1 1 1 2 4
40...................................... 2629 3.4059 1 1 2 4 7
42...................................... 5378 1.9781 1 1 1 2 4
43...................................... 110 4.0182 1 2 3 5 7
44...................................... 1461 5.2005 2 3 4 6 9
45...................................... 2340 3.5949 1 2 3 5 7
46...................................... 2995 4.8417 1 2 4 6 9
47...................................... 1173 3.9599 1 1 3 4 7
49...................................... 2364 5.2563 1 2 4 6 10
50...................................... 3268 2.1068 1 1 2 2 3
51...................................... 348 2.8908 1 1 2 3 6
52...................................... 89 2.9213 1 1 2 4 7
53...................................... 3071 3.5988 1 1 2 4 8
54...................................... 2 5.0000 1 1 9 9 9
55...................................... 1876 2.9302 1 1 2 3 6
56...................................... 729 2.8299 1 1 2 3 6
57...................................... 652 3.9525 1 2 2 5 8
58...................................... 1 2.0000 2 2 2 2 2
59...................................... 103 3.1262 1 1 2 4 6
60...................................... 3 1.0000 1 1 1 1 1
61...................................... 241 4.5726 1 1 3 5 11
63...................................... 3732 4.6072 1 2 3 5 9
64...................................... 3341 6.6417 1 2 5 8 14
65...................................... 29312 3.1709 1 2 3 4 6
66...................................... 6560 3.4703 1 2 3 4 6
67...................................... 492 3.8049 1 2 3 5 7
68...................................... 10175 4.3277 2 2 4 5 8
69...................................... 2943 3.4709 1 2 3 4 6
70...................................... 40 3.3000 1 2 3 4 5
71...................................... 128 3.9297 1 2 3 5 7
72...................................... 705 3.4610 1 2 3 4 7
73...................................... 6206 4.6695 1 2 4 6 9
74...................................... 4 3.2500 1 1 2 3 7
[[Page 30002]]
75...................................... 40909 10.5411 4 5 8 13 20
76...................................... 41015 11.7119 3 6 9 14 22
77...................................... 2184 5.1108 1 2 4 7 10
78...................................... 30978 7.6317 3 5 7 9 13
79...................................... 237994 8.6320 3 4 7 11 16
80...................................... 8120 6.0765 2 3 5 7 11
81...................................... 20 10.7000 1 6 8 11 15
82...................................... 70673 7.3185 2 3 6 9 14
83...................................... 7304 5.8976 2 3 5 7 11
84...................................... 1473 3.4725 1 2 3 4 6
85...................................... 20682 6.8707 2 3 5 9 13
86...................................... 1372 4.0532 1 2 3 5 8
87...................................... 67342 6.4329 1 3 5 8 12
88...................................... 359001 5.6528 2 3 5 7 10
89...................................... 428753 6.5589 3 4 5 8 12
90...................................... 36813 4.6811 2 3 4 6 8
91...................................... 73 5.2466 2 3 4 7 9
92...................................... 13516 6.6268 2 3 5 8 12
93...................................... 1162 4.6145 1 2 4 6 8
94...................................... 13665 6.6447 2 3 5 8 13
95...................................... 1418 3.9810 1 2 3 5 7
96...................................... 58911 5.0549 2 3 4 6 9
97...................................... 23971 4.0015 1 2 3 5 7
98...................................... 28 2.8214 1 1 2 3 6
99...................................... 26524 3.1691 1 1 2 4 6
100..................................... 10188 2.2330 1 1 2 3 4
101..................................... 20391 4.7223 1 2 4 6 9
102..................................... 4493 2.8952 1 1 2 4 5
103..................................... 517 47.0406 9 15 32 71 104
104..................................... 26171 13.3430 5 8 11 16 24
105..................................... 22843 10.1949 5 6 8 12 18
106..................................... 106957 11.0507 6 7 9 13 18
107..................................... 68189 8.3054 5 6 7 9 13
108..................................... 7462 12.0893 4 7 10 15 23
110..................................... 63215 10.0803 3 6 8 12 19
111..................................... 5557 6.1074 2 4 6 7 9
112..................................... 218111 4.2393 1 2 3 6 8
113..................................... 47795 13.1200 4 6 9 16 26
114..................................... 9030 8.8270 2 4 7 11 17
115..................................... 11560 10.2985 4 6 8 13 18
116..................................... 86830 5.0237 1 2 4 6 10
117..................................... 3723 4.0285 1 1 3 5 9
118..................................... 6649 3.0284 1 1 2 4 7
119..................................... 1684 5.1081 1 1 3 7 11
120..................................... 39395 8.4464 1 2 5 11 19
121..................................... 165994 6.9292 2 4 6 9 12
122..................................... 90608 4.6367 1 2 4 6 8
123..................................... 45927 4.4682 1 1 2 6 11
124..................................... 152443 4.5925 1 2 4 6 9
125..................................... 60680 2.9371 1 1 2 4 6
126..................................... 5118 12.8009 4 6 10 16 26
127..................................... 705250 5.7994 2 3 5 7 11
128..................................... 18457 6.3457 3 4 6 7 10
129..................................... 4439 3.1683 1 1 1 3 7
130..................................... 99388 6.2962 2 4 5 8 11
131..................................... 25429 4.8527 1 3 5 6 8
132..................................... 164147 3.3158 1 2 3 4 6
133..................................... 6113 2.8050 1 1 2 3 5
134..................................... 29364 3.6008 1 2 3 4 7
135..................................... 8043 4.4405 1 2 3 5 8
136..................................... 1143 3.0604 1 1 2 4 6
137..................................... 5 6.6000 2 2 4 8 16
138..................................... 207475 4.1925 1 2 3 5 8
139..................................... 65356 2.7468 1 1 2 3 5
140..................................... 134319 3.1700 1 2 3 4 6
141..................................... 78035 4.0805 1 2 3 5 7
142..................................... 35460 2.9406 1 1 2 4 5
143..................................... 137083 2.3957 1 1 2 3 4
144..................................... 75930 5.3732 1 2 4 7 11
145..................................... 6310 2.9853 1 1 2 4 6
[[Page 30003]]
146..................................... 9811 10.5321 6 7 9 12 17
147..................................... 1664 6.9056 4 5 7 8 10
148..................................... 148674 12.6141 6 7 10 15 22
149..................................... 14218 7.1334 4 5 7 8 10
150..................................... 24389 11.1129 4 7 9 14 20
151..................................... 4232 6.1189 2 3 6 8 11
152..................................... 4675 8.4877 4 5 7 10 14
153..................................... 1644 5.7968 3 4 6 7 9
154..................................... 34909 14.0372 4 7 11 17 27
155..................................... 4509 5.0100 2 2 4 7 9
156..................................... 2 18.0000 5 5 31 31 31
157..................................... 9420 5.6036 1 2 4 7 11
158..................................... 4328 2.7872 1 1 2 4 6
159..................................... 18163 5.0726 1 2 4 6 10
160..................................... 9493 2.7740 1 1 2 4 5
161..................................... 14884 4.2139 1 2 3 5 9
162..................................... 7335 2.0923 1 1 1 3 4
163..................................... 11 4.4545 1 1 2 6 10
164..................................... 5335 8.7134 4 5 7 10 15
165..................................... 1586 5.4061 2 3 5 7 8
166..................................... 3342 5.4333 2 3 4 7 10
167..................................... 2247 2.9653 1 2 3 4 5
168..................................... 1853 4.7210 1 2 3 6 9
169..................................... 925 2.5459 1 1 2 3 5
170..................................... 12921 11.7454 2 5 9 15 23
171..................................... 1051 5.1246 1 2 4 6 10
172..................................... 32806 7.3996 2 3 5 9 15
173..................................... 2065 3.9467 1 2 3 5 8
174..................................... 238661 5.1466 2 3 4 6 9
175..................................... 21406 3.2356 1 2 3 4 6
176..................................... 17834 5.7615 2 3 4 7 11
177..................................... 11741 4.7286 2 3 4 6 8
178..................................... 3764 3.3547 1 2 3 4 6
179..................................... 12072 6.7301 2 3 5 8 13
180..................................... 88723 5.6566 2 3 4 7 11
181..................................... 21229 3.7030 1 2 3 5 7
182..................................... 237563 4.5654 1 2 4 6 8
183..................................... 69548 3.1791 1 2 3 4 6
184..................................... 86 3.7093 1 2 3 4 7
185..................................... 4055 4.8222 1 2 4 6 10
186..................................... 2 3.0000 2 2 4 4 4
187..................................... 869 3.9298 1 2 3 5 7
188..................................... 70414 5.7816 1 3 4 7 11
189..................................... 7871 3.3750 1 1 3 4 7
190..................................... 94 4.8830 1 2 3 6 11
191..................................... 11024 14.8159 4 7 11 18 29
192..................................... 775 7.1419 2 4 6 9 13
193..................................... 8299 12.8943 5 7 11 16 23
194..................................... 660 7.4379 2 4 6 9 13
195..................................... 8718 9.8580 4 6 8 12 17
196..................................... 624 6.3462 3 4 6 8 10
197..................................... 27165 8.6986 3 5 7 10 15
198..................................... 7036 4.7172 2 3 4 6 8
199..................................... 2147 10.6954 3 5 8 14 22
200..................................... 1533 11.3503 2 4 8 14 23
201..................................... 1536 14.8932 4 7 11 18 29
202..................................... 28316 7.0896 2 3 5 9 14
203..................................... 29341 7.1571 2 3 6 9 14
204..................................... 52859 6.3341 2 3 5 8 12
205..................................... 22935 6.7787 2 3 5 8 14
206..................................... 1652 4.2240 1 2 3 5 8
207..................................... 36747 5.2866 1 2 4 7 10
208..................................... 9886 3.0404 1 1 2 4 6
209..................................... 356581 5.8918 3 4 5 7 9
210..................................... 142712 7.6249 4 5 6 9 13
211..................................... 26185 5.6079 3 4 5 7 9
212..................................... 40 6.2250 3 4 5 7 9
213..................................... 7121 8.7182 2 4 7 11 17
214..................................... 57899 5.8874 2 3 5 7 11
215..................................... 45203 3.2816 1 2 3 4 6
[[Page 30004]]
216..................................... 6357 10.2902 2 4 8 13 21
217..................................... 20641 13.7099 3 5 9 17 29
218..................................... 24497 5.6195 2 3 4 7 10
219..................................... 18723 3.4439 1 2 3 4 6
220..................................... 4 4.7500 1 1 4 4 10
221..................................... 5113 7.1731 2 3 5 9 14
222..................................... 3453 3.8199 1 2 3 5 7
223..................................... 19460 2.7002 1 1 2 3 5
224..................................... 8049 2.1070 1 1 2 3 4
225..................................... 5842 4.6251 1 2 3 6 10
226..................................... 5513 6.2507 1 2 4 7 13
227..................................... 4322 2.8538 1 1 2 3 5
228..................................... 2967 3.4553 1 1 2 4 7
229..................................... 1216 2.3528 1 1 2 3 4
230..................................... 2473 4.9713 1 2 3 6 10
231..................................... 10932 4.7551 1 2 3 6 10
232..................................... 553 4.2405 1 1 2 5 10
233..................................... 4688 8.2445 2 3 6 10 16
234..................................... 2165 3.8859 1 2 3 5 8
235..................................... 5517 5.8182 1 3 4 6 11
236..................................... 39637 5.5891 2 3 4 7 10
237..................................... 1654 4.2019 1 2 3 5 8
238..................................... 7601 9.3428 3 4 7 11 17
239..................................... 60377 6.9698 2 3 5 8 13
240..................................... 13251 6.9282 2 3 5 8 14
241..................................... 2990 4.2331 1 2 3 5 8
242..................................... 2825 7.1487 2 3 5 9 14
243..................................... 80090 5.1221 2 3 4 6 9
244..................................... 12427 5.3968 1 3 4 6 10
245..................................... 4382 4.0895 1 2 3 5 7
246..................................... 1268 4.2437 1 2 3 5 8
247..................................... 11432 3.6810 1 2 3 5 7
248..................................... 7374 4.9761 1 2 4 6 9
249..................................... 10329 3.9287 1 1 3 5 8
250..................................... 3558 4.6501 1 2 3 5 9
251..................................... 2107 3.0019 1 1 2 4 5
253..................................... 18921 5.2431 1 3 4 6 10
254..................................... 9245 3.5230 1 2 3 4 6
255..................................... 1 6.0000 6 6 6 6 6
256..................................... 4394 5.6445 1 2 4 7 11
257..................................... 22632 3.2017 1 2 3 4 6
258..................................... 16954 2.2782 1 1 2 3 4
259..................................... 3995 3.1975 1 1 2 3 7
260..................................... 4550 1.6642 1 1 1 2 3
261..................................... 2213 2.2350 1 1 2 3 4
262..................................... 659 4.0030 1 1 3 5 8
263..................................... 29107 12.4970 3 5 9 15 24
264..................................... 3357 7.2848 2 3 6 9 14
265..................................... 4141 7.0995 1 2 5 8 14
266..................................... 2553 3.5719 1 1 2 5 7
267..................................... 223 4.1839 1 1 2 5 9
268..................................... 1177 3.7961 1 1 2 4 7
269..................................... 10062 8.5178 2 3 6 11 17
270..................................... 3072 3.2080 1 1 2 4 7
271..................................... 22910 7.7195 3 4 6 9 14
272..................................... 5988 6.6757 2 3 5 8 13
273..................................... 1387 5.3677 1 2 4 6 11
274..................................... 2619 7.1229 1 3 5 9 15
275..................................... 240 3.8042 1 1 2 5 8
276..................................... 939 4.7444 1 3 4 6 8
277..................................... 80070 6.2309 2 3 5 7 11
278..................................... 24752 4.8306 2 3 4 6 8
279..................................... 7 4.4286 2 2 4 6 6
280..................................... 13778 4.7052 1 2 3 6 9
281..................................... 5819 3.3805 1 1 3 4 6
282..................................... 5 12.0000 1 1 3 14 41
283..................................... 5280 5.0146 1 2 4 6 10
284..................................... 1748 3.5463 1 2 3 5 7
285..................................... 5591 12.0757 3 5 9 15 23
286..................................... 2071 7.2038 3 4 5 8 13
[[Page 30005]]
287..................................... 6659 12.2050 3 5 8 14 24
288..................................... 1201 5.8485 3 4 5 6 9
289..................................... 5476 3.4830 1 1 2 3 7
290..................................... 8792 2.5875 1 1 2 3 4
291..................................... 94 2.1596 1 1 2 3 4
292..................................... 5173 11.2101 2 4 8 14 22
293..................................... 271 5.8782 1 2 4 7 12
294..................................... 83801 5.2493 2 3 4 6 10
295..................................... 3650 4.1052 1 2 3 5 8
296..................................... 231553 5.7556 2 3 4 7 11
297..................................... 31811 3.8626 1 2 3 5 7
298..................................... 112 3.1786 1 1 2 4 7
299..................................... 1130 5.4823 1 2 4 7 11
300..................................... 15618 6.6234 2 3 5 8 13
301..................................... 1968 4.3664 1 2 3 5 8
302..................................... 7967 10.9728 5 6 8 13 19
303..................................... 19228 9.4496 4 5 8 11 17
304..................................... 13035 9.5744 2 4 7 11 19
305..................................... 2446 4.3385 1 2 4 5 8
306..................................... 11608 5.7505 1 2 4 7 12
307..................................... 2480 2.5375 1 1 2 3 4
308..................................... 9697 6.4016 1 2 4 8 13
309..................................... 3353 2.5577 1 1 2 3 5
310..................................... 27418 4.3367 1 2 3 5 9
311..................................... 8484 2.0532 1 1 2 2 4
312..................................... 1866 4.6833 1 2 3 6 10
313..................................... 659 2.2656 1 1 2 3 4
315..................................... 28342 8.5520 1 2 5 11 19
316..................................... 84578 6.9970 2 3 5 9 14
317..................................... 841 2.9441 1 1 2 3 6
318..................................... 6158 6.6325 1 3 5 8 13
319..................................... 422 2.8815 1 1 2 4 6
320..................................... 175874 5.8692 2 3 5 7 10
321..................................... 23491 4.2793 2 3 4 5 7
322..................................... 97 4.3196 2 2 3 5 8
323..................................... 17371 3.3739 1 1 2 4 7
324..................................... 7972 2.0066 1 1 2 2 4
325..................................... 6977 4.2005 1 2 3 5 8
326..................................... 2097 2.8994 1 1 2 4 5
327..................................... 15 3.1333 1 1 2 3 12
328..................................... 671 3.9091 1 2 3 5 8
329..................................... 107 2.4393 1 1 2 3 5
331..................................... 43921 5.8404 2 3 4 7 11
332..................................... 4398 3.5489 1 1 3 5 7
333..................................... 338 5.5621 1 2 4 7 11
334..................................... 19279 5.4196 3 4 5 6 8
335..................................... 9751 4.0561 2 3 4 5 6
336..................................... 59003 3.7602 1 2 3 4 7
337..................................... 34115 2.4160 1 2 2 3 4
338..................................... 3724 5.0709 1 2 3 6 11
339..................................... 2119 4.5880 1 2 3 6 10
340..................................... 1 1.0000 1 1 1 1 1
341..................................... 5932 3.1123 1 1 2 3 6
342..................................... 192 4.1927 1 2 3 6 8
344..................................... 3517 3.1137 1 1 2 3 6
345..................................... 1357 3.7900 1 1 3 5 8
346..................................... 5156 6.2853 1 3 5 8 12
347..................................... 372 2.9624 1 1 2 4 6
348..................................... 3204 4.4860 1 2 3 5 8
349..................................... 741 2.6815 1 1 2 3 5
350..................................... 6300 4.6057 2 3 4 6 8
351..................................... 2 2.5000 2 2 3 3 3
352..................................... 541 3.9279 1 1 3 5 8
353..................................... 2701 8.3425 3 4 6 9 16
354..................................... 9931 5.9823 3 3 5 7 10
355..................................... 5561 3.6306 2 3 3 4 5
356..................................... 29723 2.8078 1 2 3 3 4
357..................................... 6569 9.3230 4 5 7 11 17
358..................................... 28651 4.4698 2 3 4 5 7
359..................................... 28099 3.0940 2 2 3 4 4
[[Page 30006]]
360..................................... 18115 3.2832 1 2 3 4 5
361..................................... 671 3.6692 1 1 2 4 8
362..................................... 1 1.0000 1 1 1 1 1
363..................................... 3892 3.4740 1 2 2 3 7
364..................................... 1856 3.4984 1 1 2 4 7
365..................................... 2435 7.1647 1 2 4 9 16
366..................................... 4449 7.0094 1 3 5 9 15
367..................................... 541 2.9704 1 1 2 4 6
368..................................... 2377 6.2680 2 3 5 8 12
369..................................... 2363 3.4435 1 1 2 4 7
370..................................... 1170 5.5453 2 3 4 5 9
371..................................... 1054 3.5911 2 3 3 4 5
372..................................... 876 3.1199 1 2 2 3 5
373..................................... 3973 2.0194 1 1 2 2 3
374..................................... 152 2.9474 1 2 2 3 4
375..................................... 7 8.4286 1 2 5 9 15
376..................................... 214 3.2710 1 1 2 4 7
377..................................... 49 4.1224 1 1 2 4 9
378..................................... 187 2.6578 1 2 2 3 4
379..................................... 358 2.9609 1 1 2 3 5
380..................................... 96 1.8333 1 1 1 2 4
381..................................... 178 2.2022 1 1 1 2 4
382..................................... 47 1.3404 1 1 1 1 2
383..................................... 1583 3.8111 1 2 3 5 8
384..................................... 132 2.9318 1 1 2 3 6
385..................................... 5 4.6000 1 1 2 4 15
389..................................... 24 7.1667 3 3 5 10 13
390..................................... 13 5.3077 2 3 4 7 7
392..................................... 2532 10.5517 4 5 8 13 21
393..................................... 2 11.0000 7 7 15 15 15
394..................................... 1791 7.4199 1 2 5 8 16
395..................................... 67638 4.9800 1 2 4 6 10
396..................................... 19 4.2632 1 1 3 7 7
397..................................... 16823 5.7741 1 2 4 7 11
398..................................... 18282 6.2511 2 3 5 8 11
399..................................... 1299 4.0154 1 2 3 5 8
400..................................... 7810 9.7049 2 3 7 12 21
401..................................... 6739 11.6630 2 5 9 15 24
402..................................... 1499 4.2368 1 1 3 6 9
403..................................... 38891 8.5771 2 3 6 11 18
404..................................... 3799 4.6594 1 2 4 6 9
406..................................... 3452 10.0200 3 4 7 13 21
407..................................... 699 4.4120 1 2 4 6 8
408..................................... 2840 7.6835 1 2 5 9 18
409..................................... 5557 5.9152 2 3 4 6 12
410..................................... 74223 3.3541 1 2 3 4 5
411..................................... 33 2.3030 1 1 1 3 6
412..................................... 30 3.3667 1 1 2 5 7
413..................................... 8747 8.0088 2 3 6 10 16
414..................................... 727 4.5571 1 2 3 6 10
415..................................... 44505 14.8769 4 7 11 18 29
416..................................... 218588 7.6808 2 4 6 9 14
417..................................... 54 4.6111 1 2 4 6 9
418..................................... 20458 6.3064 2 3 5 8 12
419..................................... 14820 5.2356 2 3 4 6 10
420..................................... 2622 3.9714 1 2 3 5 7
421..................................... 10711 4.2451 1 2 3 5 8
422..................................... 84 3.9167 1 2 3 5 6
423..................................... 10805 7.9172 2 3 6 9 16
424..................................... 1925 16.6618 2 6 10 19 31
425..................................... 15459 4.3906 1 2 3 5 8
426..................................... 4692 5.2163 1 2 4 6 11
427..................................... 1679 5.2478 1 2 4 6 11
428..................................... 923 7.6111 1 3 5 9 16
429..................................... 42295 7.8371 2 3 5 9 15
430..................................... 55585 9.0191 2 4 7 11 18
431..................................... 218 8.9037 2 3 5 9 17
432..................................... 404 5.8292 1 2 3 7 12
433..................................... 8177 3.2849 1 1 2 4 7
434..................................... 22419 5.2813 2 3 4 6 10
[[Page 30007]]
435..................................... 16398 4.5144 1 2 4 5 8
436..................................... 3530 13.7382 4 8 13 20 26
437..................................... 15594 9.9086 4 6 9 13 18
439..................................... 1041 8.4476 1 3 6 10 18
440..................................... 4797 9.4951 2 3 6 11 20
441..................................... 604 3.4619 1 1 2 4 7
442..................................... 15541 8.2678 1 3 6 10 17
443..................................... 2981 3.3603 1 1 2 4 7
444..................................... 3303 4.7802 1 2 4 6 9
445..................................... 1229 3.7079 1 1 3 4 6
447..................................... 4148 2.6437 1 1 2 3 5
448..................................... 29 1.0000 1 1 1 1 1
449..................................... 28622 4.0140 1 1 3 5 8
450..................................... 6263 2.2531 1 1 1 3 4
451..................................... 4 3.0000 1 1 1 2 8
452..................................... 21359 5.1382 1 2 4 6 10
453..................................... 3599 3.0889 1 1 2 4 6
454..................................... 3919 5.1832 1 2 3 6 10
455..................................... 884 2.7805 1 1 2 3 6
456..................................... 214 7.3178 1 1 3 8 16
457..................................... 111 4.8649 1 1 2 6 14
458..................................... 1652 15.9994 3 6 12 21 33
459..................................... 567 9.3210 2 4 7 12 19
460..................................... 2285 6.3422 1 3 5 8 13
461..................................... 3199 4.5552 1 1 2 5 11
462..................................... 9980 12.9722 4 6 11 17 24
463..................................... 13387 4.7746 1 2 4 6 9
464..................................... 3180 3.4299 1 2 3 4 7
465..................................... 215 3.7767 1 1 2 4 7
466..................................... 1750 4.7080 1 1 2 5 10
467..................................... 1582 4.2061 1 1 2 4 8
468..................................... 62754 13.9856 3 6 11 18 28
471..................................... 11592 6.7331 3 4 5 8 11
472..................................... 198 23.9192 1 5 18 34 56
473..................................... 8660 13.2808 2 4 7 19 34
475..................................... 100258 11.4467 2 5 9 15 22
476..................................... 6588 12.6252 3 7 11 16 23
477..................................... 29950 8.0288 1 2 6 10 16
478..................................... 126594 7.6907 1 3 6 10 16
479..................................... 17890 4.1892 1 2 3 5 8
480..................................... 513 27.1598 9 12 19 34 58
481..................................... 150 33.5333 19 23 30 41 54
482..................................... 6981 13.4369 5 7 10 15 24
483..................................... 39458 42.8906 14 22 34 52 78
484..................................... 382 15.3822 3 7 11 20 30
485..................................... 3406 10.4055 4 5 8 12 20
486..................................... 2358 13.1768 1 5 10 17 27
487..................................... 4134 8.1265 2 3 6 10 16
488..................................... 1737 16.4531 4 7 12 20 32
489..................................... 18692 9.5287 2 4 7 12 20
490..................................... 5357 6.0062 1 2 4 7 12
491..................................... 10675 3.9154 2 2 3 4 7
492..................................... 2207 17.8691 4 5 14 28 37
493..................................... 56437 5.6673 1 2 4 7 11
494..................................... 24927 2.3773 1 1 2 3 5
495..................................... 117 17.1197 8 11 15 21 30
----------------
11086740
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 7B.--Medicare Prospective Payment System; Selected Percentile Lengths of Stay
[FY96 MEDPAR Update 12/96 Grouper V15.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number Arithmetic 10th 25th 50th 75th 90th
DRG discharges mean LOS percentile percentile percentile percentile percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1....................................... 36587 10.0378 2 4 7 13 21
2....................................... 6771 10.5860 3 5 8 13 21
3....................................... 1 1.0000 1 1 1 1 1
4....................................... 6231 8.4710 2 3 6 10 18
[[Page 30008]]
5....................................... 102519 3.9306 1 2 3 4 8
6....................................... 417 3.2590 1 1 2 4 7
7....................................... 12033 11.5494 2 5 8 13 21
8....................................... 2346 3.5904 1 1 2 5 8
9....................................... 1716 7.0752 1 3 5 9 14
10...................................... 20105 7.2766 2 3 5 9 15
11...................................... 2931 4.2610 1 2 3 6 9
12...................................... 25980 6.8468 2 3 5 8 13
13...................................... 6321 5.7765 2 3 5 7 10
14...................................... 374962 6.7449 2 3 5 8 13
15...................................... 145044 4.0652 1 2 3 5 7
16...................................... 14000 6.0985 2 3 5 7 11
17...................................... 3087 3.7036 1 2 3 5 7
18...................................... 25611 5.8649 2 3 4 7 11
19...................................... 7093 4.1081 1 2 3 5 8
20...................................... 6049 10.5016 2 5 8 14 21
21...................................... 1178 7.0976 2 3 5 9 14
22...................................... 2888 4.7666 2 2 4 6 9
23...................................... 6027 4.5603 1 2 3 6 9
24...................................... 57786 5.3375 1 2 4 6 10
25...................................... 22109 3.6065 1 2 3 4 7
26...................................... 45 4.9111 1 2 4 6 11
27...................................... 3806 5.5008 1 1 3 7 13
28...................................... 12739 6.3365 1 3 4 8 13
29...................................... 4009 3.7381 1 2 3 5 7
31...................................... 3088 4.8374 1 2 3 6 9
32...................................... 1441 3.0743 1 1 2 3 6
34...................................... 18454 5.8051 1 3 4 7 11
35...................................... 3693 3.9163 1 2 3 5 7
36...................................... 6707 1.5408 1 1 1 2 2
37...................................... 1756 3.9169 1 1 3 4 8
38...................................... 196 2.7041 1 1 2 3 5
39...................................... 2546 2.0000 1 1 1 2 4
40...................................... 2520 3.3218 1 1 2 4 7
42...................................... 5401 1.9867 1 1 1 2 4
43...................................... 111 3.9910 1 2 3 5 7
44...................................... 1463 5.2160 2 3 4 7 9
45...................................... 2342 3.5956 1 2 3 5 7
46...................................... 3043 4.8478 1 2 4 6 9
47...................................... 1198 3.9307 1 1 3 4 7
49...................................... 2364 5.2563 1 2 4 6 10
50...................................... 3268 2.1068 1 1 2 2 3
51...................................... 348 2.8908 1 1 2 3 6
52...................................... 107 3.1589 1 1 2 3 7
53...................................... 3140 3.6080 1 1 2 4 8
54...................................... 2 5.0000 1 1 9 9 9
55...................................... 1876 2.9302 1 1 2 3 6
56...................................... 729 2.8299 1 1 2 3 6
57...................................... 620 3.9935 1 2 2 5 8
58...................................... 1 2.0000 2 2 2 2 2
59...................................... 103 3.1262 1 1 2 4 6
60...................................... 3 1.0000 1 1 1 1 1
61...................................... 241 4.5726 1 1 3 5 11
63...................................... 3732 4.6072 1 2 3 5 9
64...................................... 3341 6.6417 1 2 5 8 14
65...................................... 29330 3.1723 1 2 3 4 6
66...................................... 6560 3.4703 1 2 3 4 6
67...................................... 492 3.8049 1 2 3 5 7
68...................................... 10182 4.3274 2 2 4 5 8
69...................................... 2937 3.4705 1 2 3 4 6
70...................................... 40 3.3000 1 2 3 4 5
71...................................... 128 3.9297 1 2 3 5 7
72...................................... 734 3.4728 1 2 3 4 7
73...................................... 6210 4.6697 1 2 4 6 9
74...................................... 4 3.2500 1 1 2 3 7
75...................................... 40911 10.5412 4 5 8 13 20
76...................................... 41032 11.7128 3 6 9 14 22
77...................................... 2178 5.0987 1 2 4 7 10
78...................................... 30980 7.6317 3 5 7 9 13
79...................................... 238095 8.6329 3 4 7 11 16
[[Page 30009]]
80...................................... 8060 6.0504 2 3 5 7 11
81...................................... 6 6.8333 3 5 6 7 7
82...................................... 70681 7.3182 2 3 6 9 14
83...................................... 7334 5.8951 2 3 5 7 11
84...................................... 1480 3.4696 1 2 3 4 6
85...................................... 20681 6.8720 2 3 5 9 13
86...................................... 1375 4.0429 1 2 3 5 8
87...................................... 67349 6.4330 1 3 5 8 12
88...................................... 359037 5.6532 2 3 5 7 10
89...................................... 428964 6.5605 3 4 5 8 12
90...................................... 36711 4.6673 2 3 4 6 8
91...................................... 40 4.3750 2 3 4 5 9
92...................................... 13520 6.6271 2 3 5 8 12
93...................................... 1160 4.6147 1 2 4 6 8
94...................................... 13679 6.6439 2 3 5 8 13
95...................................... 1419 3.9831 1 2 3 5 7
96...................................... 58934 5.0552 2 3 4 6 9
97...................................... 23955 3.9986 1 2 3 5 7
98...................................... 22 3.8182 1 1 2 4 10
99...................................... 26526 3.1692 1 1 2 4 6
100..................................... 10188 2.2330 1 1 2 3 4
101..................................... 20410 4.7228 1 2 4 6 9
102..................................... 4491 2.8940 1 1 2 4 5
103..................................... 511 47.3190 9 15 32 71 104
104..................................... 26161 13.3467 5 8 11 16 24
105..................................... 22856 10.1918 5 6 8 12 18
106..................................... 106944 11.0508 6 7 9 13 18
107..................................... 68187 8.3051 5 6 7 9 13
108..................................... 7497 12.1122 4 7 10 15 23
110..................................... 63208 10.0765 3 6 8 12 19
111..................................... 5547 6.1031 2 4 6 7 9
112..................................... 142252 4.2152 1 2 3 6 8
113..................................... 47795 13.1200 4 6 9 16 26
114..................................... 9030 8.8270 2 4 7 11 17
115..................................... 13707 9.2228 2 4 8 12 18
116..................................... 160542 4.6957 1 2 4 6 9
117..................................... 3723 4.0285 1 1 3 5 9
118..................................... 6649 3.0284 1 1 2 4 7
119..................................... 1684 5.1081 1 1 3 7 11
120..................................... 39395 8.4464 1 2 5 11 19
121..................................... 170653 6.9325 2 4 6 9 12
122..................................... 85992 4.5068 1 2 4 6 8
123..................................... 45937 4.4685 1 1 2 6 11
124..................................... 152452 4.5929 1 2 4 6 9
125..................................... 60687 2.9374 1 1 2 4 6
126..................................... 5118 12.8009 4 6 10 16 26
127..................................... 705314 5.7996 2 3 5 7 11
128..................................... 18459 6.3467 3 4 6 7 10
129..................................... 4441 3.1678 1 1 1 3 7
130..................................... 99436 6.2969 2 4 5 8 11
131..................................... 25388 4.8483 1 3 5 6 8
132..................................... 164155 3.3160 1 2 3 4 6
133..................................... 6111 2.8053 1 1 2 3 5
134..................................... 29371 3.6005 1 2 3 4 7
135..................................... 8055 4.4431 1 2 3 5 8
136..................................... 1146 3.0689 1 1 2 4 6
137..................................... 3 9.0000 3 3 8 16 16
138..................................... 207593 4.1945 1 2 3 5 8
139..................................... 65375 2.7460 1 1 2 3 5
140..................................... 134325 3.1700 1 2 3 4 6
141..................................... 78304 4.0837 1 2 3 5 7
142..................................... 35576 2.9415 1 1 2 4 5
143..................................... 137087 2.3957 1 1 2 3 4
144..................................... 75955 5.3738 1 2 4 7 11
145..................................... 6306 2.9802 1 1 2 4 6
146..................................... 9812 10.5317 6 7 9 12 17
147..................................... 1663 6.9056 4 5 7 8 10
148..................................... 148695 12.6142 6 7 10 15 22
149..................................... 14197 7.1277 4 5 7 8 10
150..................................... 24394 11.1136 4 7 9 14 20
[[Page 30010]]
151..................................... 4227 6.1091 2 3 6 8 11
152..................................... 4685 8.4886 4 5 7 10 14
153..................................... 1634 5.7778 3 4 6 7 9
154..................................... 34916 14.0359 4 7 11 17 27
155..................................... 4502 5.0060 2 2 4 7 9
156..................................... 2 18.0000 5 5 31 31 31
157..................................... 9423 5.6030 1 2 4 7 11
158..................................... 4325 2.7866 1 1 2 4 6
159..................................... 18159 5.0739 1 2 4 6 10
160..................................... 9496 2.7724 1 1 2 4 5
161..................................... 14885 4.2146 1 2 3 5 9
162..................................... 7335 2.0907 1 1 1 3 4
163..................................... 10 4.7000 1 1 2 8 10
164..................................... 5342 8.7142 4 5 7 10 15
165..................................... 1579 5.3889 2 3 5 7 8
166..................................... 3344 5.4342 2 3 4 7 10
167..................................... 2245 2.9617 1 2 3 4 5
168..................................... 1816 4.7015 1 2 3 6 9
169..................................... 907 2.5480 1 1 2 3 5
170..................................... 12921 11.7454 2 5 9 15 23
171..................................... 1051 5.1246 1 2 4 6 10
172..................................... 32809 7.3996 2 3 5 9 15
173..................................... 2065 3.9467 1 2 3 5 8
174..................................... 238825 5.1461 2 3 4 6 9
175..................................... 21268 3.2303 1 2 3 4 6
176..................................... 17835 5.7613 2 3 4 7 11
177..................................... 11794 4.7272 2 3 4 6 8
178..................................... 3711 3.3393 1 2 3 4 6
179..................................... 12071 6.7278 2 3 5 8 13
180..................................... 88763 5.6576 2 3 4 7 11
181..................................... 21194 3.6978 1 2 3 5 7
182..................................... 237775 4.5664 1 2 4 6 8
183..................................... 69353 3.1731 1 2 3 4 6
184..................................... 84 3.6548 1 2 3 4 7
185..................................... 4091 4.8238 1 2 4 6 10
186..................................... 2 3.0000 2 2 4 4 4
187..................................... 869 3.9298 1 2 3 5 7
188..................................... 70432 5.7809 1 3 4 7 11
189..................................... 7853 3.3748 1 1 3 4 7
190..................................... 93 4.9247 1 2 3 5 12
191..................................... 11046 14.8284 4 7 11 18 29
192..................................... 775 7.1381 2 4 6 9 13
193..................................... 8318 12.9221 5 7 11 16 23
194..................................... 657 7.4247 2 4 6 9 13
195..................................... 8720 9.8580 4 6 8 12 17
196..................................... 622 6.3344 3 4 6 8 10
197..................................... 27180 8.7010 3 5 7 10 15
198..................................... 7031 4.7165 2 3 4 6 8
199..................................... 2148 10.6909 3 5 8 14 22
200..................................... 1535 11.3759 2 4 8 14 23
201..................................... 1540 14.9247 4 7 11 18 29
202..................................... 28333 7.0992 2 3 5 9 14
203..................................... 29347 7.1592 2 3 6 9 14
204..................................... 52863 6.3342 2 3 5 8 12
205..................................... 22950 6.7923 2 3 5 8 14
206..................................... 1650 4.2218 1 2 3 5 8
207..................................... 36763 5.2874 1 2 4 7 10
208..................................... 9874 3.0353 1 1 2 4 6
209..................................... 356581 5.8918 3 4 5 7 9
210..................................... 142751 7.6248 4 5 6 9 13
211..................................... 26179 5.6064 3 4 5 7 9
212..................................... 9 5.5556 2 3 3 5 6
213..................................... 7121 8.7182 2 4 7 11 17
216..................................... 6357 10.2902 2 4 8 13 21
217..................................... 20641 13.7099 3 5 9 17 29
218..................................... 24494 5.6207 2 3 4 7 10
219..................................... 18726 3.4427 1 2 3 4 6
220..................................... 5 4.2000 1 1 4 4 10
223..................................... 19460 2.7002 1 1 2 3 5
224..................................... 8049 2.1070 1 1 2 3 4
[[Page 30011]]
225..................................... 5842 4.6251 1 2 3 6 10
226..................................... 5512 6.2509 1 2 4 7 13
227..................................... 4323 2.8543 1 1 2 3 5
228..................................... 2967 3.4553 1 1 2 4 7
229..................................... 1216 2.3528 1 1 2 3 4
230..................................... 2473 4.9713 1 2 3 6 10
231..................................... 10931 4.7553 1 2 3 6 10
232..................................... 553 4.2405 1 1 2 5 10
233..................................... 4689 8.2457 2 3 6 10 16
234..................................... 2164 3.8812 1 2 3 5 8
235..................................... 5523 5.8175 1 3 4 6 11
236..................................... 39703 5.5917 2 3 4 7 10
237..................................... 1658 4.1978 1 2 3 5 8
238..................................... 7601 9.3428 3 4 7 11 17
239..................................... 60382 6.9698 2 3 5 8 13
240..................................... 13253 6.9292 2 3 5 8 14
241..................................... 2987 4.2266 1 2 3 5 8
242..................................... 2825 7.1487 2 3 5 9 14
243..................................... 80144 5.1231 2 3 4 6 9
244..................................... 12434 5.3963 1 3 4 6 10
245..................................... 4379 4.0877 1 2 3 5 7
246..................................... 1267 4.2447 1 2 3 5 8
247..................................... 11435 3.6810 1 2 3 5 7
248..................................... 7377 4.9753 1 2 4 6 9
249..................................... 10332 3.9334 1 1 3 5 8
250..................................... 3605 4.6624 1 2 3 5 9
251..................................... 2135 3.0070 1 1 2 4 5
253..................................... 19016 5.2421 1 3 4 6 10
254..................................... 9279 3.5245 1 2 3 4 6
256..................................... 4420 5.6344 1 2 4 7 11
257..................................... 22633 3.2019 1 2 3 4 6
258..................................... 16953 2.2778 1 1 2 3 4
259..................................... 3995 3.1975 1 1 2 3 7
260..................................... 4550 1.6642 1 1 1 2 3
261..................................... 2214 2.2344 1 1 2 3 4
262..................................... 659 4.0030 1 1 3 5 8
263..................................... 29116 12.4972 3 5 9 15 24
264..................................... 3348 7.2694 2 3 6 9 14
265..................................... 4140 7.1005 1 2 5 8 14
266..................................... 2554 3.5717 1 1 2 5 7
267..................................... 223 4.1839 1 1 2 5 9
268..................................... 936 3.5716 1 1 2 4 7
269..................................... 10077 8.5158 2 3 6 11 17
270..................................... 3072 3.1953 1 1 2 4 7
271..................................... 22910 7.7195 3 4 6 9 14
272..................................... 5990 6.6751 2 3 5 8 13
273..................................... 1385 5.3682 1 2 4 6 11
274..................................... 2618 7.1176 1 3 5 9 15
275..................................... 240 3.8042 1 1 2 5 8
276..................................... 939 4.7444 1 3 4 6 8
277..................................... 80128 6.2324 2 3 5 7 11
278..................................... 24698 4.8226 2 3 4 6 8
279..................................... 4 4.5000 2 2 2 6 8
280..................................... 13930 4.7090 1 2 3 6 9
281..................................... 5886 3.3819 1 1 3 4 6
282..................................... 1 1.0000 1 1 1 1 1
283..................................... 5284 5.0157 1 2 4 6 10
284..................................... 1745 3.5415 1 2 3 5 7
285..................................... 5591 12.0757 3 5 9 15 23
286..................................... 2071 7.2038 3 4 5 8 13
287..................................... 6659 12.2050 3 5 8 14 24
288..................................... 1201 5.8485 3 4 5 6 9
289..................................... 5476 3.4830 1 1 2 3 7
290..................................... 8792 2.5875 1 1 2 3 4
291..................................... 94 2.1596 1 1 2 3 4
292..................................... 5173 11.2101 2 4 8 14 22
293..................................... 271 5.8782 1 2 4 7 12
294..................................... 83789 5.2505 2 3 4 6 10
295..................................... 3687 4.0966 1 2 3 5 8
296..................................... 231836 5.7562 2 3 4 7 11
[[Page 30012]]
297..................................... 31640 3.8523 1 2 3 5 7
298..................................... 95 2.5263 1 1 2 3 5
299..................................... 1130 5.4823 1 2 4 7 11
300..................................... 15620 6.6238 2 3 5 8 13
301..................................... 1968 4.3664 1 2 3 5 8
302..................................... 7967 10.9728 5 6 8 13 19
303..................................... 19228 9.4496 4 5 8 11 17
304..................................... 13039 9.5748 2 4 7 11 19
305..................................... 2442 4.3276 1 2 4 5 8
306..................................... 11607 5.7509 1 2 4 7 12
307..................................... 2482 2.5363 1 1 2 3 4
308..................................... 9610 6.4318 1 2 4 8 13
309..................................... 3296 2.5713 1 1 2 3 5
310..................................... 27425 4.3364 1 2 3 5 9
311..................................... 8487 2.0526 1 1 2 2 4
312..................................... 1870 4.6904 1 2 3 6 10
313..................................... 664 2.2651 1 1 2 3 4
315..................................... 28343 8.5525 1 2 5 11 19
316..................................... 84582 6.9972 2 3 5 9 14
317..................................... 841 2.9441 1 1 2 3 6
318..................................... 6162 6.6386 1 3 5 8 13
319..................................... 421 2.8005 1 1 2 4 6
320..................................... 175993 5.8700 2 3 5 7 10
321..................................... 23410 4.2695 2 3 4 5 7
322..................................... 88 4.1023 2 2 3 4 7
323..................................... 17373 3.3754 1 1 2 4 7
324..................................... 7970 2.0041 1 1 2 2 4
325..................................... 7001 4.1964 1 2 3 5 8
326..................................... 2116 2.8767 1 1 2 3 5
327..................................... 15 3.4667 1 1 2 3 12
328..................................... 674 3.9139 1 2 3 5 8
329..................................... 106 2.3491 1 1 2 3 5
331..................................... 43957 5.8366 2 3 4 7 11
332..................................... 4414 3.5353 1 1 3 5 7
333..................................... 352 5.6733 1 2 4 7 12
334..................................... 19282 5.4196 3 4 5 6 8
335..................................... 9747 4.0557 2 3 4 5 6
336..................................... 59009 3.7607 1 2 3 4 7
337..................................... 34107 2.4150 1 2 2 3 4
338..................................... 3724 5.0709 1 2 3 6 11
339..................................... 2118 4.5892 1 2 3 6 10
340..................................... 2 1.5000 1 1 2 2 2
341..................................... 5932 3.1123 1 1 2 3 6
342..................................... 192 4.1927 1 2 3 6 8
344..................................... 3517 3.1137 1 1 2 3 6
345..................................... 1357 3.7900 1 1 3 5 8
346..................................... 5156 6.2853 1 3 5 8 12
347..................................... 372 2.9624 1 1 2 4 6
348..................................... 3204 4.4978 1 2 3 5 8
349..................................... 741 2.6815 1 1 2 3 5
350..................................... 6300 4.6057 2 3 4 6 8
351..................................... 2 2.5000 2 2 3 3 3
352..................................... 541 3.9279 1 1 3 5 8
353..................................... 2701 8.3425 3 4 6 9 16
354..................................... 9927 5.9853 3 3 5 7 10
355..................................... 5565 3.6270 2 3 3 4 5
356..................................... 29685 2.8084 1 2 3 3 4
357..................................... 6569 9.3230 4 5 7 11 17
358..................................... 28653 4.4708 2 3 4 5 7
359..................................... 28097 3.0930 2 2 3 4 4
360..................................... 18115 3.2832 1 2 3 4 5
361..................................... 671 3.6692 1 1 2 4 8
362..................................... 1 1.0000 1 1 1 1 1
363..................................... 3892 3.4740 1 2 2 3 7
364..................................... 1856 3.4984 1 1 2 4 7
365..................................... 2435 7.1647 1 2 4 9 16
366..................................... 4452 7.0106 1 3 5 9 15
367..................................... 538 2.9387 1 1 2 4 6
368..................................... 2377 6.2680 2 3 5 8 12
369..................................... 2399 3.4239 1 1 2 4 7
[[Page 30013]]
370..................................... 1171 5.5448 2 3 4 5 9
371..................................... 1053 3.5897 2 3 3 4 5
372..................................... 876 3.1199 1 2 2 3 5
373..................................... 3973 2.0194 1 1 2 2 3
374..................................... 152 2.9474 1 2 2 3 4
375..................................... 7 8.4286 1 2 5 9 15
376..................................... 214 3.2710 1 1 2 4 7
377..................................... 49 4.1224 1 1 2 4 9
378..................................... 187 2.6578 1 2 2 3 4
379..................................... 358 2.9609 1 1 2 3 5
380..................................... 96 1.8333 1 1 1 2 4
381..................................... 178 2.2022 1 1 1 2 4
382..................................... 47 1.3404 1 1 1 1 2
383..................................... 1583 3.8111 1 2 3 5 8
384..................................... 132 2.9318 1 1 2 3 6
385..................................... 3 6.6667 1 1 4 15 15
389..................................... 16 6.2500 3 3 5 7 12
390..................................... 8 5.1250 2 2 3 5 7
392..................................... 2532 10.5517 4 5 8 13 21
393..................................... 2 11.0000 7 7 15 15 15
394..................................... 1791 7.4199 1 2 5 8 16
395..................................... 67648 4.9800 1 2 4 6 10
396..................................... 17 4.1176 1 1 2 7 7
397..................................... 16824 5.7741 1 2 4 7 11
398..................................... 18292 6.2478 2 3 5 8 11
399..................................... 1293 4.0162 1 2 3 5 8
400..................................... 7808 9.6883 2 3 7 12 21
401..................................... 6732 11.6693 2 5 9 15 24
402..................................... 1499 4.2368 1 1 3 6 9
403..................................... 38817 8.5440 2 3 6 11 17
404..................................... 3788 4.6378 1 2 4 6 9
406..................................... 3452 10.0200 3 4 7 13 21
407..................................... 699 4.4120 1 2 4 6 8
408..................................... 2838 7.6688 1 2 5 9 18
409..................................... 5558 5.9171 2 3 4 6 12
410..................................... 74218 3.3531 1 2 3 4 5
411..................................... 33 2.3030 1 1 1 3 6
412..................................... 30 3.3667 1 1 2 5 7
413..................................... 8746 8.0082 2 3 6 10 16
414..................................... 727 4.5571 1 2 3 6 10
415..................................... 44472 14.8801 4 7 11 18 29
416..................................... 218625 7.6812 2 4 6 9 14
417..................................... 41 4.3171 1 2 4 6 8
418..................................... 20458 6.3064 2 3 5 8 12
419..................................... 14836 5.2358 2 3 4 6 10
420..................................... 2606 3.9643 1 2 3 5 7
421..................................... 10712 4.2451 1 2 3 5 8
422..................................... 84 3.8690 1 2 3 5 5
423..................................... 10806 7.9174 2 3 6 9 16
424..................................... 1855 16.8313 2 6 10 19 31
425..................................... 15463 4.3916 1 2 3 5 8
426..................................... 4693 5.2169 1 2 4 6 11
427..................................... 1680 5.2494 1 2 4 6 11
428..................................... 923 7.6111 1 3 5 9 16
429..................................... 42341 7.8410 2 3 5 9 15
430..................................... 55603 9.0212 2 4 7 11 18
431..................................... 218 8.9037 2 3 5 9 17
432..................................... 404 5.8292 1 2 3 7 12
433..................................... 8182 3.2840 1 1 2 4 7
434..................................... 22447 5.2816 2 3 4 6 10
435..................................... 16417 4.5130 1 2 4 5 8
436..................................... 3531 13.7366 4 8 13 20 26
437..................................... 15598 9.9085 4 6 9 13 18
439..................................... 1041 8.4476 1 3 6 10 18
440..................................... 4797 9.4951 2 3 6 11 20
441..................................... 604 3.4619 1 1 2 4 7
442..................................... 15505 8.2772 1 3 6 10 17
443..................................... 2968 3.3632 1 1 2 4 7
444..................................... 3308 4.7830 1 2 4 6 9
445..................................... 1229 3.6998 1 1 3 4 6
[[Page 30014]]
447..................................... 4148 2.6437 1 1 2 3 5
448..................................... 29 1.0000 1 1 1 1 1
449..................................... 28641 4.0147 1 1 3 5 8
450..................................... 6265 2.2530 1 1 1 3 4
451..................................... 4 3.0000 1 1 1 2 8
452..................................... 21368 5.1393 1 2 4 6 10
453..................................... 3597 3.0770 1 1 2 4 6
454..................................... 3925 5.1827 1 2 3 6 10
455..................................... 892 2.7668 1 1 2 3 6
456..................................... 214 7.3178 1 1 3 8 16
457..................................... 111 4.8649 1 1 2 6 14
458..................................... 1652 15.9994 3 6 12 21 33
459..................................... 567 9.3210 2 4 7 12 19
460..................................... 2286 6.3408 1 3 5 8 13
461..................................... 3190 4.5564 1 1 2 5 11
462..................................... 9980 12.9722 4 6 11 17 24
463..................................... 13395 4.7779 1 2 4 6 9
464..................................... 3180 3.4145 1 2 3 4 7
465..................................... 215 3.7767 1 1 2 4 7
466..................................... 1751 4.7059 1 1 2 5 10
467..................................... 1583 4.2053 1 1 2 4 8
468..................................... 60012 14.0970 3 6 11 18 28
471..................................... 11592 6.7331 3 4 5 8 11
472..................................... 198 23.9192 1 5 18 34 56
473..................................... 8660 13.2826 2 4 7 19 34
475..................................... 100273 11.4470 2 5 9 15 22
476..................................... 6604 12.6364 3 7 11 16 23
477..................................... 29677 8.6003 1 3 6 11 18
478..................................... 126591 7.6914 1 3 6 10 16
479..................................... 17894 4.1872 1 2 3 5 8
480..................................... 388 24.2294 8 12 17 29 49
481..................................... 250 29.8760 17 21 26 36 50
482..................................... 6981 13.4369 5 7 10 15 24
483..................................... 39492 42.9069 14 22 34 52 78
484..................................... 382 15.3822 3 7 11 20 30
485..................................... 3406 10.4055 4 5 8 12 20
486..................................... 2298 13.2820 1 6 10 17 27
487..................................... 4186 8.1388 2 3 6 10 16
488..................................... 906 17.7770 4 7 13 22 37
489..................................... 19468 9.7616 2 4 7 12 20
490..................................... 5412 6.0458 1 2 4 7 12
491..................................... 10675 3.9154 2 2 3 4 7
492..................................... 2207 17.8691 4 5 14 28 37
493..................................... 56448 5.6678 1 2 4 7 11
494..................................... 24916 2.3746 1 1 2 3 5
495..................................... 87 17.3333 7 10 15 22 31
496..................................... 683 11.5344 4 6 9 13 22
497..................................... 19813 6.8081 2 4 5 8 12
498..................................... 10451 3.7528 1 2 3 5 7
499..................................... 37493 5.3005 2 3 4 6 10
500..................................... 34661 3.1298 1 2 3 4 6
501..................................... 2000 10.4195 4 5 8 12 19
502..................................... 3520 5.3301 2 3 4 6 10
503..................................... 3046 3.3700 1 2 3 4 6
----------------
11086638
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 8A.--Statewide Average Operating Cost-to-Charge Ratios for Urban
and Rural Hospitals (Case Weighted) April 1997
------------------------------------------------------------------------
State Urban Rural
------------------------------------------------------------------------
ALABAMA............................................... 0.400 0.449
ALASKA................................................ 0.517 0.778
ARIZONA............................................... 0.397 0.559
ARKANSAS.............................................. 0.541 0.491
CALIFORNIA............................................ 0.388 0.500
COLORADO.............................................. 0.486 0.609
CONNECTICUT........................................... 0.551 0.555
DELAWARE.............................................. 0.505 0.489
[[Page 30015]]
DISTRICT OF COLUMBIA.................................. 0.521 .......
FLORIDA............................................... 0.397 0.397
GEORGIA............................................... 0.508 0.510
HAWAII................................................ 0.458 0.528
IDAHO................................................. 0.557 0.618
ILLINOIS.............................................. 0.474 0.585
INDIANA............................................... 0.559 0.596
IOWA.................................................. 0.529 0.665
KANSAS................................................ 0.447 0.652
KENTUCKY.............................................. 0.503 0.529
LOUISIANA............................................. 0.469 0.531
MAINE................................................. 0.619 0.576
MARYLAND.............................................. 0.764 0.815
MASSACHUSETTS......................................... 0.557 0.597
MICHIGAN.............................................. 0.485 0.585
MINNESOTA............................................. 0.566 0.629
MISSISSIPPI........................................... 0.524 0.522
MISSOURI.............................................. 0.445 0.531
MONTANA............................................... 0.485 0.602
NEBRASKA.............................................. 0.495 0.660
NEVADA................................................ 0.339 0.516
NEW HAMPSHIRE......................................... 0.574 0.598
NEW JERSEY............................................ 0.458 .......
NEW MEXICO............................................ 0.466 0.537
NEW YORK.............................................. 0.569 0.654
NORTH CAROLINA........................................ 0.534 0.475
NORTH DAKOTA.......................................... 0.650 0.673
OHIO.................................................. 0.551 0.593
OKLAHOMA.............................................. 0.477 0.552
OREGON................................................ 0.585 0.638
PENNSYLVANIA.......................................... 0.410 0.540
PUERTO RICO........................................... 0.477 0.521
RHODE ISLAND.......................................... 0.577 .......
SOUTH CAROLINA........................................ 0.474 0.496
SOUTH DAKOTA.......................................... 0.542 0.639
TENNESSEE............................................. 0.532 0.557
TEXAS................................................. 0.445 0.557
UTAH.................................................. 0.596 0.639
VERMONT............................................... 0.610 0.566
VIRGINIA.............................................. 0.494 0.510
WASHINGTON............................................ 0.663 0.666
WEST VIRGINIA......................................... 0.599 0.545
WISCONSIN............................................. 0.597 0.648
WYOMING............................................... 0.514 0.751
------------------------------------------------------------------------
Table 8B.--Statewide Average Capital Cost-to-Charge Ratios (Case
Weighted) April 1997
------------------------------------------------------------------------
State Ratio
------------------------------------------------------------------------
ALABAMA........................................................ 0.054
ALASKA......................................................... 0.073
ARIZONA........................................................ 0.047
ARKANSAS....................................................... 0.055
CALIFORNIA..................................................... 0.040
COLORADO....................................................... 0.055
CONNECTICUT.................................................... 0.039
DELAWARE....................................................... 0.056
DISTRICT OF COLUMBIA........................................... 0.040
FLORIDA........................................................ 0.047
GEORGIA........................................................ 0.048
HAWAII......................................................... 0.046
IDAHO.......................................................... 0.055
ILLINOIS....................................................... 0.044
INDIANA........................................................ 0.059
IOWA........................................................... 0.055
KANSAS......................................................... 0.057
KENTUCKY....................................................... 0.054
LOUISIANA...................................................... 0.068
MAINE.......................................................... 0.045
MARYLAND....................................................... 0.013
MASSACHUSETTS.................................................. 0.063
MICHIGAN....................................................... 0.048
MINNESOTA...................................................... 0.057
MISSISSIPPI.................................................... 0.055
MISSOURI....................................................... 0.051
MONTANA........................................................ 0.058
NEBRASKA....................................................... 0.057
NEVADA......................................................... 0.033
NEW HAMPSHIRE.................................................. 0.067
NEW JERSEY..................................................... 0.045
NEW MEXICO..................................................... 0.053
NEW YORK....................................................... 0.054
NORTH CAROLINA................................................. 0.049
NORTH DAKOTA................................................... 0.074
OHIO........................................................... 0.055
OKLAHOMA....................................................... 0.056
OREGON......................................................... 0.054
PENNSYLVANIA................................................... 0.042
PUERTO RICO.................................................... 0.090
RHODE ISLAND................................................... 0.038
SOUTH CAROLINA................................................. 0.055
SOUTH DAKOTA................................................... 0.061
TENNESSEE...................................................... 0.056
TEXAS.......................................................... 0.053
UTAH........................................................... 0.058
VERMONT........................................................ 0.053
VIRGINIA....................................................... 0.058
WASHINGTON..................................................... 0.067
WEST VIRGINIA.................................................. 0.055
WISCONSIN...................................................... 0.048
WYOMING........................................................ 0.065
------------------------------------------------------------------------
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 Social Security 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 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 prospective payment system is to
create incentives for hospitals to operate efficiently and minimize
unnecessary costs while at the same time ensuring that payments are
sufficient to adequately compensate hospitals for their legitimate
costs. In addition, we share national goals of deficit reduction and
restraints on government spending in general.
We believe the proposed changes would further each of these
goals while maintaining the financial viability of the hospital
industry and ensuring access to high quality health care for
Medicare beneficiaries. We expect that these proposed changes would
ensure that the outcomes of this payment system are reasonable and
equitable while avoiding or minimizing unintended adverse
consequences.
III. Limitations of Our Analysis
As has been the case in previously published regulatory impact
analyses, the following quantitative analysis presents the projected
effects of our proposed policy changes, as well as statutory changes
effective for FY 1998, 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 April 1997, we have
included 5,087
[[Page 30016]]
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 proposed policy
changes on these hospitals are discussed below.
V. Impact on Excluded Hospitals and Units
As of April 1997, there were 1,118 specialty hospitals excluded
from the prospective payment system and instead paid on a reasonable
cost basis subject to the rate-of-increase ceiling under
Sec. 413.40. In addition, there were 2,346 psychiatric and
rehabilitation units in hospitals otherwise subject to the
prospective payment system. These excluded units are also paid in
accordance with Sec. 413.40.
In accordance with section 1886(b)(3)(B) of the Act, the update
factor applicable to the rate-of-increase limit for excluded
hospitals and units for FY 1998 would be 2.8 percent (the excluded
hospital market basket).
The impact on excluded hospitals and units of the proposed
update in the rate-of-increase limit depends on the cumulative cost
increases experienced by each excluded hospital 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.
In this context, we note that, under Sec. 413.40(d)(3), an
excluded hospital or unit whose costs exceed the rate-of-increase
limit is allowed to receive its rate-of-increase limit plus 50
percent of reasonable costs in excess of the limit, not to exceed
110 percent of its limit. In addition, under the various provisions
set forth in Sec. 413.40, 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.
We are proposing to extend certain exclusion criteria that
currently apply only to long-term care hospitals to all other
categories of excluded facilities. These criteria define a minimum
level of independence and separate control that a facility must have
in order to be excluded as a ``hospital within a hospital.'' We
expect that this provision will result in a very small decrease in
aggregate payment levels (other things being equal) by, for example,
preventing new hospital units from inappropriately qualifying for
the exemption from the-rate-of-increase ceiling that is available
only to new hospitals. To our knowledge, there are fewer than 50
facilities that would be affected by this proposal. We welcome
comments on this aspect of the impact analysis.
VI. Quantitative Impact Analysis of the Proposed Policy Changes Under
the Prospective Payment System for Operating Costs
A. Basis and Methodology of Estimates
In this proposed rule, we are announcing policy changes and
payment rate updates for the prospective payment systems for
operating and capital-related costs. We have prepared separate
analyses of the proposed changes to each system. 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 1996 MedPAR file and the most current
provider-specific file that is used for payment purposes. Although
the analyses of the changes to the operating prospective payment
system do not incorporate cost data, the most recently available
hospital cost report data were used to create some of the variables
by which hospitals are categorized. Our analysis has several
qualifications. First, we do not make adjustments for behavioral
changes that hospitals may adopt in response to these proposed
policy changes. Second, due to the interdependent nature of the
prospective payment system, it is very difficult to precisely
quantify the impact associated with each proposed change. Third, we
draw upon various sources for the data used to categorize hospitals
in the tables. In some cases, particularly the number of beds, there
is a fair degree of variation in the data from different sources. We
have attempted to construct these variables with the best available
source overall. For individual hospitals, however, some
miscategorizations are possible.
Using cases in the FY 1996 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 1998 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 1994 data).
The effects of implementing the Puerto Rico-specific
wage index to be applied to the Puerto Rico standardized amounts.
The effects of completing the phase-out of payments for
extraordinarily lengthy cases (day outlier cases) with a
corresponding increase in payments for extraordinarily costly cases
(cost outliers), in accordance with section 1886(d)(5)(A)(v) of the
Act.
The effects of geographic reclassifications by the
MGCRB that will be effective in FY 1998.
The total change in payments based on FY 1998 policies
relative to payments based on FY 1997 policies.
To illustrate the impacts of the FY 1998 proposed changes, our
analysis begins with a FY 1998 baseline simulation model using: the
FY 1997 GROUPER (version 14.0); the FY 1997 wage index; national
wage index values applied to the Puerto Rico standardized amounts;
FY 1997 outlier policy (75 percent phase-out of day outlier
payments); and no MGCRB reclassifications. Outlier payments are set
at 5.1 percent of total DRG payments.
Each proposed and statutory policy change is then added
incrementally to this baseline model, finally arriving at an FY 1998
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 1997 to FY 1998. Three factors have significant
impacts here. First is the update to the standardized amounts. In
accordance with section 1886(d)(3)(A)(iv) of the Act, we are
proposing to update the large urban and the other areas average
standardized amounts for FY 1998 using the most recently forecasted
hospital market basket increase for FY 1998 of 2.8 percent.
Similarly, section 1886(b)(3)(C)(ii) of the Act provides that the
update factor applicable to the hospital-specific rates for sole
community hospitals (SCHs) and essential access community hospitals
(EACHs) (which are treated as SCHs for payment purposes) is equal to
the market basket increase of 2.8 percent.
A second significant factor impacting changes in hospitals'
payments per case from FY 1997 to FY 1998 is a change in MGCRB
reclassification status from one year to the next. That is,
hospitals reclassified in FY 1997 that are no longer reclassified in
FY 1998 may have a negative payment impact going from FY 1997 to FY
1998; conversely, hospitals not reclassified in FY 1997 that are
reclassified in FY 1998 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 actual
outlier payments during FY 1997 will be 4.9 percent of actual total
DRG payments. When the FY 1997 final rule was published, we
projected FY 1997 outlier payments would be 5.1 percent of total DRG
payments, and the standardized amounts were reduced correspondingly.
The effects of the slightly lower than expected outlier payments
during FY 1997 (as discussed in the Addendum to this proposed rule)
are reflected in the analyses below
[[Page 30017]]
comparing our current estimates of FY 1997 payments per case to
estimated FY 1998 payments per case.
Table I demonstrates the results of our analysis. The table
categorizes hospitals by various geographic and special payment
consideration groups to illustrate the varying impacts on different
types of hospitals. The top row of the table shows the overall
impact on the 5,087 hospitals included in the analysis. This is 42
fewer hospitals than were included in the impact analysis in the FY
1997 final rule (61 FR 46305). Data for 82 hospitals that were
included in last year's analysis were not available for analysis
this year; however, data were available this year for 40 hospitals
for which data were not available last year.
The next four rows of Table I contain hospitals categorized
according to their geographic location (all urban, which is further
divided into large urban and other urban, or rural). There are 2,857
hospitals located in urban areas (MSAs or NECMAs) included in our
analysis. Among these, there are 1,580 hospitals located in large
urban areas (populations over 1 million), and 1,277 hospitals in
other urban areas (populations of 1 million or fewer). In addition,
there are 2,230 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 1998 payment classifications, including any
reclassifications under section 1886(d)(10) of the Act. For example,
the rows labeled urban, large urban, other urban, and rural show the
numbers of hospitals being paid based on these categorizations
(after consideration of geographic reclassifications) are 2,949,
1,733, 1,216, and 2,138, 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),
receive DSH payments, or some combination of these two adjustments.
There are 3,996 nonteaching hospitals in our analysis, 849 teaching
hospitals with fewer than 100 residents, and 242 teaching hospitals
with 100 or more residents.
In the DSH categories, hospitals are grouped according to their
DSH payment status, and whether they are considered urban or rural
after MGCRB reclassifications. Hospitals in the rural DSH
categories, therefore, represent hospitals that were not
reclassified for purposes of the standardized amount. (They may,
however, have been reclassified for purposes of the wage index.) The
next category groups hospitals considered urban after geographic
reclassification, in terms of whether they receive the IME
adjustment, the DSH adjustment, both, or neither.
The next four rows examine the impacts of the proposed changes
on rural hospitals by special payment groups (SCHs, rural referral
centers (RRCs), and EACHs), as well as rural hospitals not receiving
a special payment designation. The RRCs (95), SCH/EACHs (651), and
SCH/EACH and RRCs (41) shown here were not reclassified for purposes
of the standardized amount. There are four SCHs that will be
reclassified for the standardized amount in FY 1998 that, therefore,
are not included in these rows. There are eight EACHs included in
our analysis and five EACH/RRCs.
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 1995
Medicare cost report files, if available (otherwise FY 1994 data are
used). Data needed to determine ownership status or Medicare
utilization percentages were unavailable for 138 hospitals. For the
most part, these are either new hospitals or hospitals filing manual
cost reports that are not yet entered into the database.
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
1997 and FY 1998, or for either of those 2 years, by urban/rural
status. The next rows illustrate the overall number of FY 1998
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 1998 Operating Prospective Payment System
[Percent changes in payments per case]
Puerto Rico-
Number of DRG New wage Combined wage & specific Day outlier MGCRB All FY 98
hospitals recalibration data \3\ recalibration wage index phaseout reclassification changes \8\
\1\ \2\ \4\ \5\ \6\ \7\
(0) (1) (2) (3) (4) (5) (6) (7)
--------------------------------------------------------------------------------------------------------------------------------------------------------
(By Geographic Location)
--------------------------------------------------------------------------------------------------------------------------------------------------------
ALL HOSPITALS................ 5,087 0.1 0.1 0.0 0.0 0.0 0.0 3.0
URBAN HOSPITALS.......... 2,857 0.1 0.1 0.0 0.0 -0.1 -0.4 3.0
LARGE URBAN.......... 1,580 0.1 0.1 0.0 0.0 -0.2 -0.4 3.0
OTHER URBAN.......... 1,277 0.1 0.1 0.1 0.0 0.1 -0.3 3.1
RURAL HOSPITALS.......... 2,230 -0.2 0.4 0.0 0.0 0.2 2.1 3.2
BED SIZE (URBAN):
0-99 BEDS................ 720 -0.2 -0.1 -0.4 0.1 0.2 -0.4 2.9
100-199 BEDS............. 948 -0.1 0.0 -0.3 0.1 0.1 -0.4 3.0
200-299 BEDS............. 568 0.1 0.1 0.0 0.0 0.1 -0.4 3.1
300-499 BEDS............. 460 0.2 0.1 0.1 0.0 -0.1 -0.4 2.9
500 OR MORE BEDS......... 161 0.3 0.2 0.4 0.0 -0.3 -0.2 3.1
BED SIZE (RURAL):
0-49 BEDS................ 1,173 -0.4 0.4 -0.2 0.0 0.1 0.1 3.1
50-99 BEDS............... 654 -0.3 0.4 -0.1 0.0 0.2 1.2 3.2
100-149 BEDS............. 237 -0.2 0.5 0.1 0.0 0.2 2.9 3.1
150-199 BEDS............. 90 -0.1 0.4 0.2 0.0 0.2 2.7 3.5
200 OR MORE BEDS......... 76 0.0 0.3 0.2 0.0 0.2 4.0 2.9
URBAN BY CENSUS DIVISION:
NEW ENGLAND.............. 159 0.1 -0.4 -0.5 0.0 0.0 -0.3 2.4
MIDDLE ATLANTIC.......... 431 0.1 0.7 0.6 0.0 -1.0 -0.4 2.7
SOUTH ATLANTIC........... 419 0.2 -0.4 -0.4 0.0 0.1 -0.4 2.7
EAST NORTH CENTRAL....... 474 0.1 0.3 0.3 0.0 0.2 -0.3 3.4
[[Page 30018]]
EAST SOUTH CENTRAL....... 164 0.2 0.8 0.8 0.0 0.2 -0.3 4.1
WEST NORTH CENTRAL....... 191 0.2 0.1 0.1 0.0 0.2 -0.4 3.5
WEST SOUTH CENTRAL....... 367 0.2 -0.4 -0.4 0.0 0.2 -0.4 2.8
MOUNTAIN................. 129 0.3 -0.5 -0.4 0.0 0.2 -0.3 3.0
PACIFIC.................. 475 0.1 -0.2 -0.3 0.0 0.2 -0.3 2.9
PUERTO RICO.............. 48 0.0 0.5 0.3 5.9 -0.3 -0.3 9.4
RURAL BY CENSUS DIVISION:
NEW ENGLAND.............. 53 -0.2 0.7 0.3 0.0 0.2 2.0 3.5
MIDDLE ATLANTIC.......... 85 -0.2 -0.3 -0.7 0.0 0.0 1.1 2.7
SOUTH ATLANTIC........... 298 -0.2 0.4 0.1 0.0 0.2 2.3 2.7
EAST NORTH CENTRAL....... 302 -0.1 0.6 0.3 0.0 0.2 1.2 2.9
EAST SOUTH CENTRAL....... 275 -0.2 0.6 0.3 0.0 0.2 2.5 3.6
WEST NORTH CENTRAL....... 512 -0.3 0.3 -0.1 0.0 0.2 2.4 3.3
WEST SOUTH CENTRAL....... 347 -0.2 0.1 -0.3 0.0 0.2 3.2 3.2
MOUNTAIN................. 212 -0.2 0.0 -0.4 0.0 0.1 1.6 3.5
PACIFIC.................. 141 -0.2 1.1 0.8 0.0 0.1 2.1 3.7
PUERTO RICO.............. 5 -0.4 -1.4 -2.0 7.2 0.0 3.9 8.6
--------------------------------------------------------------------------------------------------------------------------------------------------------
(By Payment Categories)
--------------------------------------------------------------------------------------------------------------------------------------------------------
URBAN HOSPITALS.............. 2,949 0.1 0.1 0.1 0.0 -0.1 -0.3 3.0
LARGE URBAN.............. 1,733 0.1 0.2 0.1 0.0 -0.2 -0.3 3.0
OTHER URBAN.............. 1,216 0.1 0.0 -0.1 0.0 0.1 -0.4 3.1
RURAL HOSPITALS.......... 2,138 -0.2 0.3 0.0 0.0 0.2 1.9 3.1
TEACHING STATUS:
NON-TEACHING............. 3,996 0.0 0.1 -0.1 0.0 0.2 0.2 3.1
FEWER THAN 100 RESIDENTS. 849 0.1 0.1 0.1 0.0 0.0 -0.4 3.1
100 OR MORE RESIDENTS.... 242 0.2 0.3 0.3 0.0 -0.6 -0.1 2.9
DISPROPORTIONATE SHARE
HOSPITALS (DSH):
NON-DSH.................. 3,186 0.0 0.1 0.0 0.0 0.2 0.2 3.2
URBAN DSH:
100 BEDS OR MORE..... 1,403 0.1 0.1 0.1 0.0 -0.2 -0.3 2.9
FEWER THAN 100 BEDS.. 91 -0.3 0.0 -0.5 0.0 0.2 -0.2 2.9
RURAL DSH:
SOLE COMMUNITY (SCH). 153 -0.3 0.2 -0.3 0.0 0.0 0.1 2.9
REFERRAL CENTERS
(RRC)............... 35 -0.1 0.5 0.3 0.0 0.1 3.6 3.4
OTHER RURAL DSH:
100 BEDS OR MORE..... 79 -0.1 0.6 0.3 0.0 0.3 2.5 2.8
FEWER THAN 100 BEDS.. 140 -0.4 0.6 0.1 0.0 0.1 0.8 3.8
URBAN TEACHING AND DSH:
BOTH TEACHING AND DSH 703 0.2 0.2 0.2 0.0 -0.3 -0.4 2.9
TEACHING AND NO DSH.. 333 0.2 0.2 0.3 0.0 0.1 -0.2 3.3
NO TEACHING AND DSH.. 791 0.0 0.0 -0.2 0.0 0.1 -0.2 3.0
[[Page 30019]]
NO TEACHING AND NO
DSH................. 1,122 0.0 0.0 -0.2 0.1 0.2 -0.3 3.1
RURAL HOSPITAL TYPES:
NONSPECIAL STATUS
HOSPITALS........... 1,351 -0.2 0.4 0.0 0.0 0.2 1.6 3.0
RRC.................. 95 0.0 0.5 0.3 0.0 0.2 5.1 3.8
SCH/EACH............. 651 -0.3 0.1 -0.3 0.0 0.1 0.4 2.8
SCH/EACH AND RRC..... 41 -0.1 0.2 -0.1 0.0 0.0 1.3 2.7
TYPE OF OWNERSHIP:
VOLUNTARY................ 2,915 0.1 0.1 0.1 0.0 -0.1 -0.1 3.0
PROPRIETARY.............. 688 0.0 -0.2 -0.3 0.1 0.2 0.1 2.8
GOVERNMENT............... 1,346 0.0 0.3 0.1 0.0 0.0 0.2 3.3
UNKNOWN.................. 138 0.1 0.0 -0.1 0.3 -1.6 -0.2 2.1
MEDICARE UTILIZATION AS A
PERCENT OF INPATIENT DAYS:
0-25..................... 266 0.0 -0.4 -0.5 0.0 -0.2 -0.2 2.5
25-50.................... 1,300 0.2 0.0 0.1 0.0 -0.1 -0.2 3.0
50-65.................... 1,985 0.1 0.3 0.2 0.0 0.0 0.1 3.2
OVER 65.................. 1,397 -0.1 0.1 -0.1 0.0 0.1 0.0 2.9
UNKNOWN.................. 138 0.1 0.0 -0.1 0.3 -1.6 -0.2 2.1
--------------------------------------------------------------------------------------------------------------------------------------------------------
Hospitals Reclassified by the Medicare Geographic Review Board
--------------------------------------------------------------------------------------------------------------------------------------------------------
RECLASSIFICATION STATUS
DURING FY 97 AND FY 98:
RECLASSIFIED DURING BOTH
FY 97 AND FY 98......... 340 0.0 1.1 0.9 0.0 0.2 5.5 3.3
URBAN................ 102 0.1 1.4 1.4 0.0 0.1 2.9 3.6
RURAL................ 238 0.0 0.6 0.4 0.0 0.3 8.5 3.1
RECLASSIFIED DURING FY 98
ONLY:................... 92 0.2 0.6 0.7 0.1 0.1 3.6 9.0
URBAN................ 15 0.5 0.9 1.2 0.2 0.1 1.0 7.4
RURAL................ 77 -0.2 0.3 0.0 0.0 0.2 7.1 11.0
RECLASSIFIED DURING FY 97
ONLY.................... 203 0.0 0.3 0.2 0.0 0.0 -0.8 -0.3
URBAN................ 88 0.1 0.3 0.2 0.0 -0.1 -1.1 0.1
RURAL................ 115 -0.2 0.3 0.0 0.0 0.2 -0.1 -1.0
FY 98 RECLASSIFICATIONS:
ALL RECLASSIFIED
HOSPITALS............... 433 0.1 1.0 0.9 0.0 0.2 5.2 4.2
STANDARD AMOUNT ONLY. 96 0.0 1.8 1.7 0.1 0.1 -0.2 3.3
WAGE INDEX ONLY...... 284 0.1 0.4 0.3 0.0 0.2 7.8 4.5
BOTH................. 53 0.0 1.8 1.7 0.0 0.2 3.7 4.6
NONRECLASSIFIED...... 4,627 0.1 0.1 0.0 0.0 -0.1 -0.5 2.9
ALL URBAN RECLASSIFIED... 117 0.2 1.3 1.3 0.0 0.1 2.5 4.2
STANDARD AMOUNT ONLY. 45 0.1 1.8 1.7 0.1 0.0 -0.9 3.3
WAGE INDEX ONLY...... 33 0.3 0.5 0.7 0.0 0.0 6.4 5.1
BOTH................. 39 0.1 1.8 1.7 0.0 0.2 1.8 4.2
NONRECLASSIFIED...... 2,740 0.1 0.0 0.0 0.0 -0.1 -0.5 3.0
[[Page 30020]]
ALL RURAL RECLASSIFIED... 316 -0.1 0.6 0.4 0.0 0.2 8.3 4.3
STANDARD AMOUNT ONLY. 51 -0.2 1.9 1.6 0.0 0.4 2.5 3.2
WAGE INDEX ONLY...... 251 -0.1 0.4 0.1 0.0 0.2 8.6 4.2
BOTH................. 14 -0.1 1.8 1.6 0.0 0.5 14.7 6.5
NONRECLASSIFIED...... 1,887 -0.2 0.3 -0.1 0.0 0.1 -0.3 2.7
OTHER RECLASSIFIED:
HOSPITALS (SECTION...
1886(d)(8)(B))....... 27 -0.2 0.2 -0.1 0.0 0.2 0.8 3.4
--------------------------------------------------------------------------------------------------------------------------------------------------------
\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 1996, and hospital cost report data are from reporting periods beginning in FY 1994 and FY 1995.
\2\ This column displays the payment impacts of the recalibration of the DRG weights, based on FY 1996 MedPAR data and the DRG classification changes,
in accordance with section 1886(d)(4)(C) of the Act.
\3\ This column shows the payment effects of updating the data used to calculate the wage index with data from the FY 1994 cost reports.
\4\ This column displays the combined impacts of the reclassification and recalibration of the DRGs, the updated 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 and 2, and the FY 1998 budget neutrality factor of 0.998400.
\5\ This column illustrates the payment impacts of the Puerto Rico-specific wage index, applied to the Puerto Rico standardized amounts.
\6\ This column illustrates the payment impacts of completing the phase-out of day outlier payments, and increasing cost outlier payments, in accordance
with section 1886(d)(5) of the Act.
\7\ Shown here are the combined effects of geographic reclassification by the Medicare Geographic Classification Review Board (MGCRB). The effects shown
here demonstrate the FY 1998 payment impacts of going from no reclassifications to the reclassifications scheduled to be in effect for FY 1998.
Reclassification for prior years has no bearing on the payment impacts shown here.
\8\ This column shows changes in payments from FY 1997 to FY 1998. It incorporates all of the changes displayed in columns 3 through 6 (the changes
displayed in columns 1 and 2 are included in column 3). It also displays the impacts of the updates to the FY 1998 standardized amounts and the
hospital-specific rates, changes in hospitals' reclassification status in FY 1998 compared to FY 1997, and the difference in outlier payments from FY
1997 to FY 1998. The sum of columns 3 through 6 plus these effects may be different from the percentage changes shown here due to rounding and
interactive effects.
B. Impact of the Proposed Changes to the DRG Classifications and
Relative Weights (Column 1)
In column 1 of Table I, we present the combined effects of the
DRG reclassifications and recalibration, as discussed in section II.
of the preamble to this proposed rule. Section 1886(d)(4)(C)(i) of
the Act requires us each year to make appropriate classification
changes and to recalibrate the DRG weights in order to reflect
changes in treatment patterns, technology, and any other factors
that may change the relative use of hospital resources.
We compared aggregate payments using the FY 1997 DRG relative
weights (GROUPER version 14) to aggregate payments using the
proposed FY 1998 DRG relative weights (GROUPER version 15). Overall,
payments increase by 0.1 percent due to the DRG changes, although
this is prior to applying the budget neutrality factor for DRG and
wage index changes (see column 3). Consistent with the minor changes
we are proposing for the FY 1998 GROUPER, the redistributional
impacts of DRG reclassifications and recalibration across hospital
groups are very small (a 0.1 percent increase for large and other
urban hospitals; a 0.2 percent decrease among rural hospitals).
Within hospital categories, the net effects for urban hospitals are
small positive changes for larger hospitals (200 or more beds), and
slightly negative changes for urban hospitals with fewer than 200
beds. Among rural hospitals, the smallest rural hospitals (fewer
than 50 beds) experience a decrease of 0.4 percent. For other rural
bed size categories, slight negative impacts prevail. Only the
largest rural hospitals (200 or more beds) avoid any negative impact
from the changes.
The breakdowns by urban census division show that the increase
among urban hospitals is spread across all census categories, with
the largest increase (0.3 percent) for hospitals in the Mountain
census division. For rural hospitals, the largest decrease is 0.4
percent for the five rural hospitals in Puerto Rico. The next
largest decrease is 0.3 percent in the West North Central census
division. This pattern of negative impacts upon small and rural
hospitals is also apparent when examining the effects of DRG changes
on hospitals according to special payment categories, with the
largest decrease (0.4 percent) among rural DSH hospitals with fewer
than 100 beds.
Overall, we attribute the changes associated with DRG
recalibration to the increasing gap between the relative weights for
medical, diagnostic, and less complicated surgical DRGs and the
weights for the more complicated surgical DRGs. Since the cases
associated with the former DRGs tend to be treated more often in
smaller hospitals with fewer resources available, lower relative
weights associated with those cases would disproportionately affect
these hospitals. In general, small hospitals that serve a
disproportionate share of low-income patients fit this definition.
In contrast, larger hospitals in both urban and rural areas, which
tend to treat the latter group of DRGs, would experience small
payment increases. Teaching hospitals, which also treat the more
complicated cases, experience similar effects. We note, however,
that both the positive and negative impacts are relatively minor.
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
[[Page 30021]]
1998 is based on data submitted for hospital cost reporting periods
beginning on or after October 1, 1993 and before October 1, 1994. 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
1997 wage index based on FY 1993 wage data before geographic
reclassifications to a model using the FY 1998 prereclassification
wage index based on FY 1994 wage data.
The results indicate that the new wage data have a 0.1 percent
increase overall impact on hospital payments (prior to applying the
budget neutrality factor, see column 3). Rural hospitals generally
appear to benefit from the update. Payments increase for rural
hospitals by 0.4 percent. These increases are attributable to
relatively large increases in the wage index values for the rural
areas of particular States (although all but one changed by less
than 5 percent). Urban hospitals as a group are not significantly
affected by the updated wage data (0.1 percent increases), although
some particular categories of urban hospitals exhibit sizeable
changes.
Some of the largest changes are found among both urban and rural
hospitals grouped by census division. In almost all cases, payments
change by less than 1 percent. Our review of the wage data indicates
that these changes were attributable to improved reporting, as well
as relative changes in labor costs.
Among the urban census division categories, the East South
Central and the Middle Atlantic census divisions experience the
largest increases (0.8 and 0.7 percent, respectively). In the East
South Central, the increase stems largely from wage index increases
of 6.0 percent in the Mobile, Alabama labor market area, and an
increase of 5.2 percent in the Memphis, Tennessee labor market area.
In the Middle Atlantic division, New York City's wage index rises by
almost 1.4 percent, and Philadelphia's wage index increases by 1.3
percent. The largest decrease among urban hospitals occurs in the
Mountain census division with a decline of 0.5 percent. This
decrease is primarily due to a 3.7 percent decrease in the wage
index for Phoenix, Arizona.
Among the rural hospitals, all census divisions experience
increases except for the Middle Atlantic (and Puerto Rico, discussed
separately below) census division, which experiences a slight
decrease of 0.3 percent. The largest increase (1.1 percent) occurs
in the Pacific census division. Here, Oregon's rural wage index
rises by 3.3 percent, and Washington's rural index increases by 2.9
percent. The second largest increase (0.7 percent) occurs in the New
England census division. In this census division, the Vermont index
increases by 4.5 percent, and the Maine index increases by 1.9
percent.
In Puerto Rico, payments increase by 0.5 percent for the urban
hospitals and decrease by 1.4 percent for the five rural hospitals.
Although column 4 shows the isolated effects of introducing the
Puerto Rico-specific wage index, it is also included in the payment
simulations here showing the impacts of the new wage data. Of the
six urban areas in Puerto Rico, two experience increases in their
national and Puerto Rico-specific wage index values, including the
San Juan-Bayamon area (4.4 percent national, and 2.0 percent Puerto
Rico-specific), which contains the majority of the urban Puerto Rico
hospitals (29 of 48), and the Mayaguez area (6.4 percent national,
and 4.0 Puerto Rico-specific).
The following chart compares the shifts in wage index values for
labor market areas for FY 1998 with those from FY 1997. The majority
of labor market areas (336) experience less than a 5 percent change.
A total of 31 labor market areas experience a change between 5 and
10 percent; 14 of those experience increases. Still fewer labor
markets experience a change of more than 10 percent; one experiences
an increase, and two experience decreases. We reviewed the data for
any area that experienced a wage index change of 5 percent or more
to determine the reason for the fluctuation.
------------------------------------------------------------------------
Number of labor
market areas
Percentage change in area wage index values ---------------------
FY 1997 FY 1998
------------------------------------------------------------------------
Increase more than 10 percent..................... 1 1
Increase between 5 and 10 percent (inclusive)..... 10 14
Increase or decrease less than 5 percent
(inclusive)...................................... 334 336
Decrease between 5 and 10 percent................. 9 17
Decrease more than 10 percent..................... 3 2
------------------------------------------------------------------------
Under the proposed FY 1998 wage index, 94.2 percent of urban
hospitals and 99.9 percent of rural hospitals would experience a
change in their wage index of less than 5 percent. Among urban
hospitals, 153 would experience a change of between 5 and 10 percent
(66 increasing and 87 decreasing), while only 3 rural hospitals fall
into this category, all decreasing. Ten urban hospitals and no rural
hospitals would experience a change of more than 10 percent. 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..................... 4 0
Increase between 5 and 10 percent (inclusive)..... 66 0
Increase or decrease less than 5 percent.......... 2663 2217
Decrease between 5 and 10 percent (inclusive)..... 87 3
Decrease more than 10 percent..................... 6 0
------------------------------------------------------------------------
D. Combined Impact of DRG and Wage Index Changes--Including Budget
Neutrality Adjustment (Column 3)
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 pointed out in the Addendum to this
proposed rule, we compared aggregate payments using the FY 1997 DRG
relative weights and wage index to aggregate payments using the FY
1998 DRG relative weights and wage index. Based on this comparison,
we computed a wage and recalibration budget neutrality factor of
0.998400. 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 3. 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 and 2, minus the approximately 0.2 percent
decrease attributable to the budget neutrality factor. There may, of
course, be some variation of plus or minus 0.1 percent due to
rounding. In calculating the total changes shown in column 7,
readers should begin with this column and add across, excluding the
impacts shown in columns 1 and 2.
E. Puerto Rico-Specific Wage Index (Column 4)
As described in section III. of the preamble to this proposed
rule, we are proposing to adopt a Puerto Rico-specific wage index
for FY 1998. These wage index values would be applied to the Puerto
Rico standardized amounts. Column 4 shows the effect of implementing
this proposed change results in no payment impact for the All
Hospitals row. In Puerto Rico, payments increase by 5.9 percent
among urban hospitals, and 7.2 percent among rural hospitals. As
shown in Table 4F of the Addendum, the Puerto Rico-specific wage
index values are considerably higher than Puerto Rico's national
wage indexes (shown in Table 4A of the Addendum). This results in
the increases shown in this column.
As indicated above, this change is shown in isolation here for
ease in reading Table I. To actually calculate the national DRG and
wage index budget neutrality factors, the Puerto Rico-specific wage
index was included. As described in the Addendum, we also computed a
DRG reclassification and recalibration budget neutrality adjustment
for the Puerto Rico standardized amounts equal to 0.999224.
F. Outlier Changes (Column 5)
Currently, Medicare provides extra payment in addition to the
basic DRG payment amount for extremely costly or extraordinarily
lengthy cases (cost outliers and day outliers, respectively).
Beginning with FY 1995, section 1886(d)(5)(A) of the Act requires
the Secretary to phase-out payments for day outliers. Under the
[[Page 30022]]
requirements of section 1886(d)(5)(A)(v), the proportion of day
outlier payments to total outlier payments is reduced from FY 1994
levels as follows: 75 percent of FY 1994 levels in FY 1995, 50
percent of FY 1994 levels in FY 1996, and 25 percent of FY 1994
levels in FY 1997. For discharges occurring after September 30,
1997, the Secretary will no longer pay for day outliers under the
provisions of section 1886(d)(5)(A)(I) of the Act. This reduction in
day outlier payments will be offset by an increase in cost outlier
payments.
As discussed in the Addendum, for FY 1998, we are proposing that
a case would receive cost outlier payments if its costs exceed the
DRG amount plus $7,600. We are also proposing to maintain the
marginal cost factor for cost outliers at 80 percent.
The payment impacts of these changes are minimal. Hospital
categories negatively affected by phasing-out day outliers are
consistent with the categories negatively affected in previous
years: urban Middle Atlantic census division (1.0 percent decline);
urban hospitals with 500 or more beds (0.3 percent decline);
teaching hospitals with 100 or more residents (0.6 percent decline);
and hospitals for which data were unavailable to calculate Medicare
utilization rates (1.5 percent decline). This last category contains
a number of New York City public hospitals that file manual cost
reports. Because the changes to the outlier policy result in a shift
in payments from cases paid as day outliers to cases paid as cost
outliers, this indicates that these categories have higher
percentages of day outliers.
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 1998. 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.
By March 30 of each year, the MGCRB makes reclassification
determinations that will be effective for the next fiscal year,
which begins on October 1. The MGCRB may approve a hospital's
reclassification request for the purpose of using the other area's
standardized amount, wage index value, or both. Effective FY 1997,
rural hospitals can no longer be reclassified to an other urban area
for purposes of the standardized amount under section 1886(d)(10) of
the Act.
The proposed FY 1998 wage index values incorporate all of the
MGCRB's reclassification decisions for FY 1998. The wage index
values also reflect any decisions made by the HCFA Administrator
through the appeals and review process for MGCRB decisions as of
March 29, 1997. 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 1998.
The overall effect of geographic reclassification is required to
be budget neutral by section 1886(d)(8)(D) of the Act. Therefore, we
applied an adjustment of 0.995127 to ensure that the effects of
reclassification are budget neutral. (See section II.A.4 of the
Addendum to this proposed rule.)
As a group, rural hospitals benefit from geographic
reclassification. Their payments rise 2.1 percent, while payments to
urban hospitals decline 0.4 percent. Large urban hospitals lose 0.4
percent because, as a group, they have the smallest percentage of
hospitals that are reclassified (fewer than 2 percent of large urban
hospitals are reclassified). There are enough hospitals in other
urban areas that are reclassified to limit the decrease in payments
to urban hospitals stemming from the budget neutrality offset to 0.3
percent. Among urban hospital groups generally (that is, bed size,
census division, and special payment status), payments generally
fall between 0.3 and 0.4 percent. Urban hospitals with 500 or more
beds have the lowest decline, only 0.2 percent, owing to the
reclassification of 9 hospitals within this category.
A positive impact is evident among all rural hospital groups.
The smallest effect among the rural census divisions is 1.1 percent
for the Middle Atlantic division. The largest impacts are in rural
Puerto Rico and the West South Central, with increases of 3.9
percent and 3.2 percent, respectively.
Among rural hospitals designated as RRCs, 45 hospitals are
reclassified for purposes of the wage index only, leading to the 5.1
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 4.0 percent increase in payments.
Rural hospitals reclassified for FY 1997 and FY 1998 experience
an 8.5 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 1998 only experience a 7.1 percent increase in
payments, while rural hospitals reclassified for FY 1997 only
experience a 0.1 decrease in payments. Urban hospitals reclassified
for FY 1997 but not FY 1998 experience a 1.1 percent decline in
payments overall. This appears to be due to the combined impacts of
the budget neutrality adjustment, and a number of Bergen-Passaic,
New Jersey hospitals in this category that experience a 4.5 percent
drop in their wage index after reclassification. Urban hospitals
reclassified for FY 1998 but not for FY 1997 experience a 1.0
percent increase in payments.
The FY 1998 Reclassification rows of Table I show the changes in
payments per case for all FY 1998 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 14.7 percent increase in payments. In addition, rural
hospitals reclassified just for the wage index receive an 8.6
percent payment increase. The overall impact on reclassified
hospitals is to increase their payments per case by an average of
5.2 percent for FY 1998.
Among the 27 rural hospitals deemed to be urban under section
1886(d)(8)(B) of the Act, payments increase 0.8 percent due to MGCRB
reclassification. This is because, although these hospitals are
treated as being attached to an urban area in our baseline (their
redesignation is ongoing, rather than annual like the MGCRB
reclassifications), they are eligible for MGCRB reclassification.
For FY 1998, one hospital in this category reclassified to a large
urban area.
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, which
corresponds closely with the geographic reclassification budget
neutrality factor. Rural nonreclassified hospitals decrease slightly
less, experiencing a 0.3 percent decrease. This occurs because the
wage index values in some rural areas increase after reclassified
hospitals are excluded from the calculation of those indexes.
The number of reclassifications for purposes of the standardized
amount, or for both the standardized amount and the wage index, has
declined from 210 in FY 1997 to 149 in FY 1998. The number of wage
index only reclassifications increased slightly from 274 in FY 1997
to 284 in FY 1998.
The foregoing analysis was based on MGCRB and HCFA Administrator
decisions made by March 29 of this year. As previously noted, there
may be changes to some MGCRB decisions through the appeals, review,
and applicant withdrawal process. The outcome of these cases will be
reflected in the analysis presented in the final rule.
H. All Changes (Column 7)
Column 7 compares our estimate of payments per case,
incorporating all changes reflected in this proposed rule for FY
1998 (including statutory changes), to our estimate of payments per
case in FY 1997. It includes the effects of the 2.8 percent update
to the standardized amounts and the hospital-specific rates for SCHs
and EACHs, and reflects the 0.2 percentage point difference between
the projected outlier payments in FY 1998 (5.1 percent of total DRG
payments) and the current estimate of the percentage of actual
outlier payments in FY 1997 (4.9 percent), as described in the
introduction to this Appendix and the Addendum.
We also note that column 7 includes the impacts of FY 1998 MGCRB
reclassifications compared to the payment impacts of FY 1997
reclassifications. Column 6, however, shows
[[Page 30023]]
the impact of going from no MGCRB reclassifications to the FY 1998
reclassifications. Therefore, when comparing FY 1998 payments to FY
1997, the percent changes due to FY 1998 reclassifications shown in
column 6 need to be offset by the effects of reclassification on
hospitals' FY 1997 payments (column 4 of Table 1, September 1, 1996
final rule; 61 FR 46306). For example, the impact of MGCRB
reclassifications on rural hospitals' FY 1997 payments was
approximately a 2.3 percent increase, offsetting the 2.1 percent
increase in column 6. Therefore, the net change in FY 1998 payments
due to reclassification for rural hospitals is actually closer to a
decrease of 0.2 percent relative to FY 1997. 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 3 through 6, plus the other impacts
that we are able to identify.
The overall payment increase from FY 1998 to FY 1997 for all
hospitals is a 3.0 percent increase. This reflects the 0.0 percent
net change in total payments due to the proposed changes for FY 1998
shown in columns 3 through 6, the 2.8 percent update for FY 1998,
and the 0.2 percent higher outlier payments in FY 1998 compared to
FY 1997, as discussed above.
Hospitals in urban areas experience a 3.0 percent rise in
payments per case over FY 1997. Similar to all hospitals nationally,
this is primarily due to the factors discussed above: the 2.8
percent update and a 0.2 percent higher level of outlier payments
estimated for FY 1998. Urban hospitals lose 0.1 percent due to the
phase-out of the day outlier policy. Their 0.4 negative impact in FY
1998 due to reclassification is offset by a similar impact from FY
1997 reclassifications. Hospitals in large and other urban areas
experience 3.0 percent and 3.1 percent increases, respectively.
Hospitals in rural areas experience a 3.2 percent increase. This
larger increase for rural hospitals appears to be primarily
attributable to RRCs experiencing a 3.8 percent increase in payments
overall for FY 1998. The 45 RRCs that were reclassified for the wage
index experience a 4.7 percent overall increase in payments from FY
1997 to FY 1998. Although a small number, they tend to be large
hospitals and therefore have a disproportionate impact in the rural
category. In fact, these 45 hospitals represented 7 percent of all
rural discharges during FY 1996 (2 percent of all rural hospitals).
Puerto Rico stands out as having large payment increases for FY
1998, with urban Puerto Rico hospitals' payments increasing by 9.4
percent, and rural Puerto Rico hospitals' payments increasing by 8.6
percent. As noted earlier, this is largely due to the proposed
implementation of the Puerto Rico-specific wage index during FY
1998.
Among other census divisions, urban East South Central displays
the largest increase, 4.1 percent. This is related to the 0.8
percent increase due to the new wage data. Similarly, rural Pacific
and rural East South Central display above average increases, 3.6
and 3.5 percent respectively. The smallest increase, on the other
hand, occurs in urban New England, with a 2.4 percent payment
increase. This also appears to be due to the updated wage data (the
Boston wage index value declines by 1.5 percent).
The only hospital groups with negative payment impacts from FY
1997 to FY 1998 are hospitals that were reclassified for FY 1997 and
are not reclassified for FY 1998. Overall, these hospitals lose 0.3
percent. The urban hospitals in this category actually experience
slight payment increases over FY 1997 (0.1 percent), while the rural
hospitals lose 1.0 percent. On the other hand, hospitals
reclassified for FY 1998 that were not reclassified for FY 1997
would experience the greatest payment increases: 11.0 percent for 77
rural hospitals in this category and 7.4 percent for 15 urban
hospitals.
Reclassification appears to be a significant factor influencing
the payment increases for a number of rural hospital groups with
above average overall payment increases in column 7. This impact is
illustrated most clearly when one examines the rows categorizing
hospitals by their reclassification status for FY 1998. All
nonreclassified hospitals have an average payment increase of 2.9
percent. The average payment increase for all reclassified hospitals
is 4.2 percent.
Among SCH/EACHs, the payment increase is 2.8 percent. The
primary reason for this below average increase is that there is
minimal impact upon these hospitals from the higher estimated FY
1998 outlier payments. Because this hospital group receives their
hospital-specific rate if the hospitals exceed the applicable
Federal amount (including outliers), and the hospital-specific rate
is not adjusted for outliers, there is less of an impact due to
changes in outlier payment levels.
Table II.--Impact Analysis of Changes for FY 1998 Operating Prospective Payment System
[Payments per case]
Average FY Average FY
Number of 1997 1998
hospitals payment per payment per All changes
\1\ case case
(1) (2) (3) (4)
----------------------------------------------------------------------------------------------------------------
(By Geographic Location)
----------------------------------------------------------------------------------------------------------------
ALL HOSPITALS.............................................. 5,087 6,759 6,965 3.0
URBAN HOSPITALS........................................ 2,857 7,332 7,554 3.0
LARGE URBAN........................................ 1,580 7,884 8,117 3.0
OTHER URBAN........................................ 1,277 6,624 6,831 3.1
RURAL HOSPITALS........................................ 2,230 4,454 4,594 3.2
BED SIZE (URBAN):
0-99 BEDS.............................................. 720 4,916 5,059 2.9
100-199 BEDS........................................... 948 6,170 6,354 3.0
200-299 BEDS........................................... 568 6,878 7,092 3.1
300-499 BEDS........................................... 460 7,827 8,055 2.9
500 OR MORE BEDS....................................... 161 9,573 9,873 3.1
BED SIZE (RURAL):
0-49 BEDS.............................................. 1,173 3,650 3,763 3.1
50-99 BEDS............................................. 654 4,169 4,302 3.2
100-149 BEDS........................................... 237 4,623 4,768 3.1
150-199 BEDS........................................... 90 4,803 4,972 3.5
200 OR MORE BEDS....................................... 76 5,576 5,740 2.9
URBAN BY CENSUS DIVISION:
NEW ENGLAND............................................ 159 7,851 8,039 2.4
MIDDLE ATLANTIC........................................ 431 8,113 8,335 2.7
SOUTH ATLANTIC......................................... 419 7,002 7,190 2.7
[[Page 30024]]
EAST NORTH CENTRAL..................................... 474 7,037 7,279 3.4
EAST SOUTH CENTRAL..................................... 164 6,537 6,807 4.1
WEST NORTH CENTRAL..................................... 191 6,945 7,186 3.5
WEST SOUTH CENTRAL..................................... 367 6,815 7,009 2.8
MOUNTAIN............................................... 129 7,101 7,315 3.0
PACIFIC................................................ 475 8,406 8,648 2.9
PUERTO RICO............................................ 48 2,692 2,946 9.4
RURAL BY CENSUS DIVISION:
NEW ENGLAND............................................ 53 5,270 5,456 3.5
MIDDLE ATLANTIC........................................ 85 4,745 4,871 2.7
SOUTH ATLANTIC......................................... 298 4,636 4,761 2.7
EAST NORTH CENTRAL..................................... 302 4,501 4,634 2.9
EAST SOUTH CENTRAL..................................... 275 4,125 4,274 3.6
WEST NORTH CENTRAL..................................... 512 4,148 4,284 3.3
WEST SOUTH CENTRAL..................................... 347 4,004 4,133 3.2
MOUNTAIN............................................... 212 4,779 4,947 3.5
PACIFIC................................................ 141 5,578 5,783 3.7
PUERTO RICO............................................ 5 2,074 2,253 8.6
----------------------------------------------------------------------------------------------------------------
(By Payment Categories)
----------------------------------------------------------------------------------------------------------------
URBAN HOSPITALS............................................ 2,949 7,294 7,515 3.0
LARGE URBAN............................................ 1,733 7,738 7,970 3.0
OTHER URBAN............................................ 1,216 6,634 6,839 3.1
RURAL HOSPITALS............................................ 2,138 4,433 4,570 3.1
TEACHING STATUS:
NON-TEACHING........................................... 3,996 5,492 5,662 3.1
FEWER THAN 100 RESIDENTS............................... 849 7,201 7,425 3.1
100 OR MORE RESIDENTS.................................. 242 11,006 11,321 2.9
DISPROPORTIONATE SHARE HOSPITALS (DSH):
NON-DSH................................................ 3,186 5,806 5,991 3.2
URBAN DSH:
100 BEDS OR MORE................................... 1,403 7,970 8,203 2.9
FEWER THAN 100 BEDS................................ 91 5,110 5,260 2.9
RURAL DSH:
SOLE COMMUNITY (SCH)............................... 153 4,386 4,513 2.9
REFERRAL CENTERS (RRC)............................. 35 5,391 5,576 3.4
OTHER RURAL DSH:
100 BEDS OR MORE................................... 79 4,311 4,431 2.8
FEWER THAN 100 BEDS................................ 140 3,592 3,730 3.8
(1) (2) (3) (4)
----------------------------------------------------------------------------------------------------------------
URBAN TEACHING AND DSH:
BOTH TEACHING AND DSH.............................. 703 8,953 9,210 2.9
TEACHING AND NO DSH................................ 333 7,395 7,641 3.3
NO TEACHING AND DSH................................ 791 6,393 6,587 3.0
NO TEACHING AND NO DSH............................. 1,122 5,675 5,853 3.1
RURAL HOSPITAL TYPES:
NONSPECIAL STATUS HOSPITALS........................ 1,351 4,001 4,121 3.0
RRC................................................ 95 5,382 5,586 3.8
SCH/EACH........................................... 651 4,555 4,683 2.8
SCH/EACH and RRC................................... 41 5,463 5,609 2.7
TYPE OF OWNERSHIP:
VOLUNTARY.............................................. 2,915 6,932 7,143 3.0
PROPRIETARY............................................ 688 6,143 6,315 2.8
GOVERNMENT............................................. 1,346 6,283 6,490 3.3
UNKNOWN................................................ 138 7,582 7,743 2.1
MEDICARE UTILIZATION AS A PERCENT OF INPATIENT DAYS:
0--25.................................................. 266 8,849 9,066 2.5
25--50................................................. 1,300 8,227 8,475 3.0
50--65................................................. 1,985 6,183 6,382 3.2
OVER 65................................................ 1,397 5,251 5,402 2.9
UNKNOWN................................................ 138 7,582 7,743 2.1
----------------------------------------------------------------------------------------------------------------
[[Page 30025]]
Hospitals Reclassified by the Medicare Geographic Review Board
----------------------------------------------------------------------------------------------------------------
RECLASSIFICATION STATUS DURING FY 97 AND FY 98:
RECLASSIFIED DURING BOTH FY 97 AND FY 98............... 340 6,123 6,328 3.3
URBAN.............................................. 102 7,231 7,490 3.6
RURAL.............................................. 238 5,248 5,410 3.1
RECLASSIFIED DURING FY 98 ONLY......................... 92 5,843 6,372 9.0
URBAN.............................................. 15 7,940 8,526 7.4
RURAL.............................................. 77 4,384 4,872 11.1
RECLASSIFIED DURING FY 97 ONLY:
URBAN.............................................. 203 6,063 6,045 -0.3
RURAL.............................................. 88 7,054 7,062 0.1
FY 98 RECLASSIFICATIONS................................ 115 4,738 4,685 -1.1
ALL RECLASSIFIED HOSPITALS......................... 433 6,077 6,334 4.2
STANDARD AMOUNT ONLY........................... 96 5,927 6,120 3.3
WAGE INDEX ONLY................................ 284 6,085 6,360 4.5
BOTH........................................... 53 6,251 6,539 4.6
NONRECLASSIFIED................................ 4,627 6,836 7,037 2.9
ALL URBAN RECLASSIFIED............................. 117 7,340 7,650 4.2
STANDARD AMOUNT ONLY........................... 45 6,449 6,659 3.3
WAGE INDEX ONLY................................ 33 9,513 9,996 5.1
BOTH........................................... 39 6,457 6,731 4.2
NONRECLASSIFIED................................ 2,740 7,332 7,549 3.0
ALL RURAL RECLASSIFIED............................. 316 5,100 5,317 4.3
STANDARD AMOUNT ONLY........................... 51 4,505 4,651 3.2
WAGE INDEX ONLY................................ 251 5,163 5,381 4.2
BOTH........................................... 14 5,337 5,683 6.5
NONRECLASSIFIED................................ 1,887 4,216 4,329 2.7
OTHER RECLASSIFIED:
HOSPITALS (SECTION 1886(d)(8)(B)).............. 27 4,740 4,902 3.4
----------------------------------------------------------------------------------------------------------------
\1\ These payment amounts per case do not reflect any estimates of annual case-mix increase.
Table II presents the projected impact of the proposed changes
for FY 1998 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 1998 with the average estimated per case
payments for FY 1997, 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 data that were unavailable in previous impact
analyses for the capital prospective payment system. Specifically,
we have cost report data for the fourth year of the capital
prospective payment system (cost reports beginning in FY 1995)
available through the December 1996 update of the Health Care
Provider Cost Report Information System (HCRIS). We also have
updated information on the projected aggregate amount of obligated
capital approved by the fiscal intermediaries. However, our impact
analysis of payment changes for capital-related costs is still
limited by the lack of hospital-specific data on several items.
These are the hospital's projected new capital costs for each year,
its projected old capital costs for 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.
Moreover, our policy of recognizing certain obligated
capital as old capital makes it difficult to project future capital-
related costs for individual hospitals. Under Sec. 412.302(c), a
hospital is required to notify its intermediary that it has
obligated capital by the later of October 1, 1992, or 90 days after
the beginning of the hospital's first cost reporting period under
the capital prospective payment system. The intermediary must then
notify the hospital of its determination whether the criteria for
recognition of obligated capital have been met by the later of the
end of the hospital's first cost reporting period subject to the
capital prospective payment system or 9 months after the receipt of
the hospital's notification. The amount that is recognized as old
capital is limited to the lesser of the actual allowable costs when
the asset is put in use for patient care or the estimated costs of
the capital expenditure at the time it was obligated. We have
substantial information regarding intermediary determinations of
projected aggregate obligated capital amounts. However, we still do
not know when these projects will actually be put into use for
patient care, the actual amount that will be recognized as obligated
capital when the project is put into use, or the Medicare share of
the recognized costs. Therefore, we do not know actual obligated
capital commitments for purposes of the FY 1998 capital cost
projections. We discuss in Appendix B the assumptions and
computations we employ to generate the amount of obligated capital
commitments for use in the FY 1998 capital cost projections.
In Table III of this appendix, we present the redistributive
effects that are expected to occur between ``hold-harmless''
hospitals and ``fully prospective'' hospitals in FY 1998. In
addition, we have integrated sufficient hospital-specific
information into our actuarial model to project the impact of the
[[Page 30026]]
proposed FY 1998 capital payment policies by the standard
prospective payment system hospital groupings. We caution that while
we now have actual information on the effects of the transition
payment methodology and interim payments under the capital
prospective payment system and cost report data for most hospitals,
we need to randomly generate numbers for the change in old capital
costs, new capital costs for each year, and obligated amounts that
will be put in use for patient care services and recognized as old
capital each year. We continue to be unable to predict accurately FY
1998 capital costs for individual hospitals, but with the more
recent data on the experience to date under the capital prospective
payment system, there is adequate information to estimate the
aggregate impact on most hospital groupings.
We present the transition payment methodology by hospital
grouping in Table IV. In Table V we present the results of the
cross-sectional analysis using the results of our actuarial model.
This table presents the aggregate impact of the FY 1998 payment
policies.
B. Projected Impact Based on the Proposed FY 1998 Actuarial Model
1. Assumptions
In this impact analysis, we model dynamically the impact of the
capital prospective payment system from FY 1997 to FY 1998 using a
capital cost model. The FY 1998 model, described in Appendix B of
this proposed rule, integrates actual data from individual hospitals
with randomly generated capital cost amounts. We have capital cost
data from cost reports beginning in FY 1989 through FY 1995 received
through the December 1996 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, 1997 in the provider-specific file. We used these data to
determine the proposed FY 1998 capital rates. However, we do not
have individual hospital data on old capital changes, new capital
formation, and actual obligated capital costs. We have data on costs
for capital in use in FY 1993, and we age that capital by a formula
described in Appendix B. We therefore need to randomly generate only
new capital acquisitions for any year after FY 1993. All Federal
rate payment parameters are assigned to the applicable hospital.
Recently available cost report data indicate that old capital
costs are declining faster than we previously projected.
Consequently, for FY 1998 we are projecting faster declines in old
capital. To make up for the larger declines in old capital, we are
projecting faster growth in new capital. The combination of these
two factors will make the 100-percent Federal rate higher than the
hold-harmless rate for some hold-harmless hospitals. Therefore, we
are now projecting that more hospitals will move to the 100-percent
Federal rate than previously projected.
For purposes of this impact analysis, the FY 1998 actuarial
model includes the following assumptions:
Medicare inpatient capital costs per discharge will
increase at the following rates during these periods:
------------------------------------------------------------------------
Average percentage increase in capital costs per discharge
-------------------------------------------------------------------------
Percentage
Fiscal year increase
------------------------------------------------------------------------
1996........................................................ 3.84
1997........................................................ 4.46
1998........................................................ 4.50
------------------------------------------------------------------------
The Medicare case-mix index will increase by 1.0
percent in FY 1997 and FY 1998.
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 1998 update for inflation is 1.10 percent (see section
III of the Addendum).
2. Results
We have used the actuarial model to estimate the change in
payment for capital-related costs from FY 1997 to FY 1998. Table III
shows the effect of the capital prospective payment system on low
capital cost hospitals and high capital cost hospitals. We consider
a hospital to be a low capital cost hospital if, based on a
comparison of its initial hospital-specific rate and the applicable
Federal rate, it will be paid under the fully prospective payment
methodology. A high capital cost hospital is a hospital that, based
on its initial hospital-specific rate, will be paid under the hold-
harmless payment methodology. Based on our actuarial model, the
breakdown of hospitals is as follows:
Capital Transition Payment Methodology
----------------------------------------------------------------------------------------------------------------
FY 1998 FY 1998
Percent of FY 1998 percent of percent of
Type of hospital hospitals percent of capital capital
discharges costs payments
----------------------------------------------------------------------------------------------------------------
Low Cost Hospital........................................... 66 62 58 59
High Cost Hospital.......................................... 34 38 42 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 in use
for patient care). If the redetermined hospital-specific rate is
greater than the adjusted Federal rate, these hospitals will be paid
under the hold-harmless payment methodology. Regardless of whether
the hospital became a hold-harmless payment hospital as a result of
a redetermination, we have continued to show these hospitals as low
capital cost hospitals in Table III.
Assuming no behavioral changes in capital expenditures, Table
III displays the percentage change in payments from FY 1997 to FY
1998 using the above described actuarial model. With the proposed
Federal rate, we estimate aggregate Medicare capital payments will
increase by 7.19 percent in FY 1998.
Table III.--Impact of Proposed Changes for FY 1998 on Payments per Discharge
[FY 1997 payments per discharge]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Adjusted Average Hospital Hold
Number of Discharges Federal Federal specific harmless Exceptions Total
hospitals payment percent payment payment payment payment
--------------------------------------------------------------------------------------------------------------------------------------------------------
Low Cost Hospitals........................................ 3,330 6,844,215 $469.21 63.86 $134.59 $2.72 $56.19 $662.70
Fully Prospective..................................... 3,068 6,162,124 439.28 60.00 149.48 ......... 60.85 649.61
100% Federal Rate..................................... 251 658,508 756.30 100.00 ......... ......... 13.60 769.90
Hold Harmless......................................... 11 23,583 274.74 33.13 ......... 789.18 27.68 1,091.61
High Cost Hospitals....................................... 1,684 4,194,629 745.99 98.04 ......... 20.38 24.58 790.95
[[Page 30027]]
100% Federal Rate..................................... 1,590 4,037,189 760.08 100.00 ......... ......... 24.02 784.10
Hold Harmless......................................... 94 157,441 384.62 49.19 ......... 542.92 39.14 966.68
Total Hospitals................................... 5,014 11,038,844 574.38 77.13 83.44 9.43 44.18 711.44
--------------------------------------------------------------------------------------------------------------------------------------------------------
[FY 1998 payments per discharge]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Adjusted Average Hospital Hold
Number of Discharges Federal Federal specific harmless Exceptions Total Percent
hospitals payment percent payment payment payment payment change
--------------------------------------------------------------------------------------------------------------------------------------------------------
Low Cost Hospitals............................. 3,330 7,007,946 $541.97 72.94 $101.16 $1.65 $63.03 $707.81 6.81
Fully Prospective.......................... 3,068 6,309,538 518.20 70.00 112.35 ......... 67.55 698.11 7.47
100% Federal Rate.......................... 254 685,995 763.67 100.00 ......... ......... 21.61 785.29 2.00
Hold Harmless.............................. 8 12,413 371.31 36.27 ......... 931.58 56.43 1,359.32 24.52
High Cost Hospitals............................ 1,684 4,294,976 767.03 99.15 ......... 9.38 28.59 804.99 1.77
100% Federal Rate.......................... 1,618 4,201,847 775.10 100.00 ......... ......... 28.26 803.36 2.46
Hold Harmless.............................. 66 93,129 402.78 57.09 ......... 432.39 43.27 878.44 -9.13
Total Hospitals........................ 5,014 11,302,922 627.49 83.15 62.72 4.59 49.94 744.74 4.68
--------------------------------------------------------------------------------------------------------------------------------------------------------
We project that low capital cost hospitals paid under the fully
prospective payment methodology will experience an average increase
in payments per case of 6.81 percent, and high capital cost
hospitals will experience an average increase of 1.77 percent.
For hospitals paid under the fully prospective payment
methodology, the Federal rate payment percentage will increase from
60 percent to 70 percent and the hospital-specific rate payment
percentage will decrease from 40 to 30 percent in FY 1998. 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 49.19 percent to 57.09
percent. We estimate the percentage of hold-harmless hospitals paid
based on 100 percent of the Federal rate will increase from 94.6
percent to 96.2 percent.
We expect that the average hospital-specific rate payment per
discharge will decrease from $83.44 in FY 1997 to $62.72 in FY 1998.
This is partly due to the decrease in the hospital-specific rate
payment percentage from 40 percent in FY 1997 to 30 percent in FY
1998.
We are proposing no changes in our exceptions policies for FY
1998. As a result, the minimum payment levels would be:
90 percent for sole community hospitals;
80 percent for urban hospitals with 100 or more beds
and a disproportionate share patient percentage of 20.2 percent or
more; or,
70 percent for all other hospitals.
We estimate that exceptions payments will increase from 6.21
percent of total capital payments in FY 1997 to 6.71 percent of
payments in FY 1998. The number and amount of exceptions payments is
expected to increase throughout the transition period. The projected
distribution of the payments is shown in the table below:
Estimated FY 1998 Exceptions Payments
------------------------------------------------------------------------
Percent of
Type of hospital No. of exceptions
hospitals payments
------------------------------------------------------------------------
Low Capital Cost................................. 332 78
High Capital Cost................................ 183 22
----------------------
Total........................................ 515 100
------------------------------------------------------------------------
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) Percentage
(1) Total No. Percentage Percentage paid full
of hospitals paid hold- paid full Prospective
harmless (A) federal (B) rate
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
All hospitals............................. 5,014 1.5 37.3 61.2
Large urban areas (populations over 1
million)................................. 1,543 1.7 45.4 52.9
Other urban areas (populations of 1
million or fewer)........................ 1,254 1.6 45.7 52.7
Rural areas............................... 2,217 1.3 27.0 71.8
Urban hospitals........................... 2,797 1.6 45.5 52.8
0-99 beds............................. 671 2.4 39.5 58.1
100-199 beds.......................... 938 2.3 52.1 45.5
200-299 beds.......................... 567 0.9 46.9 52.2
300-499 beds.......................... 460 0.4 40.9 58.7
500 or more beds...................... 161 0.6 41.0 58.4
Rural hospitals........................... 2,217 1.3 27.0 71.8
0-49 beds............................. 1,162 1.2 18.9 79.9
[[Page 30028]]
50-99 beds............................ 652 1.8 32.2 66.0
100-149 beds.......................... 237 0.8 42.2 57.0
150-199 beds.......................... 90 0.0 32.2 67.8
200 or more beds...................... 76 0.0 51.3 48.7
By Region
Urban by Region........................... 2,797 1.6 45.5 52.8
New England........................... 158 0.0 27.8 72.2
Middle Atlantic....................... 426 1.4 38.0 60.6
South Atlantic........................ 413 1.9 57.4 40.7
East North Central.................... 471 0.6 36.7 62.6
East South Central.................... 160 0.6 58.8 40.6
West North Central.................... 188 1.6 41.0 57.4
West South Central.................... 344 3.5 64.8 31.7
Mountain.............................. 123 3.3 52.0 44.7
Pacific............................... 466 1.9 39.9 58.2
Puerto Rico........................... 48 0.0 29.2 70.8
Rural by Region........................... 2,217 1.3 27.0 71.8
New England........................... 53 0.0 22.6 77.4
Middle Atlantic....................... 84 2.4 28.6 69.0
South Atlantic........................ 294 1.0 34.4 64.6
East North Central.................... 301 0.0 23.3 76.7
East South Central.................... 273 0.4 37.0 62.6
West North Central.................... 511 1.0 19.8 79.3
West South Central.................... 345 1.4 29.9 68.7
Mountain.............................. 211 5.2 21.8 73.0
Pacific............................... 140 0.7 27.9 71.4
Large urban areas (populations over 1 million) 1,695 1.7 45.0 53.3
Other urban areas (populations of 1 million or
fewer)....................................... 1,193 1.5 45.3 53.2
Rural areas................................... 2,126 1.3 26.8 71.9
Teaching Status:
Non-teaching.............................. 3,925 1.5 37.2 61.3
Fewer than 100 Residents.................. 848 1.5 39.4 59.1
100 or more Residents..................... 241 0.8 32.8 66.4
Disproportionate share hospitals (DSH):
Non-DSH................................... 3,128 1.6 33.7 64.7
Urban DSH:
100 or more beds...................... 1,397 1.1 47.7 51.2
Less than 100 beds.................... 85 2.4 31.8 65.9
Rural DSH:
Sole Community (SCH/EACH)............. 153 3.9 22.2 73.9
Referral Center (RRC/EACH)............ 35 0.0 51.4 48.6
Other Rural:
100 or more beds...................... 79 0.0 48.1 51.9
Less than 100 beds.................... 137 0.0 26.3 73.7
Urban teaching and DSH:
Both teaching and DSH..................... 702 1.0 38.7 60.3
Teaching and no DSH....................... 332 2.4 35.8 61.7
No teaching and DSH....................... 780 1.4 54.0 44.6
No teaching and no DSH.................... 1,074 1.9 45.7 52.4
Rural Hospital Types:
Non special status hospitals.............. 1,340 0.4 25.9 73.7
RRC/EACH.................................. 95 0.0 43.2 56.8
SCH/EACH.................................. 650 3.5 25.2 71.2
SCH, RRC and EACH......................... 41 0.0 41.5 58.5
Type of Ownership:
Voluntary.................................
Voluntary............................. 2,997 1.2 36.9 61.9
Proprietary........................... 673 3.4 65.7 30.9
Government............................ 1,344 1.0 24.1 74.9
Medicare Utilization as a Percent of Inpatient
Days:
0-25...................................... 254 3.1 33.9 63.0
25-50..................................... 1,293 1.9 44.4 53.7
50-65..................................... 1,980 1.2 37.9 61.0
Over 65................................... 1,391 1.2 30.2 68.6
----------------------------------------------------------------------------------------------------------------
[[Page 30029]]
As we explain in Appendix B, we were not able to determine a
hospital-specific rate for 73 of the 5,087 hospitals in our
database. Consequently, the payment methodology distribution is
based on 5,014 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
under the hold-harmless methodology.
The percentage of hospitals paid fully Federal (100 percent of
the Federal rate) as hold-harmless hospitals is expected to increase
to 37.3 percent in FY 1998.
Table IV indicates that 61.2 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 previous section, takes account of the effects of
redeterminations. In other words, this figure does not include low
cost hospitals that, following a hospital-specific rate
redetermination, are now paid under the hold-harmless methodology.)
As expected, a relatively higher percentage of rural and
governmental hospitals (71.8 percent and 74.9 percent, respectively
by payment classification) are being paid under the fully
prospective methodology. This is a reflection of their lower than
average capital costs per case. In contrast, only 30.9 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 1998 actuarial model to estimate the potential
impact of our proposed changes for FY 1998 on total capital payments
per case, using a universe of 5,014 hospitals. The individual
hospital payment parameters are taken from the best available data,
including: the January 1, 1997 update to the provider-specific file,
cost report data, and audit information supplied by intermediaries.
Table V presents estimates of payments per case under our model for
FY 1997 and FY 1998 (columns 2 and 3). Column 4 shows the total
percentage change in payments from FY 1997 to FY 1998. Column 5
presents the percentage change in payments that can be attributed to
Federal rate changes alone.
Federal rate changes represented in Column 5 include the 0.11
percent decrease in the Federal rate, a 1.0 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 4
includes the effects of the Federal rate changes represented in
column 3. Column 4 also reflects the effects of all other changes,
including: the change from 60 percent to 70 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 4.7 percent in FY 1998. The
results show that the effect of the Federal rate changes alone is to
increase payments by 1.1 percent. In addition to the increase
attributable to the Federal rate changes, a 3.6 percent increase is
attributable to the effects of all other changes.
Our comparison by geographic location shows that capital
payments per case to urban and rural hospitals experience similar
rates of increase (4.7 percent and 4.4 percent, respectively).
Payments per case for urban hospitals will increase at about the
same rate as payments per case for rural hospitals (1.2 percent and
0.9 percent, respectively) from the Federal rate changes alone.
Urban hospitals will gain the same as rural hospitals (3.5 percent)
from the effects of all other changes.
By region, there is relatively little variation compared to some
previous years. All regions are estimated to receive increases in
total capital payments per case, partly due to the increased share
of payments that is based on the Federal rate (from 60 to 70
percent). Changes by region vary from a low of 0.7 percent increase
(Mountain urban region) to a high of 10.3 percent increase (rural
hospitals of the Mountain region).
By type of ownership, government hospitals are projected to have
the largest rate of increase (5.3 percent, 1.1 percent due to
Federal rate changes and 4.2 percent from the effects of all other
changes). Payments to voluntary hospitals will increase 4.9 percent
(a 1.1 percent increase due to Federal rate changes and a 3.8
percent increase from the effects of all other changes) and payments
to proprietary hospitals will increase 2.3 percent (a 1.2 percent
increase due to Federal rate changes and a 1.1 percent increase from
the effects of all other 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. 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 1998 compared to the effects of reclassification for FY 1997, we
show the average payment percentage increase for hospitals
reclassified in each fiscal year and in total. For FY 1998
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 1998 as a whole are projected to
experience a 5.3 percent increase in payments (a 2.0 percent
increase attributable to Federal rate changes and a 3.3 percent
increase attributable to the effects of all other changes). Payments
to nonreclassified hospitals will increase slightly less (4.8
percent) than reclassified hospitals (5.3 percent) overall. Payments
to nonreclassified hospitals will increase slightly less than
reclassified hospitals from the Federal rate changes (1.2 percent
compared to 2.0 percent), but they will gain about the same from the
effects of all other changes (3.6 percent compared to 3.3 percent).
Table V.--Comparison of Total Payments Per Case
[FY 1997 Payments Compared To FY 1998 Payments]
----------------------------------------------------------------------------------------------------------------
Average FY Average FY Portion
Number of 1997 1998 attributable
hospitals payments/ payments/ All changes to Federal
case case rate change
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
All hospitals............................. 5,014 711 745 4.7 1.1
Large urban areas (populations over 1
million)................................. 1,543 798 835 4.6 1.1
Other urban areas (populations of 1
million or fewer)........................ 1,254 682 716 5.0 1.2
Rural areas............................... 2,217 567 592 4.4 0.9
Urban hospitals........................... 2,797 747 782 4.7 1.2
0-99 beds............................. 671 611 640 4.7 0.9
[[Page 30030]]
100-199 beds.......................... 938 675 701 3.7 1.1
200-299 beds.......................... 567 723 753 4.2 1.2
300-499 beds.......................... 460 754 795 5.4 1.1
500 or more beds...................... 161 914 963 5.5 1.4
Rural hospitals........................... 2,217 567 592 4.4 0.9
0-49 beds............................. 1,162 412 447 8.6 0.8
50-99 beds............................ 652 438 461 5.2 1.2
100-149 beds.......................... 237 547 566 3.5 1.1
150-199 beds.......................... 90 494 518 5.0 1.5
200 or more beds...................... 76 1,116 1,140 2.2 0.5
By Region:
Urban by Region........................... 2,797 747 782 4.7 1.2
New England........................... 158 734 772 5.1 0.6
Middle Atlantic....................... 426 821 861 4.8 0.9
South Atlantic........................ 413 726 757 4.3 1.0
East North Central.................... 471 690 725 5.1 1.3
East South Central.................... 160 671 714 6.4 2.4
West North Central.................... 188 774 824 6.4 1.4
West South Central.................... 344 736 759 3.1 1.4
Mountain.............................. 123 827 832 0.7 0.9
Pacific............................... 466 812 856 5.4 1.1
Puerto Rico........................... 48 298 309 3.7 1.2
Rural by Region........................... 2,217 567 592 4.4 0.9
New England........................... 53 541 575 6.3 1.8
Middle Atlantic....................... 84 481 494 2.9 0.6
South Atlantic........................ 294 897 919 2.6 0.3
East North Central.................... 301 462 491 6.1 1.0
East South Central.................... 273 427 449 5.0 1.7
West North Central.................... 511 536 556 3.8 1.1
West South Central.................... 345 454 474 4.3 1.2
Mountain.............................. 211 554 611 10.3 1.7
Pacific............................... 140 535 574 7.4 1.4
By Payment Classification:
All hospitals............................. 5,014 711 745 4.7 1.1
Large urban areas (populations over 1
million)................................. 1,695 786 822 4.6 1.1
Other urban areas (populations of 1
million or fewer)........................ 1,193 682 716 5.0 1.2
Rural areas............................... 2,126 568 593 4.3 0.9
Teaching Status:
Non-teaching.......................... 3,925 624 649 4.0 1.1
Fewer than 100 Residents.............. 848 756 796 5.3 1.1
100 or more Residents................. 241 969 1,021 5.4 1.1
Urban DSH:
100 or more beds.................. 1,397 773 811 4.9 1.1
Less than 100 beds................ 85 579 626 8.2 1.2
Rural DSH:
Sole Community (SCH/EACH)......... 153 421 448 6.3 0.7
Referral Center (RRC/EACH)........ 35 1,932 1,964 1.7 0.4
Other Rural:
100 or more beds.................. 79 462 474 2.6 1.1
Less than 100 beds................ 137 446 470 5.5 1.5
Urban teaching and DSH:
Both teaching and DSH..................... 702 838 882 5.2 1.1
Teaching and no DSH....................... 332 792 837 5.7 1.2
No teaching and DSH....................... 780 669 697 4.2 1.2
No teaching and no DSH.................... 1,074 644 667 3.5 1.2
Rural Hospital Types:
Non special status hospitals.............. 1,340 431 451 4.6 0.9
RRC/EACH.................................. 95 664 693 4.5 1.2
SCH/EACH.................................. 650 465 499 7.4 1.1
SCH, RRC and EACH......................... 41 1,868 1,888 1.1 0.4
Hospitals Reclassified by the Medicare
Geographic Classification Review Board:
Reclassification Status During FY97 and
FY98:
Reclassified During Both FY97 and FY98 340 673 704 4.5 1.2
Reclassified During FY98 Only......... 92 581 639 10.0 6.7
Reclassified During FY97 Only......... 172 618 622 0.6 -2.0
FY98 Reclassifications:
All Reclassified Hospitals............ 432 658 693 5.3 2.0
[[Page 30031]]
All Nonreclassified Hospitals......... 4,510 719 753 4.8 1.2
All Urban Reclassified Hospitals...... 117 726 764 5.2 1.8
Urban Nonreclassified Hospitals....... 2,680 748 783 4.7 1.1
All Reclassified Rural Hospitals...... 315 605 638 5.5 2.1
Rural Nonreclassified Hospitals....... 1,875 555 577 4.0 0.5
Other Reclassified Hospitals (Section
1886(D)(8)(B))........................... 27 512 531 3.8 1.6
Type of Ownership:
Voluntary................................. 2,997 715 751 4.9 1.1
Proprietary............................... 673 685 701 2.3 1.2
Government................................ 1,344 712 749 5.3 1.1
Medicare Utilization as a percent of Inpatient
Days:
0-25...................................... 254 768 832 8.4 0.5
25-50..................................... 1,293 808 841 4.0 1.2
50-65..................................... 1,980 690 724 5.0 1.1
Over 65................................... 1,391 593 617 4.2 1.0
----------------------------------------------------------------------------------------------------------------
Appendix B: Technical Appendix on the New 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 have used the capital acquisition model since the start of
prospective payments for capital costs. We now have 4 years of cost
reports under the capital prospective payment system. Consequently,
we have developed a new capital cost model to replace the capital
acquisition model. This new 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, 1996 update of the cost
reports for PPS-IX (cost reporting periods beginning in FY 1992),
PPS-X (cost reporting periods beginning in FY 1993), PPS-XI (cost
reporting periods beginning in FY 1994), and PPS-XII (cost reporting
periods beginning in FY 1995). In addition to model payments, we use
the January 1, 1997 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 excluded from the capital
prospective payment system, we excluded these hospitals from our
model.
We developed FY 1992, FY 1993, FY 1994, FY 1995, FY 1996, and FY
1997 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
------------------------------------------------------------------------
Provider-Specific File Only................................ 115
Provider-Specific and Audit File........................... 4,972
------------
Total.................................................. 5,087
------------------------------------------------------------------------
Ninety-six of the 5,087 hospitals had unusable or missing data
or had no cost reports available. We determined from the cost
reports that 23 of the 96 hospitals were paid under the hold-
harmless methodology. Since the hospital-specific amount is not used
to determine payments for these hospitals, we were able to include
these 23 hospitals in the analysis. Seventy-three hospitals could
not be used in the analysis because of insufficient information.
They account for less than 0.3 percent of admissions so any effect
should be minimal. Therefore, we used data from cost reports from
5,014 hospitals for the analysis.
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 (greater
than 20 percent) changes in bed-size. 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 only for 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, therefore, decrease as assets become fully depreciated, and
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 greatest proportion of rates being at the low end. We use the
gamma distribution to estimate individual hospital rates of
increase.
(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
[[Page 30032]]
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.) 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 are
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 1996 MedPAR file using the FY 1998 DRG relative weights
published in section V. of the Addendum of this proposed rule. The
case-mix index is increased each year after FY 1996 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 1.4 percent in FY 1997 and 1.0 percent in FY 1998.
(Since we are using FY 1996 cases for our analysis, the FY 1996
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 1997, the budget neutrality adjustment factor
was 1.00123. To determine the factor for FY 1998, we first
determined the portion of the Federal rate that would be paid for
each hospital in FY 1998 based on its applicable payment
methodology. Using our model, we then compared estimated aggregate
Federal rate payments based on the FY 1997 DRG relative weights and
the FY 1997 geographic adjustment factor to estimated aggregate
Federal rate payments based on the FY 1998 relative weights and the
FY 1998 geographic adjustment factor. In making the comparison, we
held the FY 1998 Federal rate portion constant and set the other
budget neutrality adjustment factor and the exceptions reduction
factor to 1.00. We determined that, to achieve budget neutrality for
the changes in the geographic adjustment factor and DRG
classifications and relative weights, an incremental budget
neutrality adjustment of 1.00013 for FY 1998 should be applied to
the previous cumulative FY 1997 adjustment of 1.00123, yielding a
cumulative adjustment of 1.00136 through FY 1998. The following
table summarizes the adjustment factors for each fiscal year:
Budget Neutrality Adjustment for DRG Reclassifications and Recalibration
and the Geographic Adjustment Factor
------------------------------------------------------------------------
Incremental Cumulative
Fiscal year adjustment adjustment
------------------------------------------------------------------------
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.................................... 1.00013 1.00136
------------------------------------------------------------------------
The methodology used to determine the recalibration and
geographic (DRG/GAF) budget neutrality adjustment factor is similar
to that used in establishing budget neutrality adjustments under the
prospective payment system for operating costs. One difference is
that, under the operating prospective payment system, the budget
neutrality adjustments for the effect of geographic
reclassifications are determined separately from the effects of
other changes in the hospital wage index and the DRG relative
weights. Under the capital prospective payment system, there is a
single DRG/GAF budget neutrality adjustment factor for changes in
the geographic adjustment factor (including geographic
reclassification) and the DRG relative weights. In addition, there
is no adjustment for the effects that geographic reclassification
has on the other payment parameters, such as the payments for
serving low-income patients or the large urban add-on 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 FY 1992, FY 1993, FY
1994, FY 1995, FY 1996, and FY 1997, the proposed FY 1998 factor,
and the estimated factors that would be applicable through FY 2002.
We caution that, except with respect to FY 1992, FY 1993, FY 1994,
FY 1995, FY 1996 and FY 1997, these are estimates only, and are
subject to revisions resulting from continued methodological
refinements, more recent data, and any payment policy changes that
may occur. In this regard, we note that in making these projections
we have assumed that the cumulative DRG/GAF budget neutrality
adjustment factor will remain at 1.0014 for FY 1998 and later
because we do not have sufficient information to estimate the change
that will occur in the factor for years after FY 1998.
The projections are as follows:
[[Page 30033]]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Exceptions Budget DRG/GAF Outlier Federal rate
Fiscal year Update factor reduction neutrality adjustment adjustment Federal rate (after 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.................................... 1.10 .9276 N/A 1.0001 .9449 .............. 438.43
1999.................................... 1.30 .9286 N/A \4\1.0000 \4\.9449 .............. 444.61
2000.................................... 1.30 .9173 N/A 1.0000 .9449 .............. 444.91
2001.................................... 1.30 .9070 N/A 1.0000 .9449 .............. 445.63
2002.................................... 1.40 \5\1.0000 N/A 1.0000 .9449 .............. 498.20
--------------------------------------------------------------------------------------------------------------------------------------------------------
\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: Future adjustments are, for purposes of this projection, assumed to remain at the same level.
\5\ 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: Revised Hospital Market Basket Data Sources
A. Introduction: Market Basket Relative Weights and Choice of Price
Proxy Variables for the Operating Hospital Input Price Indexes
In the August 30, 1996 final rule (61 FR 46323), we discussed in
detail the current 1992-based hospital market baskets, and noted
that we would revise the hospital market baskets when new cost data
for 1992 became available. This appendix describes the technical
features of the revisions to the 1992-based indexes that we are
proposing in this rule in section IV of the preamble. For both the
prospective payment and excluded hospital market baskets, the
differences between the proposed revised market basket and the
current market basket are noted.
We present this description of the hospital operating market
baskets in three steps:
A synopsis of the differences between the current 1992-
based market baskets and the proposed revisions to those market
baskets.
A description of the methodology used to develop the
cost category weights in the proposed revised market baskets, making
note of the differences from the methodology used to develop the
1992-based current market baskets.
A description of the data sources used to measure price
change for each component of the proposed revised market baskets,
making note of the differences from the price proxies used in the
1992-based current hospital market baskets.
B. Synopsis of Differences
Two major differences exist between the 1992-based current
hospital market baskets and the proposed hospital market baskets.
The first major change is that the proposed revised hospital market
baskets are based on additional hospital expenditure data--data not
available until after the publication of the August 30, 1996 final
rule. The 1992-based current market baskets were derived from
hospital cost reports for cost reporting periods beginning on or
after October 1, 1991 and before October 1, 1992, augmented by
information from the latest available (1987) Input-Output Table for
the hospital industry, produced by the Bureau of Economic Analysis,
U.S. Department of Commerce. In addition to the data sources cited
above, the proposed revised hospital market baskets use data from
the 1992 Asset and Expenditure Survey, produced by the U.S.
Department of Commerce, Economic and Statistics Administration,
Bureau of the Census. These are more recent data made available
after the publication of the FY 1997 final rule.
The second major difference is that some cost categories have
been combined with other cost categories to better reflect the new
data sources. Specifically, the Transportation Services category has
been combined with All Other Non-labor Intensive Services; Business
Services and Computer and Data Processing Services with All Other
Labor Intensive Services; and part of Fuel Oil, Coal, etc. was
combined with Natural Gas into Fuels, Nonhighway. The remainder of
the Fuel Oil, Coal, etc. was combined with Miscellaneous Products.
These category mergers reflect the Bureau of the Census categories
in the Asset and Expenditure Survey and its information on services.
C. Methodology for Developing the Proposed Revised Cost Category
Weights
Cost category weights for the proposed revised market baskets
were developed in three stages. First, base weights for the six main
categories (wages and salaries, employee benefits, pharmaceuticals,
nonmedical professional fees, professional liability insurance, and
all other expenses) were obtained from the 1992-based hospital
market baskets. As the base year is not changing, these weights,
developed last year from HCRIS data and the American Hospital
Association (AHA) Annual Survey information, will not change. The
weight for All Other Expenses was divided into subcategories using
cost shares from the 1992 Asset and Expenditure Survey for
Hospitals, U.S. Department of Commerce, Economics and Statistics
Administration, Bureau of the Census. These subcategories were
further divided using cost shares from the 1987 Input-Output Table
for the hospital industry, produced by the U.S. Department of
Commerce, Bureau of Economic Analysis (BEA), aged to 1992 using
price changes.
A description of the source of the six main category weights is
found in the August 30, 1996 final rule (61 FR 46323). The weight
for the Utilities category, as well as those for the Electricity,
Fuels Nonhighway, and Water and Sewerage Maintenance cost
categories, was derived from the 1992 Asset and Expenditure Survey.
The All Other Goods and Services category has more subcategories
than any other market basket category. Goods found in this category
include: direct service food, contract service food,
pharmaceuticals, chemicals, medical instruments, photo supplies,
rubber and plastics, paper products, apparel, machinery and
equipment and miscellaneous products. Services found in this
category include telephone services, postage, other labor-intensive
services, and other nonlabor-intensive services. The share for
pharmaceuticals was derived from the 1992 Medicare cost reports.
Relative shares for the other subcategories were derived from the
1992 Asset and Expenditure Survey, augmented by data from the 1987
Input-Output Table produced by BEA for the hospital industry, aged
forward to 1992 using price changes, and then standardized to be
consistent with data from the Asset and Expenditure Survey.
D. Price Proxies Used to Measure Cost Category Growth
Descriptions of the price proxies used to measure cost category
price growth in the current hospital market baskets are found in the
August 30, 1996 final rule (61 FR 46324). The price proxies used for
the proposed revised hospital market baskets are the same as those
for the current market baskets. Four cost categories in the current
hospital market baskets have been combined with other cost
categories to better reflect new data sources.
For further discussion of the rationale for choosing specific
price proxies, we refer the reader to the September 3, 1986 final
rule (51 FR 31582).
Appendix D
May 27, 1997
The Honorable Albert Gore, Jr.
President of the Senate
[[Page 30034]]
Washington, D.C. 20510
Dear Mr. President: Section 1886(e)(3)(B) of the Social Security
Act (the Act) requires me to report to Congress the initial estimate
of the applicable percentage increase in inpatient hospital payment
rates for fiscal year (FY) 1998 that I will recommend for hospitals
subject to the Medicare prospective payment system (PPS) and for
hospitals and units excluded from PPS. This submission constitutes
the required report.
Current law mandates an update for all PPS hospitals equal to
the market basket rate of increase. Based on the recent changes in
delivery of hospital inpatient care, with an increasing reliance on
hospital outpatient and postacute care services and a corresponding
decrease in use of hospital inpatient services, we recommend an
update for hospitals in both large urban and other areas of zero
percent.
Sole community hospitals (SCHs) are the sole source of care in
their area and are afforded special payment protection to maintain
access to services for Medicare beneficiaries. SCHs are paid the
higher of a hospital-specific rate or the Federal PPS rate. Current
law mandates that the FY 1998 update to hospital-specific rates for
SCHs equal the market basket rate of increase. We recommend an
update to hospital-specific rates equal to our recommended increase
for all PPS hospitals, zero percent.
Hospitals and distinct part hospital units excluded from PPS are
paid based on their reasonable costs subject to a limit under the
Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982. Current
law mandates an update for all hospitals and distinct part units
excluded from PPS equal to the rate of increase in the excluded
hospital market basket. Consistent with our recommendation for PPS
hospitals, we recommend an increase in the TEFRA limit of zero
percent.
A final recommendation on the appropriate percentage increases
for FY 1998 will be made nearer the beginning of the new Federal
fiscal year based on the most current data available at that time.
The final recommendation will incorporate our analysis of the latest
estimates of all relevant factors, including recommendations by
ProPAC.
Section 1886(d)(4)(C)(iv) of the Act also requires that I
include in my report recommendations with respect to adjustments to
the diagnosis-related group (DRG) weighting factors. At this time I
do not anticipate recommending any adjustment to the DRG weighting
factors for FY 1998.
I am pleased to provide this recommendation to you. I am also
sending a copy of this letter to the Speaker of the House of
Representatives.
Sincerely,
Donna E. Shalala
May 27, 1997
The Honorable Newt Gingrich
Speaker of the House of Representatives
Washington, D.C. 20515
Dear Mr. Speaker: Section 1886(e)(3)(B) of the Social Security
Act (the Act) requires me to report to Congress the initial estimate
of the applicable percentage increase in inpatient hospital payment
rates for fiscal year (FY) 1998 that I will recommend for hospitals
subject to the Medicare prospective payment system (PPS) and for
hospitals and units excluded from PPS. This submission constitutes
the required report.
Current law mandates an update for all PPS hospitals equal to
the market basket rate of increase. Based on the recent changes in
delivery of hospital inpatient care, with an increasing reliance on
hospital outpatient and postacute care services and a corresponding
decrease in use of hospital inpatient services, we recommend an
update for hospitals in both large urban and other areas of zero
percent.
Sole community hospitals (SCHs) are the sole source of care in
their area and are afforded special payment protection to maintain
access to services for Medicare beneficiaries. SCHs are paid the
higher of a hospital-specific rate or the Federal PPS rate. Current
law mandates that the FY 1998 update to hospital-specific rates for
SCHs equal the market basket rate of increase. We recommend an
update to hospital-specific rates equal to our recommended increase
for all PPS hospitals, zero percent.
Hospitals and distinct part hospital units excluded from PPS are
paid based on their reasonable costs subject to a limit under the
Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982. Current
law mandates an update for all hospitals and distinct part units
excluded from PPS equal to the rate of increase in the excluded
hospital market basket. Consistent with our recommendation for PPS
hospitals, we recommend an increase in the TEFRA limit of zero
percent.
A final recommendation on the appropriate percentage increases
for FY 1998 will be made nearer the beginning of the new Federal
fiscal year based on the most current data available at that time.
The final recommendation will incorporate our analysis of the latest
estimates of all relevant factors, including recommendations by
ProPAC.
Section 1886(d)(4)(C)(iv) of the Act also requires that I
include in my report recommendations with respect to adjustments to
the diagnosis-related group (DRG) weighting factors. At this time I
do not anticipate recommending any adjustment to the DRG weighting
factors for FY 1998.
I am pleased to provide this recommendation to you. I am also
sending a copy of this letter to the President of the Senate.
Sincerely,
Donna E. Shalala
Appendix E: Recommendation of Update Factors for Operating Cost
Rates of Payment for Inpatient Hospital Services
I. Background
Several provisions of the Act address the setting of update
factors for inpatient services furnished in FY 1998 by hospitals
subject to the prospective payment system and those excluded from
the prospective payment system. Section 1886(b)(3)(B)(i)(XIII) of
the Act sets the FY 1998 percentage increase in the operating cost
standardized amounts equal to the rate of increase in the hospital
market basket for prospective payment hospitals in all areas.
Section 1886(b)(3)(B)(iv) of the Act sets the FY 1998 percentage
increase in the hospital-specific rates applicable to sole community
hospitals equal to the rate set forth in section 1886(b)(3)(B)(i) of
the Act, that is, the same update factor as all other hospitals
subject to the prospective payment system, or the rate of increase
in the market basket. Section 1886(b)(3)(B)(ii) of the Act sets the
FY 1998 percentage increase in the rate of increase limits for
hospitals excluded from the prospective payment system equal to the
rate of increase in the excluded hospital market basket.
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 1997 forecast of the FY 1998
revised market basket increase of 2.8 percent for hospitals subject
to the prospective payment system, the proposed updates in the
standardized amounts are 2.8 percent for hospitals in both large
urban and other areas. The proposed update in the hospital-specific
rate applicable to sole community hospitals is 2.8 percent (that is,
the market basket rate of increase). The proposed update for
hospitals excluded from the prospective payment system is the
percentage increase in the excluded hospital market basket
(currently estimated at 2.8 percent).
Sections 1886(e)(2)(A) and (3)(A) of the Act require that the
Prospective Payment Assessment Commission (ProPAC) recommend to the
Congress by March 1, 1997 an update factor that takes into account
changes in the market basket rate of increase index, hospital
productivity, technological and scientific advances, the quality of
health care provided in hospitals, and long-term cost effectiveness
in the provision of inpatient hospital services.
In its March 1, 1997 report, ProPAC recommended update factors
to the standardized amounts equal to zero percentage points for
hospitals in both large urban and other areas (Recommendation 2).
ProPAC did not make a separate recommendation for the hospital-
specific rates applicable to sole community hospitals. The
components of ProPAC's update factor recommendations are described
in detail in the ProPAC report, which is published as Appendix F to
this document. We discuss ProPAC's recommendations concerning the
update factors and our responses to these recommendations below.
Section 1886(e)(4) of the Act requires that the Secretary,
taking into consideration the recommendations of ProPAC, recommend
update factors for each fiscal year that take into account the
amounts necessary for the efficient and effective delivery of
medically appropriate and necessary care of high quality. Under
section 1886(e)(5) of the Act, we are required to publish the update
factors recommended under section 1886(e)(4) of the Act.
Accordingly, this appendix provides the recommendations of
appropriate update factors, the analysis underlying our
recommendations, and our responses to the
[[Page 30035]]
ProPAC recommendations concerning the update factors.
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 zero
percentage points for hospitals located in large urban and other
areas. We are also recommending an update of zero percentage points
to the hospital-specific rate for sole community hospitals. 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.
We recommend that hospitals excluded from the prospective
payment system receive a zero update. This update is consistent with
the updates provided to the prospective payment hospitals. 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.
As required by section 1886(e)(4) of the Act, we have taken into
consideration the recommendations of ProPAC in setting these
recommended update factors. Our responses to the ProPAC
recommendations concerning the update factors are discussed below.
III. ProPAC Recommendation for Updating the Prospective Payment System
Standardized Amounts
For FY 1998, ProPAC's update framework would support an update
between -0.6 percent and 1.4 percent. ProPAC notes the significant
changes occurring in health care delivery, including the drop in
hospital lengths of stay for Medicare beneficiaries since 1990 and
the increase in beneficiaries' use of hospital outpatient services
and postacute care. Because payment rates reflect care that is no
longer furnished as part of the hospital stay, ProPAC recommends
that hospitals in large urban and other areas receive an update of
zero percent. However, it emphasizes that, because of uncertainty
about the future and the extent of changes in productivity and
service delivery, its recommendation applies for only one year.
Response: We agree with ProPAC's recommendation that the update
for FY 1998 for prospective payment system hospitals located in
large urban and other areas be equal to zero percentage point. Our
recommendation is supported by the following analyses that measure
changes in hospital productivity, scientific and technological
advances, practice pattern changes, and changes in case mix:
Productivity: Service level productivity is defined as
the ratio of total service output to full-time equivalent employees
(FTEs). While we recognize that productivity is a function of many
variables (for example, labor, nonlabor material, and capital
inputs), we use a labor productivity measure since this update
framework applies to operating payment. To recognize that we are
apportioning the short run output changes to the labor input and not
considering the nonlabor inputs, we weight our productivity measure
for operating costs by the share of direct labor services in the
market basket rate of increase to determine the expected effect on
cost per case.
Our recommendation for the service productivity component is
based on historical trends in productivity and total output for both
the hospital industry and the general economy, and projected levels
of future hospital service output. ProPAC has also estimated
cumulative service productivity growth to be 4.9 percent from 1985-
1989, or 1.2 percent annually. At the same time, ProPAC estimates
total output growth at 3.4 percent annually, implying a ratio of
service productivity growth to output growth of 0.35. Our Medicare
Provider Analysis and Review (MedPAR) file analysis indicates total
Medicare service output (charges per admission, adjusted for CPI
change) decreased 1.6 percent from 1987-1996, or an approximate
average annual decrease of 0.2 percent. Since it is not possible at
this time to develop a productivity measure specific to Medicare
patients, we examined productivity (output per hour) and output
(gross domestic product) for the economy. Depending on the exact
time period, annual changes in productivity range from 0.3 to 0.35
percent of the change in output (that is, a 1.0 percent increase in
output would be correlated with 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 higher in years that output growth is larger than
the historical trend. Based on the above estimates from both the
hospital industry and the economy, we have chosen to employ the
range of ratios of productivity change to output change of 0.30 to
0.35.
The expected change in total hospital service output is the
product of projected growth in total admissions (adjusted for
outpatient usage), projected real case-mix growth, and expected
quality enhancing intensity growth, net of expected decline in
intensity due to reduction of cost ineffective practice. Case-mix
growth and intensity numbers for Medicare are used as proxies for
those of the total hospital, since case-mix increases (used in the
intensity measure as well) are unavailable for non-Medicare
patients. Thus, expected output growth is simply the sum of the
expected change in intensity (0.0 percent), projected admissions
change (2.4 percent for FY 1998), and projected real case-mix growth
(0.8 percent), or 3.2 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 (3.2 percent) by the ratio
of historical service productivity change to total service growth of
0.30 to 0.35 and by the direct labor share percentage (0.614)
provides our productivity standard of 0.6 to 0.7 percent.
ProPAC also believes hospitals should be given an incentive for
additional productivity improvement. ProPAC measures productivity as
the ratio of hospital admissions (adjusted for case mix and
outpatient services) per FTE employee (adjusted for changes in skill
mix). ProPAC includes in its productivity measurement the effect of
changes in practice patterns. We treat practice pattern changes as a
portion of our intensity adjustment, described below. In the past,
ProPAC has expected hospitals to achieve productivity gains ranging
from 0.5 percent to 2.0 percent per year. This year, recognizing
changes in lengths of stay and sites of service, ProPAC believes a
productivity adjustment in the range of -3.0 to -1.0 percentage
points is required in fiscal year 1998. The adjustment is intended
to share productivity equally between hospitals and Medicare.
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 1998, we
recommend an adjustment of 0.0 percent. The basis of this
recommendation is discussed below.
We have no empirical evidence that accurately gauges the level
of quality-enhancing technology changes. Typically, a specific new
technology increases cost in some uses and decreases cost in other
uses. Concurrently, health status is improved in some situations
while in other situations it may be unaffected or even worsened
using the same technology. It is difficult to separate out the
relative significance of each of the cost increasing effects for
individual technologies and new technologies.
The quality enhancing technology component is intended to
recognize the use of services that increase cost but whose value in
terms of enhanced health-status is commensurate with these costs.
Such services may result from technological change, or in some
cases, increased use of existing technologies. The latter recognizes
that as cost and medical effectiveness studies become available,
some increased use of existing, as well as new, services may be
warranted.
The component for reduction of cost-ineffective practice
recognizes that some improvements in practice patterns could be made
so that the intensity of services provided is more consistent with
the efficient use of limited resources. That is, improvements could
be made so that the number of services provided during an inpatient
stay, and their complexity, produce an improvement in health status
that is consistent with the cost of care. This component of our
update recommendation is
[[Page 30036]]
intended to encourage both hospitals and physicians to more
carefully consider the cost-effectiveness of medical care. This
component of the framework also accounts for real within-DRG change,
since that should be directly reflected in the CMI-adjusted growth
in real charges per case.
Following methods developed by HCFA's Office of the Actuary for
deriving hospital output estimates from total hospital charges, we
have developed Medicare-specific intensity measures based on a 5-
year average using FY 1992-1996 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.
In determining case-mix constant intensity, we found that
observed case-mix increase was 1.8 percent in FY 1992, 0.9 percent
in FY 1993, 0.8 percent in FY 1994, 1.7 percent in FY 1995, and 1.6
percent in FY 1996. For FY 1992, 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 rather a fairly steady
1.0 to 1.5 percent per year. We use 1.4 percent as the upper bound
because the RAND study did not take into account that hospitals may
have induced doctors to document medical records more completely in
order to improve payment. Following that study, we consider up to
1.4 percent of observed case-mix change as real for FY 1991 through
FY 1994. Based on this analysis, we believe that all of the observed
case-mix increase for FY 1993 and FY 1994 is real.
Given estimates of real case-mix increase of 1.0 percent for FY
1992, 0.9 percent for FY 1993, 0.8 percent for FY 1994, 1.0 percent
for FY 1995, and 1.0 percent for FY 1996, we estimate that case-mix
constant intensity declined by an average 1.4 percent during FY 1992
through FY 1996, for a cumulative decrease of 7.0 percent. If we
assume that real case-mix increase was 1.4 percent for FY 1992, 0.9
percent for FY 1993, 0.8 percent for FY 1994, 1.4 percent for FY
1995, and 1.4 percent for FY 1996, we estimate that case-mix
constant intensity declined by an average 1.6 percent during FY 1992
through FY 1996, for a cumulative decrease of 7.5 percent. Since we
estimate that intensity has declined during that period, we are
recommending a 0.0 percent intensity adjustment for FY 1998.
Quality Enhancing New Science and Technology: For FY
1998, ProPAC has computed the adjustment for scientific and
technological advances to be a future-oriented policy target
intended to provide additional funds for hospitals to adopt quality-
enhancing, cost increasing health care innovations. In the past,
ProPAC has included an adjustment ranging from 0.3 to 1.0 percentage
points. ProPAC believes that the cost-competitive environment now
faced by hospitals may dampen the adoption of new technologies as
they closely evaluate their relative costs and benefits. Therefore,
ProPAC recommends an adjustment of 0.4 percentage points for the
increase in operating costs due to scientific and technological
advances.
Change in Case Mix: Our analysis takes into account
projected changes in case mix, adjusted for changes attributable to
improved coding practices. For our FY 1998 update recommendation, we
are projecting a 1.0 percent increase in the case-mix index. We
define real case-mix increase as actual changes in the mix (and
resource requirements) of Medicare patients as opposed to changes in
coding behavior that result in assignment of cases to higher-
weighted DRGs but do not reflect greater resource requirements. For
FY 1998, we believe that real case-mix increase is equal to our
projected change in case mix less 0.2 percent. We estimate that
changes in coding behavior account for an increase of 0.2 percentage
points in our projected case-mix change. Our net adjustment to case-
mix change for FY 1998 is 0.2 percentage points.
The 0.0 percent figure used in the ProPAC framework represents
ProPAC's projection for observed case-mix change. ProPAC's net
adjustment for case mix is 0.0 percentage points.
Effect of FY 1996 DRG Reclassification and
Recalibration: We estimate that DRG reclassification and
recalibration for FY 1996 resulted in a 0.0 percent increase in the
case-mix index when compared with the case-mix index that would have
resulted if we had not made the reclassification and recalibration
changes to the GROUPER. ProPAC does not make an adjustment for DRG
reclassification and recalibration in its update recommendation.
Correction for Market Basket Forecast Error: The
estimated market basket percentage increase used to update the FY
1996 payment rates was 3.5 percent. Our most recent data indicate
the actual FY 1996 increase was 2.7 percent, primarily reflecting
that the actual increase in wages, benefits, and chemical prices was
lower than projected. The resulting forecast error in the FY 1996
market basket rate of increase is 0.8 percentage points. Under our
update framework, we make a forecast error correction if our
estimate is off by 0.25 percentage points or more. Therefore, we are
recommending an adjustment of -0.8 percentage points to reflect this
overestimation of the FY 1996 market basket rate of increase. The
following is a summary of the update ranges supported by our
analyses compared to ProPAC's framework.
Table 1.--Comparison of FY 1998 Update Recommendations
----------------------------------------------------------------------------------------------------------------
HHS ProPAC
----------------------------------------------------------------------------------------------------------------
Market Basket............................................... MB MB
Difference between HCFA & ProPAC Market Baskets............. ........................ 0.0
---------------------------------------------------
Subtotal.............................................. MB MB
===================================================
Policy Adjustments Factors:
Productivity............................................ -0.6 to -0.7 -3.0 to -1.0
Intensity............................................... 0.0 ........................
Science & Technology................................ ........................ 0.4
Practice Patterns................................... ........................ (1)
Real Within DRG Change.............................. ........................ (2)
---------------------------------------------------
Subtotal.......................................... -0.6 to -0.7 -2.6 to -0.6
===================================================
Case-Mix Adjustment Factors:
Projected Case-Mix Change............................... -1.0 ........................
Real Across DRG Change.................................. 0.8 ........................
Real Within DRG Change.................................. (3) 0.0
---------------------------------------------------
Subtotal.............................................. -0.2 0.0
===================================================
Effect of 1996 Reclassification & Recalibration............. 0.0 ........................
Forecast Error Correction................................... -0.8 -0.8
[[Page 30037]]
Total Recommended Update.................................... MB -1.7 to MB -1.6 MB -3.4 to MB -1.4
----------------------------------------------------------------------------------------------------------------
(1) Included in ProPAC's Productivity Measure.
(2) Included in ProPAC'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 market basket minus 1.6 percentage points, we
are recommending an update of zero percentage points. We believe
that this update factor appropriately adjusts for changes occurring
in health care delivery including the relative decrease in use of
hospital inpatient services and the corresponding increase in use of
hospital outpatient and postacute care services. We agree with
ProPAC that a zero update for FY 1998 would not disadvantage the
hospital industry nor harm Medicare beneficiaries. We also recommend
that the hospital-specific rates applicable to sole community
hospitals be increased by the same update, zero percentage points.
IV. ProPAC Recommendation for Updating the Rate-of-Increase Limits for
Excluded Hospitals
ProPAC recommends an update factor equal to a 2.0 percent
average increase in TEFRA target amounts for excluded hospitals and
units (Recommendation 13). This reflects a reduction of 0.8
percentage points from HCFA's market basket increase forecast of 2.8
percent. The reduction consists of an adjustment of -0.7 percentage
points to account for the forecast error in the FY 1996 market
basket rate of increase, an adjustment of -0.1 percentage points for
the difference between the forecasts for HCFA's and ProPAC's market
baskets, and no allowance for new technology.
Response: We recommend that hospitals excluded from the
prospective payment system also receive a zero update. This update
is consistent with the updates provided to the prospective payment
hospitals. 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.
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[FR Doc. 97-14248 Filed 5-30-97; 8:45 am]
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