25576 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Health Care Financing Administration

42 CFR Parts 405, 412, and 413

[HCFA–1003–P]

RIN 0938–AI22

Medicare Program; Changes to the

Hospital Inpatient Prospective

Payment Systems and Fiscal Year 1999

Rates

AGENCY: Health Care Financing

Administration (HCFA), HHS.

ACTION: Proposed rule.

SUMMARY: We are proposing to revise the

Medicare hospital inpatient prospective

payment systems for operating costs and

capital-related costs to implement

applicable statutory requirements,

including section 4407 of the Balanced

Budget Act of 1997, as well as changes

arising from our continuing experience

with the systems. In addition, in the

addendum to this proposed rule, we are

describing proposed changes in the

amounts and factors necessary to

determine rates for Medicare hospital

inpatient services for operating costs

and capital-related costs. These changes

would be applicable to discharges

occurring on or after October 1, 1998.

We are also setting forth proposed rateof-increase limits as well as proposing

changes for hospitals and hospital units

excluded from the prospective payment

systems.

DATES: Comments will be considered if

received at the appropriate address, as

provided below, no later than 5 p.m. on

July 7, 1998.

ADDRESSES: Mail written comments (an

original and three copies) to the

following address: Health Care

Financing Administration, Department

of Health and Human Services,

Attention: HCFA–1003–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, ashington, 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

HCFA–1003–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 document, send

your request to: New Orders,

Superintendent of Documents, P.O. Box

371954, Pittsburgh, PA 15250–7954.

Specify the date of the issue requested

and enclose a check or money order

payable to the Superintendent of

Documents, or enclose your Visa or

Master Card number and expiration

date. Credit card orders can also be

placed by calling the order desk at (202)

512–1800 or by faxing to (202) 512–

2250. The cost for each copy is $8.00.

As an alternative, you can view and

photocopy the Federal Register

document at most libraries designated

as Federal Depository Libraries and at

many other public and academic

libraries throughout the country that

receive the Federal Register.

This Federal Register document is

also available from the Federal Register

online database through GPO Access, a

service of the U.S. Government Printing

Office. Free public access is available on

a Wide Area Information Server (WAIS)

through the Internet and via

asynchronous dial-in. Internet users can

access the database by using the World

Wide Web; the Superintendent of

Documents home page address is http:/

/www.access.gpo.gov/suldocs/, by

using local WAIS client software, or by

telnet to swais.access.gpo.gov, then

login as guest (no password required).

Dial-in users should use

communications software and modem

to call (202) 512–1661; type swais, then

login as guest (no password required).

FOR FURTHER INFORMATION CONTACT:

Nancy Edwards, (410) 786–4531,

Operating Prospective Payment, DRG,

and Wage Index Issues.

Tzvi Hefter, (410) 786–4487, Capital

Prospective Payment, Excluded

Hospitals, and Graduate Medical

Education Issues.

SUPPLEMENTARY INFORMATION:

I. Background

A. Summary

Sections 1886(d) and (g) of the Social

Security Act (the Act), set forth a system

of payment for the operating costs of

acute care hospital inpatient stays under

Medicare Part A (Hospital Insurance)

based on prospectively-set rates. Section

1886(g) of the Act requires the Secretary

to pay for the capital-related costs of

hospital inpatient stays under a

prospective payment system. Under

these prospective payment systems,

Medicare payment for hospital inpatient

operating and capital-related costs is

made at predetermined, specific rates

for each hospital discharge. Discharges

are classified according to a list of

diagnosis-related groups (DRGs).

Certain specialty hospitals are

excluded from the prospective payment

systems. Under section 1886(d)(1)(B) of

the Act, the following hospitals and

units are excluded from PPS:

psychiatric hospitals or units,

rehabilitation hospitals or units,

children’s hospitals, long term care

hospitals, and cancer hospitals. For

these hospitals and units, Medicare

payment for operating costs is based on

reasonable costs subject to a hospitalspecific annual limit.

Under section 1886(a)(4) of the Act,

costs incurred in connection with

approved graduate medical education

(GME) programs are excluded from the

operating costs of inpatient hospital

services. Hospitals with approved GME

programs are paid for the direct costs of

GME in accordance with section 1886(h)

of the Act; the amount of payment for

direct GME costs for a cost reporting

period is based on the number of the

hospital’s residents in that period and

the hospital’s costs per resident in a

base year.

The regulations governing the

hospital inpatient prospective payment

system are located in 42 CFR Part 412.

The regulations governing excluded

hospitals are located in both Parts 412

and 413, and the graduate medical

education regulations are found in Part

413.

On August 29, 1997, we published a

final rule with comment period in the

Federal Register (62 FR 45966) setting

forth both statutorily required changes

and other changes to the Medicare

hospital inpatient prospective payment

systems for both operating costs and

capital-related costs, which were

effective for discharges occurring on or

after October 1, 1997. This rule also
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25577

implemented changes addressing

payments for excluded hospitals and

payments for graduate medical

education costs. This final rule with

comment period followed a proposed

rule published in the Federal Register

on June 2, 1997 (62 FR 29902) that set

forth proposed updates and changes.

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, 1998.

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 1999 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 the following:

• FY 1999 wage index update.

• Changes to the data categories

included in the wage index.

• Revisions to the wage index based

on hospital redesignations.

3. Other Decisions and Changes to the

Prospective Payment System for

Inpatient Operating and Graduate

Medical Education Costs

In section IV. of this preamble, we

discuss several provisions of the

regulations in 42 CFR parts 412 and 413

and set forth certain proposed changes

concerning the following:

• Definition of transfer cases.

• Rural referral centers.

• Disproportionate share adjustment.

• Bad debts.

• Direct graduate medical education

programs.

4. Changes to the Prospective Payment

System for Capital-Related Costs

In section V. of this preamble, we

discuss several provisions of the

regulations in 42 CFR part 412 and set

forth certain proposed changes and

clarifications concerning the following:

• Capital indirect medical education

payments.

• Payments to new hospitals.

5. Changes for Hospitals and Hospital

Units Excluded from the Prospective

Payment Systems

In section VI. of this preamble, we

discuss the following criteria governing

excluded hospital issues:

• Hospital-within-a-hospital.

• Adjustments to the target amounts

for FY 1999.

6. Determining Prospective Payment

Operating and Capital Rates and Rate-ofIncrease Limits

In the addendum to this proposed

rule, we set forth proposed changes to

the amounts and factors for determining

the FY 1999 prospective payment rates

for operating costs and capital-related

costs. We are also proposing update

factors for determining the rate-ofincrease limits for cost reporting periods

beginning in FY 1999 for hospitals and

hospital units excluded from the

prospective payment system.

7. Impact Analysis

In Appendix A, we set forth an

analysis of the impact that the proposed

changes described in this proposed rule

would have on affected entities.

8. Capital Acquisition Model

Appendix B contains the technical

appendix on the proposed FY 1999

capital cost model.

9. 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 a

recommended update factor for FY 1999

for both hospitals included in and

hospitals excluded from the prospective

payment systems. This report is

included as Appendix C to this

proposed rule.

10. Proposed Recommendation of

Update Factor for Hospital Inpatient

Operating Costs

As required by sections 1886(e)(4) and

(e)(5) of the Act, Appendix D provides

our recommendation of the appropriate

percentage change for FY 1999 for the

following:

• Large urban area and other area

average standardized amounts (and

hospital-specific rates applicable to sole

community and Medicare-dependent,

small rural hospitals) for hospital

inpatient services paid for under the

prospective payment system for

operating costs.

• Target rate-of-increase limits to the

allowable operating costs of hospital

inpatient services furnished by hospitals

and hospital units excluded from the

prospective payment system.

11. Discussion of Medicare Payment

Advisory Commission

Recommendations

The Balanced Budget Act of 1997

abolished the Prospective Payment

Assessment Commission (ProPAC) and

created the Medicare Payment Advisory

Commission (MedPAC). Under section

1805(b) of the Act, MedPAC is required

to submit a report to Congress, not later

than March 1 of each year, that reviews

and makes recommendations on

Medicare payment policies. The March

1, 1998 report made several

recommendations concerning hospital

inpatient payment policies. We

reviewed those recommendations and

this document sets forth our responses

to those recommendations.

Although it has been our practice to

include a reprint of ProPAC’s March 1

report as an appendix to the proposed

rule, we are not following that practice

with MedPAC reports. For further

information relating specifically to that

report or to obtain a copy of the report,

contact MedPAC at (202) 653–7220.

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, 1998 are discussed below.
25578 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

1A single title combined with two DRG numbers

is used to signify pairs. Generally, the first DRG is

for cases with CC and the second DRG is for cases

without CC. If a third number is included, it

represents cases with patients who are age 0–17.

Occasionally, a pair of DRGs is split between age

>17 and age 0–17.

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 Revision, Clinical Modification

(ICD–9–CM). The Medicare fiscal

intermediary enters the information into

its claims system and subjects it to a

series of automated screens called the

Medicare Code Editor (MCE). These

screens are designed to identify cases

that require further review before

classification into a DRG can be

accomplished.

After screening through the MCE and

any further development of the claims,

cases are classified by the GROUPER

software program into the appropriate

DRG. The GROUPER program was

developed as a means of classifying

each case into a DRG on the basis of the

diagnosis and procedure codes and

demographic information (that is, sex,

age, and discharge status). It is used

both to classify past cases in order to

measure relative hospital resource

consumption to establish the DRG

weights and to classify current cases for

purposes of determining payment. The

records for all Medicare hospital

inpatient discharges are maintained in

the Medicare Provider Analysis and

Review (MedPAR) file. The data in this

file are used to evaluate possible DRG

classification changes and to recalibrate

the DRG weights.

Currently, cases are assigned to one of

496 DRGs in 25 major diagnostic

categories (MDCs). Most MDCs are

based on a particular organ system of

the body (for example, MDC 6, Diseases

and Disorders of the Digestive System);

however, some MDCs are not

constructed on this basis since they

involve multiple organ systems (for

example, MDC 22, Burns).

In general, cases are assigned to an

MDC based on the principal diagnosis,

before assignment to a DRG. However,

there are five DRGs to which cases are

directly assigned on the basis of

procedure codes. These are the DRGs for

liver, bone marrow, and lung 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 1999 and other decisions

concerning DRGs are set forth below.

Unless otherwise noted, our DRG

analysis is based on the full (100

percent) FY 1997 MedPAR file based on

bills received through September 1997.

2. MDC 5 (Diseases and Disorders of the

Circulatory System)

In the August 29, 1997 hospital

inpatient final rule with comment

period (62 FR 45974), we noted that,

because of the many recent changes in

heart surgery, we were considering

conducting a comprehensive review of

the MDC 5 surgical DRGs. We have

begun that review, and based upon our

analysis thus far, we believe it is

appropriate to propose some DRG

changes immediately. These proposed

changes are set forth below.

a. Coronary Bypass. There are two

DRGs that capture coronary bypass

procedures: DRG 106 (Coronary Bypass

with Cardiac Catheterization) and DRG

107 (Coronary Bypass without Cardiac

Catheterization). The procedures that

allow a coronary bypass case to be

assigned to DRG 106 include

percutaneous valvuloplasty,

percutaneous transluminal coronary

angioplasty (PTCA), cardiac

catheterization, coronary angiography,

and arteriography.

In analyzing the FY 1997 MedPAR

file, we noted that, of cases assigned to

DRG 106, the average standardized

charges for coronary bypass cases with

PTCA were significantly higher than

those cases without PTCA. There were

approximately 4,400 cases in DRG 106

where PTCA is performed as a

secondary procedure. These cases have

an average standardized charge of

approximately $69,000. The average

charge of the approximately 95,000

cases in DRG 106 without PTCA is

approximately $52,000.

Based on this analysis, we are

proposing to create a new DRG for

coronary bypass cases with PTCA. The

cases currently in DRG 106 without

PTCA would be assigned to another

DRG and the cases currently assigned to

DRG 107 would be unmodified. Because

we would replace two DRGs with three

new DRGs, we would revise the DRG

numbers and titles accordingly. The

new DRGs and their titles are set forth

below:

DRG 106 Coronary Bypass with PTCA

DRG 107 Coronary Bypass with Cardiac

Catheterization

DRG 109 Coronary Bypass without Cardiac

Catheterization

We note that DRG 109 has been an

empty DRG for the last several years.

b. Implantable Heart Assist System

and Annuloplasty. In the August 29,

1997 final rule with comment period,

we moved implant of an implantable,

pulsatile heart assist system (procedure

code 37.66) from DRGs 110 and 111

(Major Cardiovascular Procedures) 1 to

DRG 108 (Other Cardiothoracic

Procedures). Although this move

improved payment for these procedures,

they were still much more expensive

than the other cases in DRG 108

($96,000 for heart assist versus an

average of $54,000 for all other cases in

the FY 1996 MedPAR file). We stated

that we would continue to review the

MDC 5 surgical DRGs in an attempt to

find a DRG placement for these cases

that would be more similar in terms of

resource use.

In reviewing the FY 1997 MedPAR

file, we note that heart assist system

implant continues to be the most

expensive procedure in DRG 108. In

fact, other than heart transplant, heart

assist system implant is the most

expensive procedure in MDC 5. The

average FY 1997 charge for these cases,

when assigned to DRG 108, is over

$150,000 compared to about $53,000 for

all cases in DRG 108. Obviously, the

charges for heart assist implant are

increasing at a much greater rate than

the average charges for DRG 108. In

addition, the length of stay for cases

coded with 37.66 is approximately 32

days compared to about 11 days for all

other DRG 108 cases.
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25579

One possibility for improving

payment for these cases is to move them

to DRGs 104 and 105 (Cardiac Valve

Procedures). Those DRGs, which split

on the basis of the performance of

cardiac catheterization, have average

charges of approximately $66,000 and

$51,000, respectively. While heart assist

implant cases are still more expensive

than the average case in these DRGs,

payment would be improved. Clinically,

placement of heart assist implant in

DRGs 104 and 105 is not without

precedent. Effective with FY 1988, we

placed implant of a total automatic

implantable cardioverter defibrillator

(AICD) in these DRGs. In addition, the

vast majority of procedures assigned to

DRG 108 involve surgically splitting

open the sternum to perform the

procedure. However, implant of the

heart assist device does not require this

approach.

While reviewing the DRG 108 cases,

we also noted that procedure code 35.33

(annuloplasty) is assigned to this DRG.

Annuloplasty is a valve procedure and

is clinically more similar to the cases

assigned to DRGs 104 and 105 than it is

to the cases assigned to DRG 108. In

addition, the average standardized

charge for annuloplasty cases assigned

to DRG 108 is about $67,000, well above

the overall average charge of

approximately $53,000 for cases in DRG

108. Therefore, we are proposing to

move annuloplasty from DRG 108 to

DRGs 104 and 105.

In order to more accurately reflect the

cases assigned to DRGs 104 and 105, we

would retitle them as follows:

DRG 104 Cardiac Valve and Other Major

Cardiothoracic Procedures with Cardiac

Catheterization

DRG 105 Cardiac Valve and Other Major

Cardiothoracic Procedures without

Cardiac Catheterization.

3. MDC 22 (Burns)

Under the current DRG system, burn

cases are assigned to one of six DRGs in

MDC 22 (Burns), which have not been

revised since 1986. In our FY 1998

hospital inpatient proposed rule (June 2,

1997; 62 FR 29912), in response to

inquiries we had received, we indicated

that we would conduct a comprehensive

review of MDC 22 to determine whether

changes in these DRGs could more

appropriately capture the variation in

resource use associated with different

classes of burn patients. We solicited

public comments on this issue,

particularly asking for recommendations

on ways to categorize related diagnosis

and procedure codes to produce DRG

groupings that would be more

homogeneous in terms of resource use.

Among the comments we received

was a proposal (endorsed by the

American Burn Association (ABA)) for

restructuring the DRGs based on several

statistical and clinical criteria, including

age, severity of the burn, and the

presence of complications or

comorbidities. Although this proposal

was structured for a patient population

encompassing all ages of patients, we

believed that it showed great promise

for Medicare patients as well. During

the last several months, we have worked

closely with representatives of the ABA

and with the clinicians who developed

the proposal in order to refine it for

Medicare purposes.

Based on this work, we are proposing

a new set of DRGs for burn cases. Under

this proposal, we would replace the six

existing DRGs in MDC 22 with eight

new DRGs. For ease of reference and

classification, the current DRGs in MDC

22, DRGs 456 through 460 and 472,

would no longer be valid, and we would

establish new DRGs 504 through 511 to

contain all cases that currently group to

MDC 22. (The complete titles of the new

DRGs are set forth below.)

In reviewing the Medicare burn cases,

we found that the most important

distinguishing characteristic in terms of

resource use was the amount of body

surface affected by the burn and how

much of that burn was a 3rd degree

burn. The second most important factor

was whether or not the patient received

a skin graft. Thus, a patient with burns

covering at least 20 percent of body

area, with at least 10 percent of that a

3rd degree burn, consumed the most

resources. However, if a patient met

these criteria and did not receive a skin

graft, then the case was much less

expensive and the average length of stay

fell from over 30 days to 8 days. The

first two proposed burn DRGs would

reflect these distinctions (DRGs 504 and

505).

After classifying the most extensive

burn cases, we found that the patients

with 3rd degree burns that did not meet

the criteria to be assigned to DRGs 504

and 505 were the most expensive of the

remaining cases (that is, those patients

whose burns that did not meet the at

least 20 percent body area or at least 10

percent 3rd degree criteria). These burns

are referred to clinically as ‘‘fullthickness burns.’’ A subset of these fullthickness burn cases, those with skin

graft or an inhalation injury, were much

more expensive than the other cases.

After dividing these patients into two

groups, with or without skin graft or

inhalation injury, we examined whether

other factors had an influence on

resource use. We found that patients

who had a CC (complication or

comorbidity) or a concomitant

significant trauma consumed more

resources whether or not they had a skin

graft or inhalation injury. Thus, the next

four DRGs were defined as fullthickness burns with skin graft or

inhalation injury with or without CC or

significant trauma, or full-thickness

burns without skin graft or inhalation

injury with or without CC or significant

trauma (DRGs 506 through 509).

Finally, the last two proposed DRGs

(510 and 511) are for cases with

nonextensive burns. These cases are

also split on the basis of CCs or

concomitant significant trauma.

Consistent with the recommendations

of several commenters on last year’s

proposed rule, the new burn DRGs

would no longer include a separate DRG

for cases in which burn patients were

transferred to another acute care facility.

Overall, we estimate that these proposed

changes would increase by more than 25

percent the amount of variation in

resource use explained by the DRGs in

MDC 22. They would also improve the

clinical coherence of the cases within

each DRG. Thus, we believe that the

proposed DRGs would provide for

improved payment for cases assigned to

MDC 22.

The specific diagnosis and procedure

codes that would be included in each of

the eight DRGs and their titles are as

follows:

DRGs 504 and 505—Extensive 3rd

Degree Burns with and without Skin

Graft

DRGs 504 and 505 would include all

cases with burns involving at least 20

percent of body surface area combined

with a 3rd degree burn covering at least

10 percent of body surface area. Thus,

these cases would have diagnosis codes

of 948.xx, with a fourth digit of 2 or

higher (indicating that burn extends

over 20 percent or more of body surface)

and a fifth digit of 1 or higher

(indicating a 3rd degree burn extending

over 10 percent or more of body

surface). Cases with the appropriate

diagnosis codes would be classified into

DRG 504 if one of the following skin

graft procedure codes is present:

85.82 Split-thickness graft to breast

85.83 Full-thickness graft to breast

85.84 Pedicle graft to breast

86.60 Free skin graft, NOS

86.61 Full-thickness skin graft to hand

86.62 Other skin graft to hand

86.63 Full-thickness skin graft to other sites

86.65 Heterograft to skin

86.66 Homograft to skin

86.67 Dermal regenerative graft (new code

in FY 1999—see Table 6A in section V.

of the Addendum)

86.69 Other skin graft to other sites

86.70 Pedicle of flap graft, NOS
25580 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

86.71 Cutting and preparation of pedicle

grafts or flaps

86.72 Advancement of pedicle graft

86.73 Attachment of pedicle or flap graft to

hand

86.74 Attachment of pedicle or flap graft to

other sites

86.75 Revision of pedicle or flap graft

86.93 Insertion of tissue expander

DRGs 506 and 507—Full Thickness

Burn with Skin Graft or Inhalation

Injury with or without CC or Significant

Trauma

These DRGs would include all other

cases of 3rd degree burns that also have

either a skin graft or an inhalation

injury. Thus, these cases would have

diagnosis codes of 941.xx through

946.xx, and 949.xx, with a fourth digit

of 3 or higher, as well as cases with

codes of 948.xx that did not group into

DRGs 504 or 505 (that is, 948.00, 948.01,

and 948.1x through 948.9x with a fifth

digit of 0). In addition, cases classified

into DRGs 506 and 507 must have either

one of the skin graft procedure codes

listed above or one of the following

diagnosis codes for inhalation injuries:

518.5 Pulmonary insufficiency following

trauma and surgery

518.81 Respiratory failure

518.84 Acute and chronic respiratory

failure (new code in FY 1999—see Table

6A in section V. of the Addendum)

947.1 Burn of larynx, trachea, or lung

987.9 Toxic effect of gas, fume, or vapor,

NOS

Cases that meet both of these coding

criteria would be assigned to DRG 506

if there is a diagnosis code indicating

either a CC (based on the standard DRG

CC list) or concomitant significant

trauma (based on the significant trauma

diagnosis codes, listed by body site,

used for classification in MDC 24).

DRGs 508 and 509—Full Thickness

Burn without Skin Graft or Inhalation

Injury with or without CC or Significant

Trauma

These DRGs would include all other

cases of 3rd degree burns. Thus, these

DRGs would include all cases without a

skin graft or inhalation injury that have

diagnosis codes of 941.xx through

946.xx, and 949.xx, with a fourth digit

of 3 or higher, as well as cases with

codes of 948.xx that did not group into

DRGs 504 or 505. DRG 508 would also

require a secondary diagnosis from the

standard CC list or the trauma list based

on the significant trauma diagnosis

codes, listed by body site, used for

classification in MDC 24.

DRGs 510 and 511—Nonextensive

Burns with and without CC or

Significant Trauma

The remaining burn cases would be

classified into one of these two DRGs,

depending on whether or not the claim

included a diagnosis code reflecting the

presence of a CC or a significant trauma,

as explained above.

4. Legionnaires’ Disease

Effective with discharges occurring on

or after October 1, 1997, a new diagnosis

code was created for pneumonia due to

Legionnaires’ disease (code 482.84). In

the August 29, 1997 final rule with

comment period, we assigned this code

to DRGs 79, 80, and 81 (Respiratory

Infections and Inflammations) (62 FR

46090). However, we did not include

this code as a human immunodeficiency

virus (HIV) major related condition in

MDC 25 (HIV Infections). Because

pneumonia due to Legionnaires’ disease

is a serious respiratory condition that

has a deleterious effect on patients with

HIV, we are proposing to assign

diagnosis code 482.84 to DRG 489 (HIV

with Major Related Condition) as a

major related condition. In addition, we

did not assign the code as a major

problem in DRGs 387 (Prematurity with

Major Problems) and 389 (Full Term

Neonate with Major Problems). These

DRGs are assigned to MDC 15

(Newborns and Other Neonates with

Conditions Originating in the Perinatal

Period). Again, as a part of this

proposed rule, we would assign

diagnosis code 482.84 as a major

problem in DRGs 387 and 389 because

of its effect on resource use in treating

newborns.

5. Surgical Hierarchies

Some inpatient stays entail multiple

surgical procedures, each one of which,

occurring by itself, could result in

assignment of the case to a different

DRG within the MDC to which the

principal diagnosis is assigned. It is,

therefore, necessary to have a decision

rule by which these cases are assigned

to a single DRG. The surgical hierarchy,

an ordering of surgical classes from

most to least resource intensive,

performs that function. Its application

ensures that cases involving multiple

surgical procedures are assigned to the

DRG associated with the most resourceintensive surgical class.

Because the relative resource intensity

of surgical classes can shift as a function

of DRG reclassification and

recalibration, we reviewed the surgical

hierarchy of each MDC, as we have for

previous reclassifications, to determine

if the ordering of classes coincided with

the intensity of resource utilization, as

measured by the same billing data used

to compute the DRG relative weights.

A surgical class can be composed of

one or more DRGs. For example, in

MDC 5, the surgical class ‘‘heart

transplant’’ consists of a single DRG

(DRG 103) and the class ‘‘major

cardiovascular procedures’’ consists of

two DRGs (DRGs 110 and 111).

Consequently, in many cases, the

surgical hierarchy has an impact on

more than one DRG. The methodology

for determining the most resourceintensive surgical class involves

weighting each DRG for frequency to

determine the average resources for each

surgical class. For example, assume

surgical class A includes DRGs 1 and 2

and surgical class B includes DRGs 3, 4,

and 5. Assume also that the average

charge of DRG 1 is higher than that of

DRG 3, but the average charges of DRGs

4 and 5 are higher than the average

charge of DRG 2. To determine whether

surgical class A should be higher or

lower than surgical class B in the

surgical hierarchy, we would weight the

average charge of each DRG by

frequency (that is, by the number of

cases in the DRG) to determine average

resource consumption for the surgical

class. The surgical classes would then

be ordered from the class with the

highest average resource utilization to

that with the lowest, with the exception

of ‘‘other OR procedures’’ as discussed

below.

This methodology may occasionally

result in a case involving multiple

procedures being assigned to the lowerweighted DRG (in the highest, most

resource-intensive surgical class) of the

available alternatives. However, given

that the logic underlying the surgical

hierarchy provides that the GROUPER

searches for the procedure in the most

resource-intensive surgical class this

result is unavoidable.

We note that, notwithstanding the

foregoing discussion, there are a few

instances when a surgical class with a

lower average relative weight is ordered

above a surgical class with a higher

average relative weight. For example,

the ‘‘other OR procedures’’ surgical

class is uniformly ordered last in the

surgical hierarchy of each MDC in

which it occurs, regardless of the fact

that the relative weight for the DRG or

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
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25581

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 higherordered 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.

At this time, we would revise the

surgical hierarchy for MDC 3 (Diseases

and Disorders of the Ear, Nose, Mouth

and Throat) as follows:

• We would reorder Sinus and

Mastoid Procedures (DRGs 53–54) above

Myringotomy with Tube Insertion

(DRGs 61–62).

• We would reorder Mouth

Procedures (DRGs 168–169) above

Tonsil and Adenoid Procedure Except

Tonsillectomy and/or Adeniodectomy

Only (DRGs 57–58).

6. Refinement of Complications and

Comorbidities List

There is a standard list of diagnoses

that are considered CCs. We developed

this list using physician panels to

include those diagnoses that, when

present as a secondary condition, would

be considered a substantial

complication or comorbidity. In

previous years, we have made changes

to the standard list of CCs, either by

adding new CCs or deleting CCs already

on the list. At this time, we do not

propose to delete any of the diagnosis

codes on the CC list.

In the September 1, 1987 final notice

concerning changes to the DRG

classification system (52 FR 33143), we

modified the GROUPER logic so that

certain diagnoses included on the

standard list of CCs would not be

considered a valid CC in combination

with a particular principal diagnosis.

Thus, we created the CC Exclusions

List. We made these changes to preclude

coding of CCs for closely related

conditions, to preclude duplicative

coding or inconsistent coding from

being treated as CCs, and to ensure that

cases are appropriately classified

between the complicated and

uncomplicated DRGs in a pair.

In the May 19, 1987 proposed notice

concerning changes to the DRG

classification system (52 FR 18877), we

explained that the excluded secondary

diagnoses were established using the

following five principles:

• Chronic and acute manifestations of

the same condition should not be

considered CCs for one another (as

subsequently corrected in the

September 1, 1987 final notice (52 FR

33154)).

• Specific and nonspecific (that is,

not otherwise specified (NOS))

diagnosis codes for a condition should

not be considered CCs for one another.

• Conditions that may not co-exist,

such as partial/total, unilateral/bilateral,

obstructed/unobstructed, and benign/

malignant, should not be considered

CCs for one another.

• The same condition in anatomically

proximal sites should not be considered

CCs for one another.

• Closely related conditions should

not be considered CCs for one another.

The creation of the CC Exclusions List

was a major project involving hundreds

of codes. The FY 1988 revisions were

intended to be only a first step toward

refinement of the CC list in that the

criteria used for eliminating certain

diagnoses from consideration as CCs

were intended to identify only the most

obvious diagnoses that should not be

considered complications or

comorbidities of another diagnosis. For

that reason, and in light of comments

and questions on the CC list, we have

continued to review the remaining CCs

to identify additional exclusions and to

remove diagnoses from the master list

that have been shown not to meet the

definition of a CC. (See the September

30, 1988 final rule for the revision made

for the discharges occurring in FY 1989

(53 FR 38485); the September 1, 1989

final rule for the FY 1990 revision (54

FR 36552); the September 4, 1990 final

rule for the FY 1991 revision (55 FR

36126); the August 30, 1991 final rule

for the FY 1992 revision (56 FR 43209);

the September 1, 1992 final rule for the

FY 1993 revision (57 FR 39753); the

September 1, 1993 final rule for the FY

1994 revisions (58 FR 46278); the

September 1, 1994 final rule for the FY

1995 revisions (59 FR 45334); the

September 1, 1995 final rule for the FY

1996 revisions (60 FR 45782); the

August 30, 1996 final rule for the FY

1997 revisions (61 FR 46171); and the

August 29, 1997 final rule for the FY

1998 revisions (62 FR 45966)).

We are proposing a limited revision of

the CC Exclusions List to take into

account the changes that will be made

in the ICD–9–CM diagnosis coding

system effective October 1, 1998. (See

section II.B.8, below, for a discussion of

ICD–9–CM changes.) These proposed

changes are being made in accordance

with the principles established when we

created the CC Exclusions List in 1987.

Tables 6F and 6G 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, 1998. 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 6F—Additions to the CC

Exclusions List. Beginning with

discharges on or after October 1, 1998,

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 6G—Deletions from the CC

Exclusions List. Beginning with

discharges on or after October 1, 1998

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
25582 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

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, 1997, and 1998) and

those in Tables 6F and 6G 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, 1998.

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 15.0, is available for $195.00,

which includes $15.00 for shipping and

handling. Version 16.0 of this manual,

which will include the final FY 1999

DRG changes, will be available in

October 1998 for $225.00. 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.

7. Review of Procedure Codes in DRGs

468, 476, and 477

Each year, we review cases assigned

to DRG 468 (Extensive OR Procedure

Unrelated to Principal Diagnosis), DRG

476 (Prostatic OR Procedure Unrelated

to Principal Diagnosis), and DRG 477

(Nonextensive OR Procedure Unrelated

to Principal Diagnosis) in order to

determine whether it would be

appropriate to change the procedures

assigned among these DRGs.

DRGs 468, 476, and 477 are reserved

for those cases in which none of the OR

procedures performed is related to the

principal diagnosis. These DRGs are

intended to capture atypical cases, that

is, those cases not occurring with

sufficient frequency to represent a

distinct, recognizable clinical group.

DRG 476 is assigned to those discharges

in which one or more of the following

prostatic procedures are performed and

are unrelated to the principal diagnosis:

60.0 Incision of prostate

60.12 Open biopsy of prostate

60.15 Biopsy of periprostatic tissue

60.18 Other diagnostic procedures on

prostate and periprostatic tissue

60.21 Transurethral prostatectomy

60.29 Other transurethral prostatectomy

60.61 Local excision of lesion of prostate

60.69 Prostatectomy NEC

60.81 Incision of periprostatic tissue

60.82 Excision of periprostatic tissue

60.93 Repair of prostate

60.94 Control of (postoperative) hemorrhage

of prostate

60.95 Transurethral balloon dilation of the

prostatic urethra

60.99 Other operations on prostate

All remaining OR procedures are

assigned to DRGs 468 and 477, with

DRG 477 assigned to those discharges in

which the only procedures performed

are nonextensive procedures that are

unrelated to the principal diagnosis.

The original list of the ICD–9–CM

procedure codes for the procedures we

consider nonextensive procedures, if

performed with an unrelated principal

diagnosis, was published in Table 6C in

section IV. of the Addendum to the

September 30, 1988 final rule (53 FR

38591). As part of the final rules

published on September 4, 1990, August

30, 1991, September 1, 1992, September

1, 1993, September 1, 1994, September

1, 1995, August 30, 1996, and August

29, 1997, we moved several other

procedures from DRG 468 to 477, as

well as moving some procedures from

DRG 477 to 468. (See 55 FR 36135, 56

FR 43212, 57 FR 23625, 58 FR 46279,

59 FR 45336, 60 FR 45783, 61 FR 46173,

and 62 FR 45981, respectively.)

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 did not identify any

necessary changes; therefore, we are not

proposing to move any procedures from

DRGs 468 and 477 to one of the surgical

DRGs.

b. Reassignment of Procedures Among

DRGs 468, 476, and 477. We also

reviewed the list of procedures that

produce assignments to DRGs 468, 476,

and 477 to ascertain if any of those

procedures should be moved from one

of these DRGs to another based on

average charges and length of stay.

Generally, we move only those

procedures for which we have an

adequate number of discharges to

analyze the data. Based on our review

this year, we are not proposing to move

any procedures from DRG 468 to DRGs

476 or 477, from DRG 476 to DRGs 468

or 477, or from DRG 477 to DRGS 468

or 476.

8. Changes to the ICD–9–CM Coding

System

As 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 the Tabular

List and Alphabetic Index for Diseases

while HCFA has lead responsibility for

the ICD–9–CM procedure codes

included in the Tabular List and

Alphabetic Index for Procedures.

The Committee encourages

participation in the above process by

health-related organizations. In this

regard, the Committee holds public

meetings for discussion of educational

issues and proposed coding changes.

These meetings provide an opportunity

for representatives of recognized

organizations in the coding 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 5 and December 4 and 5,

1997, and finalized the coding changes

after consideration of comments

received at the meetings and in writing
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25583

within 30 days following the December

1997 meeting. The initial meeting for

consideration of coding issues for

implementation in FY 2000 will be held

on June 4, 1998. Copies of the minutes

of the 1997 meetings can be obtained

from the HCFA Home Page @ http://

www.hcfa.gov/pubaffr.htm, under the

‘‘What’s New’’ listing. Paper copies of

these minutes are no longer available

and the mailing list has been

discontinued. We encourage

commenters to address suggestions on

coding issues involving diagnosis codes

to: Donna Pickett, Co-Chairperson; ICD–

9–CM Coordination and Maintenance

Committee; NCHS; Room 1100; 6525

Belcrest Road; Hyattsville, Maryland

20782. Comments may be sent by E-mail

to: dfp4@cdc.gov.

Questions and comments concerning

the procedure codes should be

addressed to: Patricia E. Brooks, CoChairperson; ICD–9–CM Coordination

and Maintenance Committee; HCFA,

Center for Health Plans and Providers,

Plan and Provider Purchasing Policy

Group, Division of Acute Care; 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, 1998. 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

classifications.

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, 1998. The

corresponding new or expanded

diagnosis codes are included in Table

6A. Procedure codes that have been

replaced by expanded codes, other

codes, or have been deleted are in Table

6D (Invalid Procedure Codes). Revisions

to diagnosis code titles are in Table 6E

(Revised Diagnosis Code Titles), which

also include the proposed DRG

assignments for these revised codes. For

FY 1999, there are no revisions to

procedure code titles.

9. Other Issues—

a. Palliative Care. Effective October 1,

1996 (FY 1997), we introduced a

diagnosis code to allow the

identification of those cases in which

palliative care was delivered to a

hospital inpatient. This code, V66.7

(Encounter for palliative care), was

unusual in that there had been no

previous code assignment that included

the concept of palliative care. Since this

was a new concept, instructional

materials were developed and

distributed by the AHA as well as

specialty groups on the use of this new

code. With new codes, it sometimes

takes several years for physician

documentation to improve and for

coders to become accustomed to looking

for this type of information in order to

assign a code. There is an inclusion note

listed under V66.7 which indicates that

this code should be used as a secondary

diagnosis only; the patient’s medical

problem would always be listed first.

Currently, use of diagnosis code V66.7

does not have an impact on DRG

assignment. Consistent with prior

practice, we have waited until the FY

1997 data became available for analysis

before considering any possible

modifications to the DRGs.

In analyzing the FY 1997 bills

received through September 1997, we

found that 4,769 discharges included

V66.7 as a secondary diagnosis. These

cases were widely distributed

throughout 199 DRGs. The vast majority

of these DRGs included five or fewer

discharges with use of palliative care.

Only 12 DRGs included more than 100

cases. These were the following:

DRG Title Number of

cases

10 ................................................................ Nervous System Neoplasms with CC ............................................................................ 144

14 ................................................................ Specific Cerebrovascular Disorders Except TIA ............................................................ 272

79 ................................................................ Respiratory Infections and Inflammations Age >17 with CC ......................................... 139

82 ................................................................ Respiratory Neoplasms .................................................................................................. 526

89 ................................................................ Simple Pneumonia and Pleurisy Age >17 with CC ....................................................... 200

127 .............................................................. Heart Failure and Shock ................................................................................................. 184

172 .............................................................. Digestive Malignancy with CC ........................................................................................ 226

203 .............................................................. Malignancy of Hepatobiliary System or Pancreas ......................................................... 285

239 .............................................................. Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy ........ 218

296 .............................................................. Nutritional and Miscellaneous Metabolic Disorders Age >17 with CC .......................... 173

403 .............................................................. Lymphoma and Non-Acute Leukemia with CC .............................................................. 178

416 .............................................................. Septicemia Age >17 ....................................................................................................... 147

Six of these DRGs are cancer-related;

however, the other DRGs are quite

diverse. Upon further analysis, we

found that, for the most part, discharges

with code V66.7 do not significantly

differ in length of stay from the

discharges in the same DRG without

code V66.7. Discharges with code V66.7

are sometimes longer and sometimes

shorter and the comparative length of

stay for a given DRG tends to vary by

only one day. In general, the average

charges for a palliative care case

discharge with a secondary code of

V66.7 were lower than the charges for

other discharges within the DRG.

However, these differences were

relatively small and were well within

the standard variation of charges for

cases in the DRG.

One approach we could take to revise

the DRGs would be to divide those

DRGs with a large number of cases

coded with V66.7 into two different

DRGs, with and without palliative care.

However, the relatively small

proportion of cases in each DRG argues

against this approach; no DRG has more

than 1 percent of its cases coded with

palliative care and, in most cases, the

percentage is well under 1 percent. An

alternative approach would be to group

all palliative care cases, regardless of the

underlying disease or condition, into

one new DRG. However, the charges of

these cases are so varied that this is not

a logical choice. In addition, there is a

lack of clinical coherence in such an

approach. The underlying diagnoses of
25584 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

these cases range from respiratory

conditions to heart failure to septicemia.

Because there are so few cases in the FY

1997 data and they are so widely

dispersed among different DRGs, we are

not proposing a DRG modification at

this time. We will make a more detailed

analysis of these cases over the next

year based on a more complete FY 1997

data file as well as review of the FY

1998 cases that will be available later

this year. As time goes by, hospital

coders and physicians should become

more aware of this code and we hope

that more complete data will assist our

decision making process.

b. PTCA. Effective with discharges

occurring on or after October 1, 1997,

we reassigned cases of PTCA with

coronary artery stent implant from DRG

112 to DRG 116. In the August 29, 1997

final rule with comment period, we

responded to several commenters who

contended that PTCA cases treated with

platelet inhibitors were as resource

intensive as the PTCA with stent

implant cases and that these cases

should also be moved to DRG 116.

However, there is currently no code that

describes the infusion of platelet

inhibitors. Therefore, we were unable to

make any changes in the DRGs for FY

1998.

As set forth in Table 6B, New

Procedure Codes in section V. of the

addendum to this proposed rule, a new

procedure code for injection or infusion

of platelet inhibitors (code 99.20) will

be effective with discharges occurring

on or after October 1, 1998. Our usual

policy on new codes is to assign them

to the same DRG or DRGs as their

predecessor code. Because infusion of

platelet inhibitors is currently assigned

to a non-OR procedure code, we

followed our usual practice and

designated code 99.20 as a non-OR code

that does not affect DRG assignment.

We will not have any data on this new

code until we receive bills for FY 1999.

Thus, we would be unable to make any

changes in DRG assignment until FY

2001. We note, however, that the

Conference Report that accompanied the

Balanced Budget Act of 1997 contained

language stating that ‘‘* * * in order to

ensure that Medicare beneficiaries have

access to innovative new drug therapies,

the Conferees believe that HCFA should

consider, to the extent feasible, reliable,

validated data other than MedPAR data

in annually recalibrating and

reclassifying the DRGs.’’ (H.R. Rep. No.

105–217.734). At this time, we have

received no data that would allow us to

make an appropriate modification of

DRG 112 for PTCA cases with platelet

infusion therapy. When we develop the

final rule, we will review and analyze

any data we receive about the use of

platelet inhibitors for Medicare

beneficiaries. If we believe that the data

are adequate to allow identification of

the percentage of cases in DRG 112 that

receive this therapy and the charge and

length of stay data convince us that

these cases should be moved, we will

consider such a move effective for

discharges occurring on or after October

1, 1998.

C. Recalibration of DRG Weights

We are proposing to use the same

basic methodology for the FY 1999

recalibration as we did for FY 1998. (See

the August 29, 1997 final rule with

comment (62 FR 45982).) 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 1997 MedPAR file, rather than

the FY 1996 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

1997 MedPAR data, based on bills

received by HCFA through December

1997, from all hospitals subject to the

prospective payment system and shortterm acute care hospitals in waiver

States. The FY 1997 MedPAR file

includes data for approximately 11.2

million Medicare discharges.

The methodology used to calculate

the proposed DRG relative weights from

the FY 1997 MedPAR file is as follows:

• To the extent possible, all the

claims were regrouped using the

proposed DRG classification revisions

discussed above in section II.B of this

preamble. As noted in section II.B.5,

due to the unavailability of revised

GROUPER software, we simulate most

major classification changes to

approximate the placement of cases

under the proposed reclassification.

However, there are some changes that

cannot be modeled.

• Charges were standardized to

remove the effects of differences in area

wage levels, indirect medical education

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, heartlung, liver, and lung transplant centers

that have cases in the FY 1995 MedPAR

file. (Medicare coverage for heart, heartlung, 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 1999. Using the

FY 1997 MedPAR data set, there are 38

DRGs that contain fewer than 10 cases.

We computed the weights for the 38

low-volume DRGs by adjusting the FY

1998 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
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25585

changes, result in an average case

weight that is different from the average

case weight before recalibration.

Therefore, the new weights are

normalized by an adjustment factor, so

that the average case weight after

recalibration is equal to the average case

weight before recalibration. This

adjustment is intended to ensure that

recalibration by itself neither increases

nor decreases total payments under the

prospective payment system.

Section 1886(d)(4)(C)(iii) of the Act

requires that beginning with FY 1991,

reclassification and recalibration

changes be made in a manner that

assures that the aggregate payments are

neither greater than nor less than the

aggregate payments that would have

been made without the changes.

Although normalization is intended to

achieve this effect, equating the average

case weight after recalibration to the

average case weight before recalibration

does not necessarily achieve budget

neutrality with respect to aggregate

payments to hospitals because payment

to hospitals is affected by factors other

than average case weight. Therefore, as

we have done in past years and as

discussed in section II.A.4.b of the

Addendum to this proposed rule, we are

proposing to make a budget neutrality

adjustment to assure that the

requirement of section 1886(d)(4)(C)(iii)

of the Act is met.

III. Proposed Changes to the Hospital

Wage Index

A. Background

Section 1886(d)(3)(E) of the Act

requires that, as part of the methodology

for determining prospective payments to

hospitals, the Secretary must adjust the

standardized amounts ‘‘for area

differences in hospital wage levels by a

factor (established by the Secretary)

reflecting the relative hospital wage

level in the geographic area of the

hospital compared to the national

average hospital wage level.’’ In

accordance with the broad discretion

conferred 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 wagerelated costs incurred in furnishing

skilled nursing services. We also adjust

the wage index, as discussed below in

section III.F, 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 1999 Wage Index Update

The proposed FY 1999 wage index in

section V of the Addendum (effective

for hospital discharges occurring on or

after October 1, 1998 and before October

1, 1999) is based on the data collected

from the Medicare cost reports

submitted by hospitals for cost reporting

periods beginning in FY 1995 (the FY

1998 wage index was based on FY 1994

wage data). The proposed FY 1999 wage

index includes the following categories

of data, which were also included in the

FY 1998 wage index:

• Total salaries and hours from shortterm, acute care hospitals.

• Home office costs and hours.

• Direct patient care contract labor

costs and hours.

The proposed wage index also

continues to exclude the direct salaries

and hours for nonhospital services such

as skilled nursing facility services, home

health services, or other subprovider

components that are not subject to the

prospective payment system. Finally, as

discussed in detail in the August 29,

1997 final rule with comment period,

we would calculate a separate Puerto

Rico-specific wage index and apply it to

the Puerto Rico standardized amount.

(See 62 FR 45984 and 46041) This wage

index is based solely on Puerto Rico’s

data.

For FY 1999 we are proposing to

include two changes to the categories:

we will add contract labor costs and

hours for top management positions and

replace the fringe benefit category with

the wage-related costs associated with

hospital and home office salaries

category. These two changes reflect

changes to the Medicare cost report that

were implemented in the FY 1995

hospital prospective payment system

September 1, 1994 final rule with

comment period (59 FR 45355). The

changes were made to the cost report for

cost reporting periods beginning during

FY 1995. Because we are using wage

data from the FY 1995 cost report for the

proposed FY 1999 wage index, these

two changes will be reflected in the

wage index for the first time in FY 1999.

As discussed in detail in the

September 1, 1994 final rule with

comment period (59 FR 45355), we

expanded the definition of contract

services reported on the Worksheet S–

3 to include the labor-related costs

associated with contract personnel in a

hospital’s top four management

positions: Chief Executive Officer

(CEO)/Hospital Administrator, Chief

Operating Officer (COO), Chief

Financial Officer (CFO), and Nursing

Administrator. We also revised the cost

report to reflect a change in terminology

from ‘‘fringe benefits’’ to ‘‘wage-related

costs,’’ to promote the consistent

reporting of these costs. (See September

1, 1994 final rule with comment period

59 FR 45356–45359.) We made this

change in terminology because we

believe that it will eliminate confusion

regarding those wage-related costs that

are incorporated in the wage index

versus the broader definition of fringe

benefits recognized under the Medicare

cost reimbursement principles. Wagerelated costs, which include core and

other wage-related costs, are reported on

the Form HCFA–339, the Provider Cost

Report Reimbursement Questionnaire.

Finally, we have analyzed the wage

data for the following costs, which were

separately reported for the first time on

the FY 1995 cost reports:

• Physician Part A costs.

• Resident and Certified Registered

Nurse Anesthetist (CRNA) Part A costs.

• Overhead cost and hours by cost

center.

Our analysis and proposals

concerning these data are set forth

below in section III.C.
25586 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

C. Proposals Concerning the FY 1999

Wage Index

1. Physician Part A Costs.

Currently, if a hospital directly

employs a physician, the Part A portion

of the physician’s salary and wagerelated costs (that is, administrative and

teaching service) is included in the

calculation of the wage index. However,

the costs for contract physician Part A

services are not included. Our policy

has been that, to be included in the

wage index calculation, a contracted

service must be related to direct patient

care, or, beginning with the FY 1999

wage index, top level management (see

discussion above). Because some States

have laws that prohibit hospitals from

directly hiring physicians, the hospitals

in those States have claimed that they

are disadvantaged by the wage index’s

exclusion of contract physician Part A

costs. We began collecting separate

wage data for both direct and contract

physician Part A services on the FY

1995 cost report in order to analyze this

issue. As we discussed in the September

1, 1994 final rule with comment period

(59 FR 45354), our original purpose in

collecting these data was to exclude all

Part A physician costs from the wage

index.

When we made the change to the cost

report, there were five States in which

hospitals were prohibited from directly

employing physicians. We understand

that only two States currently maintain

this prohibition: Texas and California.

Thus, the number of hospitals affected

by our current policy has decreased.

Nevertheless, the fact that hospitals in

these two States are still prohibited from

directly employing physicians for Part A

services and, therefore, must enter into

contractual agreements with physicians

for these services, perpetuates the

perceived inequity.

The main reasons we planned to

exclude all Part A physician costs rather

than include the contract costs was our

concern that it would be difficult to

accurately attribute the Part A costs and

hours of these contract physicians and

including these costs could

inappropriately inflate the hospitals’

average hourly wages. That is, we

anticipated that average costs for

contract physicians would be

significantly higher than the costs for

those physicians directly employed by

the hospital. However, our analysis of

the data shows that the average hourly

wages for contract physician Part A

costs are very similar to, and, in fact

slightly lower than, the costs for salaried

Part A physician services.

Based on this result, we believe that

continuing to include the direct

physician Part A costs and adding the

costs for contract physicians would be

the better policy. Thus, we are

proposing to calculate the FY 1999 wage

index including both direct and contract

physician Part A costs.

Of the 5,115 hospitals included in the

FY 1995 wage data file, approximately

23 percent reported contract physician

Part A costs. Including these costs

would raise the wage index values for

one MSA (2 hospitals) by more than 5

percent and 5 MSAs (60 hospitals) by

between 2 and 5 percent. One Statewide

rural area (68 hospitals) would

experience a decrease between 2 and 5

percent. The wage index values for the

remaining 365 areas (5,055 hospitals)

would be relatively unaffected,

experiencing changes of between -2 and

2 percent. We understand that an

unusually large number of hospitals

have requested changes to these wage

data; therefore, there may be relatively

significant differences between the wage

data file used to calculate the proposed

wage index and the final corrected wage

data in the file used to calculate the

final wage index. Because of this, we

will reevaluate our decision based on

that final wage data, which will be

submitted by April 6, 1998. If we find

significant differences in the contract

labor costs, we may reconsider our

proposal.

2. Resident and CRNA Part A Costs

The wage index presently includes

salaries and wage-related costs for

residents in approved medical

education programs and for CRNAs

employed by hospitals under the rural

pass-through provision. However,

Medicare pays for these costs outside

the prospective payment system.

Removing these costs from the wage

index calculation would be consistent

with our general policy to exclude costs

that are not paid through the

prospective payment system, but,

because they were not separately

identifiable, we could not remove them.

In the September 1, 1994 final rule

with comment period (59 FR 45355), we

stated that we would begin collecting

the resident and CRNA wage data

separately and would evaluate the data

before proposing a change in computing

the wage index. However, there were

data reporting problems associated with

these costs on the FY 1995 cost report.

The original instructions for reporting

resident costs on Line 6 of Worksheet S–

3, Part III, erroneously included

teaching physician salaries and other

teaching program costs from Worksheet

A of the cost report. Although we issued

revised instructions to correct this error,

we now understand these revisions may

not have been uniformly instituted.

Another issue relating to residents’

salaries stems from apparent

underreporting of these costs by

hospitals and inconsistent treatment of

the associated wage-related costs.

In addition, the original Worksheet S–

3 and reporting instructions did not

provide for the separate reporting of

CRNA wage-related costs. Another issue

with the FY 1995 wage data is the

inclusion of contract CRNA Part A costs

in the contract labor costs reported on

Worksheet S–3. We believe that much of

the CRNA Part A costs are reported

under contract labor, rather than under

salaried employee costs, due to the

heavy use of contract labor by rural

hospitals. We do not believe that it

would be feasible at this time to try to

remove these CRNA Part A costs from

the contract labor costs. We improved

the reporting instructions for CRNA

costs on the FY 1996 cost report.

Our analysis of the CRNA and

resident wage data submitted on the FY

1995 cost report convinces us that these

data are inaccurately and incompletely

reported by hospitals. For example,

although there are over 900 teaching

hospitals receiving graduate medical

education payments, only about 800

hospitals reported resident cost data.

Because we do not want to make a

relatively significant change in the wage

index data calculation without complete

and accurate data upon which to base

our decision, we are proposing to delay

any decision regarding excluding

resident and CRNA costs from the wage

index until at least next year. We will

review the FY 1996 data when it

becomes available later this year and

present our analysis and any proposals

in next year’s proposed rule.

3. Overhead Allocation

Prior years’ wage index calculations

have excluded the direct wages and

hours associated with certain

subprovider components that are

excluded from the prospective payment

system; however, the overhead costs

associated with excluded components

have not been removed. We have

previously attempted to remove the

overhead costs associated with these

excluded areas of the hospital on two

separate occasions. Based on the quality

of the data, as well as comments we

received from the public, these

proposals were never implemented.

In the September 1, 1995 final rule

with comment period (60 FR 45797), we

discussed the results of the second of

these efforts. Our analysis was

prompted by several suggestions from

hospital representatives that the current

methodology, which removes the higher
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25587

nursing costs in excluded areas from the

hospital’s direct salaries but leaves in

the lower general services salaries,

negatively distorts wages. However, the

results of our analysis at that time

dissuaded us from proposing to exclude

these areas’ overhead costs because the

data were unreliable. We revised the FY

1995 cost report to allow for the

reporting of the overhead salaries and

hours. We stated that we would

reexamine this issue when the FY 1995

cost report data became available.

To allocate overhead costs based on

the data reported on Worksheet S–3, we

first determined the ratio of the hours

reported directly to excluded areas

compared to the total hours. Total

overhead hours and salaries were then

multiplied by this ratio to allocate the

proportion of overhead costs

attributable to excluded areas. Next, the

overhead hours and salaries attributable

to excluded areas were subtracted from

the hospital’s total hours and salaries,

and an average hourly wage reflecting

this overhead allocation was computed.

Of the 5,115 hospitals in the FY 1995

wage data file, 3,661 reported overhead

hours (hospitals were only required to

separately report overhead hours if their

number of directly assigned excluded

hours exceeded 5 percent of their total

hours). The overhead allocation would

result in an increase in the wage index

value of more than 5 percent for only

one MSA (2 hospitals). A total of 12

labor areas (5 Statewide rural (206

hospitals) and 7 MSAs (25 hospitals))

would experience an increase of

between 2 percent and 5 percent. Only

one MSA (29 hospitals) would

experience a decline of between 2 and

5 percent. The wage index value for the

remaining 358 areas (4,921 hospitals)

would be affected by less than 2

percent.

We are proposing to include this

exclusion of overhead allocation in the

calculation of the FY 1999 wage index.

Although the overall impact on

hospitals of this change is relatively

small, we believe it is an appropriate

step toward improving the overall

consistency of the wage index.

Additionally, we believe this change

will significantly increase the accuracy

of the wage data for individual

hospitals, especially hospitals that have

a relatively small portion of their facility

devoted to acute inpatient care.

D. Verification of Wage Data From the

Medicare Cost Report

The data for the proposed FY 1999

wage index were obtained from

Worksheet S–3, Parts III and IV of the

FY 1995 Medicare cost reports. The data

file used to construct the proposed wage

index includes FY 1995 data submitted

to the Health Care Provider Cost Report

Information System (HCRIS) as of early

January 1998. 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 5,123 hospitals originally in

the data file, 851 hospitals had data

elements that failed an edit. From midJanuary to mid-February 1998,

intermediaries contacted hospitals to

revise or verify data elements that

resulted in the edit failures.

As of February 17, 1998, 31 hospitals

still had unresolved data elements.

These unresolved data elements are

included in the calculation of the

proposed FY 1999 wage index pending

their resolution before calculation of the

final FY 1999 wage index. We have

instructed the intermediaries to

complete their verification of

questionable data elements and to

transmit any changes to the wage data

(through HCRIS) no later than April 6,

1998. We expect that all unresolved data

elements will be resolved by that date.

The revised data will be reflected in the

final rule.

Also, as part of our editing process,

we deleted data for eight hospitals that

failed edits. For two of these hospitals,

we were unable to obtain sufficient

documentation to verify or revise the

data because the hospitals are no longer

participating in the Medicare program

or are in bankruptcy status. The data

from the remaining six participating

hospitals were removed because

inclusion of their data would have

significantly distorted the wage index

values. The data for these six hospitals

will be included in the final wage index

if we receive corrected data that passes

our edits. As a result, the proposed FY

1999 wage index is calculated based on

FY 1995 wage data for 5,115 hospitals.

E. 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 1999 wage

index on wage data reported on the FY

1995 Medicare cost reports. We gathered

data from each of the non-Federal,

short-term, acute care hospitals for

which data were reported on the

Worksheet S–3, Parts III and IV of the

Medicare cost report for the hospital’s

cost reporting period beginning on or

after October 1, 1994 and before October

1, 1995. In addition, we included data

from a few hospitals that had cost

reporting periods beginning in

September 1994 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 1995 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 wage-related costs, we

added the costs of contract labor for

direct patient care, certain top

management, and physician Part A

services; hospital wage-related costs,

and any home office salaries and wagerelated costs reported by the hospital, to

the net hospital salaries. The actual

calculation is the sum of lines 2, 4, 6,

and 33 of Worksheet S–3, Part III. This

calculation differs from the one

computed on line 32 of Worksheet S–3,

Part III. Therefore, a hospital’s average

hourly wage calculated under Step 2

will be different from the average hourly

wage shown on line 32, column 5.

Step 3—For each hospital, we

subtracted the reported excluded hours

from the gross hospital hours to

determine net hospital hours. To

determine total hours, we increased the

net hours by the addition of home office

hours and hours for contract labor

attributable to direct patient care,

certain top management, and physician

Part A salaries.

Step 4—For each hospital reporting

both total overhead salaries and total

overhead hours greater than zero, we

then allocated overhead costs. First, we

determined the ratio of excluded area

hours (Line 24 of Worksheet S–3, Part

III) to revised total hours (Line 9 of

Worksheet S–3, Part III, adding back

CRNA Part A, physician Part A, and

resident hours). Second, we computed

the amounts of overhead salaries and

hours to be allocated to excluded areas

by multiplying the above ratio by the

total overhead salaries and hours

reported on Line 16 of Worksheet S–3,

Part IV. Finally, we subtracted the

computed overhead salaries and hours

associated with excluded areas from the

total salaries and hours derived in Steps

2 and 3.

Step 5—For each hospital, we

adjusted the total salaries plus wagerelated costs to a common period to

determine total adjusted salaries plus

wage-related costs. To make the wage

inflation adjustment, we estimated the

percentage change in the employment
25588 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

cost index (ECI) for compensation for

each 30-day increment from October 14,

1994 through April 15, 1996, for private

industry hospital workers from the

Bureau of Labor Statistics

Compensation and Working Conditions.

For previous wage indexes, we used the

percentage change in average hourly

earnings for hospital industry workers

to make the wage inflation adjustment.

For FY 1999 we are proposing to use the

ECI for compensation for private

industry hospital workers because it

reflects the price increase associated

with total compensation (salaries plus

fringes) rather than just the increase in

salaries, which is what the average

hourly earnings category reflected. In

addition, the ECI includes managers as

well as other hospital workers. We are

also proposing to change the

methodology used to compute the

monthly update factors. This new

methodology uses actual quarterly ECI

data to determine the monthly update

factors. The methodology assures that

the update factors match the actual

quarterly and annual percent changes.

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

10/14/94 ............ 11/15/94 1.032882

11/14/94 ............ 12/15/94 1.030771

12/14/94 ............ 01/15/95 1.028721

01/14/95 ............ 02/15/95 1.026731

02/14/95 ............ 03/15/95 1.024776

03/14/95 ............ 04/15/95 1.022827

04/14/95 ............ 05/15/95 1.020886

05/14/95 ............ 06/15/95 1.018901

06/14/95 ............ 07/15/95 1.016822

07/14/95 ............ 08/15/95 1.014649

08/14/95 ............ 09/15/95 1.012446

09/14/95 ............ 10/15/95 1.010279

10/14/95 ............ 11/15/95 1.008146

11/14/95 ............ 12/15/95 1.006047

12/14/95 ............ 01/15/96 1.003981

01/14/96 ............ 02/15/96 1.001950

02/14/96 ............ 03/15/96 1.000000

03/14/96 ............ 04/15/96 0.998181

For example, the midpoint of a cost

reporting period beginning January 1,

1995 and ending December 31, 1995 is

June 30, 1995. An inflation adjustment

factor of 1.016822 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 1995 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 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

wage-related costs obtained in Step 5 for

all hospitals in that area to determine

the total adjusted salaries plus wagerelated costs for the labor market area.

Step 7—We divided the total adjusted

salaries plus wage-related costs 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 wage-related costs obtained

in Step 5 for all hospitals in the Nation

and then divided the sum by the

national sum of total hours from Step 4

to arrive at a national average hourly

wage. Using the data as described above,

the national average hourly wage is

$20.6036.

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 wage-related

costs (as calculated in Step 5) for all

hospitals in Puerto Rico and divided the

sum by the total hours for Puerto Rico

(as calculated in Step 4) to arrive at an

overall average hourly wage of $9.3339

for Puerto Rico. For each labor market

area in Puerto Rico, we calculated the

hospital wage index value by dividing

the area average hourly wage (as

calculated in Step 7) by the overall

Puerto Rico average hourly wage.

Step 11—Section 4410 of Public Law

105–33 provides that, for discharges on

or after October 1, 1997, the area wage

index applicable to any hospital that is

not located in a rural area may not be

less than the area wage index applicable

to hospitals located in rural areas in that

State. Furthermore, this wage index

floor is to be implemented in such a

manner as to assure that aggregate

prospective payment system payments

are not greater or less than those which

would have been made in the year if

this section did not apply. For FY 1999,

this change affects 229 hospitals in 34

MSAs. The MSAs affected by this

provision are identified in Table 4A by

a footnote.

F. Revisions to the Wage Index Based on

Hospital Redesignation

Under section 1886(d)(8)(B) of the

Act, hospitals in certain rural counties

adjacent to one or more MSAs are

considered to be located in one of the

adjacent MSAs if certain standards are

met. Under section 1886(d)(10) of the

Act, the Medicare Geographic

Classification Review Board (MGCRB)

considers applications by hospitals for

geographic reclassification for purposes

of payment under the prospective

payment system.

The methodology for determining the

wage index values for redesignated

hospitals is applied jointly to the

hospitals located in those rural counties

that were deemed urban under section

1886(d)(8)(B) of the Act and those

hospitals that were reclassified as a

result of the MGCRB decisions under

section 1886(d)(10) of the Act. Section

1886(d)(8)(C) of the Act provides that

the application of the wage index to

redesignated hospitals is dependent on

the hypothetical impact that the wage

data from these hospitals would have on

the wage index value for the area to

which they have been redesignated.

Therefore, as provided in section

1886(d)(8)(C) of the Act, the wage index

values were determined by considering

the following:

• If including the wage data for the

redesignated hospitals would reduce the

wage index value for the area to which

the hospitals are redesignated by 1

percentage point or less, the area wage

index value determined exclusive of the

wage data for the redesignated hospitals

applies to the redesignated hospitals.

• If including the wage data for the

redesignated hospitals reduces the wage

index value for the area to which the

hospitals are redesignated by more than

1 percentage point, the hospitals that are

redesignated are subject to that

combined wage index value.

• If including the wage data for the

redesignated hospitals increases the

wage index value for the area to which

the hospitals are redesignated, both the

area and the redesignated hospitals

receive the combined wage index value.

• The wage index value for a

redesignated urban or rural hospital

cannot be reduced below the wage

index value for the rural areas of the

State in which the hospital is located.

• Rural areas whose wage index

values would be reduced by excluding

the wage data for hospitals that have

been redesignated to another area

continue to have their wage index

values calculated as if no redesignation

had occurred.

• Rural areas whose wage index

values increase as a result of excluding
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25589

the wage data for the hospitals that have

been redesignated to another area have

their wage index values calculated

exclusive of the wage data of the

redesignated hospitals.

• The wage index value for an urban

area is calculated exclusive of the wage

data for hospitals that have been

reclassified to another area. However,

geographic reclassification may not

reduce the wage index value for an

urban area below the statewide rural

wage index value.

We note that, except for those rural

areas where redesignation would reduce

the rural wage index value, the wage

index value for each area is computed

exclusive of the wage data for hospitals

that have been redesignated from the

area for purposes of their wage index.

As a result, several urban areas listed in

Table 4a have no hospitals 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 1999 are shown in Tables

4A, 4B, 4C, and 4F in the Addendum to

this proposed rule. Hospitals that are

redesignated should use the wage index

values shown in Table 4C. Areas in

Table 4C may have more than one wage

index value because the wage index

value for a redesignated urban or rural

hospital cannot be reduced below the

wage index value for the rural areas of

the State in which the hospital is

located. When the wage index value of

the area to which a hospital is

redesignated is lower than the wage

index value for the rural areas of the

State in which the hospital is located,

the redesignated hospital receives the

higher wage index value, that is, the

wage index value for the rural areas of

the State in which it is located, rather

than the wage index value otherwise

applicable to the redesignated hospitals.

Tables 4D and 4E list the average

hourly wage for each labor market area,

prior to the redesignation of hospitals,

based on the FY 1995 wage data. In

addition, Table 3C in the Addendum to

this proposed rule includes the adjusted

average hourly wage for each hospital

based on the FY 1995 data (as calculated

from Steps 4 and 5, above). 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

§ 412.63(w)(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

may use the proposed wage data in

applying to the MGCRB for wage index

reclassifications that would be effective

for FY 2000. We note that in

adjudicating these wage index

reclassification requests during FY

1999, the MGCRB will use the average

hourly wages for each hospital and labor

market area that are reflected in the final

FY 1999 wage index.

At the time this proposed wage index

was constructed, the MGCRB had

completed its review. The proposed FY

1999 wage index values incorporate all

435 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 1999. 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 § 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 1999 must be

received by the MGCRB by June 22,

1998. A hospital that requests to

withdraw its application may not later

request that the MGCRB decision be

reinstated.

G. Requests for Wage Data Corrections

As a part of the August 29, 1997 final

rule with comment period, we

implemented a new timetable for

requesting wage data corrections (62 FR

45990). In February 1998, we notified

hospitals again of these changes through

a memorandum to the fiscal

intermediaries. To allow hospitals time

to evaluate the wage data used to

construct the proposed FY 1999 hospital

wage index, we made available to the

public a data file containing the FY

1995 hospital wage data. In a

memorandum dated February 2, 1998,

we instructed all Medicare

intermediaries to inform the prospective

payment hospitals that they serve of the

availability of the wage data file and the

process and timeframe for requesting

revisions. The wage data file was made

available February 6, 1998, through the

Internet at HCFA’s home page (http://

www.hcfa.gov). The intermediaries

were also instructed to advise hospitals

of the alternative availability of these

data through their representative

hospital organizations or directly from

HCFA. Additional details on ordering

this data file are discussed in section

IX.A of this preamble, ‘‘Requests for

Data from the Public.’’

In addition, Table 3C in the

Addendum to this proposed rule

contains each hospital’s adjusted

average hourly wage used to construct

the proposed wage index values. A

hospital can verify its adjusted average

hourly wage, as calculated from Steps 4

and 5 of the computation of the wage

index (see section III.E of this preamble,

above) based on the wage data on the

hospital’s 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 adjustment factors as

set forth above in Step 5 of the

computation of the wage index. As

noted above, however, a hospital’s

average hourly wages using this

calculation will vary from the average

hourly wages shown on Line 32 of

Worksheet S–3, Part III. An updated

Table 3C (along with applicable wage

adjustment factors) will be included in

the final rule.

We believe hospitals have had ample

time to ensure the accuracy of their FY

1995 wage data. Moreover, the ultimate

responsibility for accurately completing

the cost report rests with the hospital,

which must attest to the accuracy of the

data at the time the cost report is filed.

However, if after review of the wage

data file released February 6, a hospital

believed that its FY 1995 wage data

were incorrectly reported, the hospital

was to submit corrections along with

complete, detailed supporting

documentation to its intermediary by

March 9, 1998. To be reflected in the

final wage index, any wage data

corrections must be reviewed and

verified by the intermediary and

transmitted to HCFA on or before April

6, 1998. These deadlines are necessary
25590 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

to allow sufficient time to review and

process the data so that the final wage

index calculation can be completed for

development of the final prospective

payment rates to be published by

August 1, 1998. We cannot guarantee

that corrections transmitted to HCFA

after April 6 will be reflected in the final

wage index.

After reviewing requested changes

submitted by hospitals, intermediaries

transmitted any revised cost reports to

HCRIS and forwarded a copy of the

revised Worksheet S–3, Parts III and IV

to the hospitals. If requested changes

were not accepted, fiscal intermediaries

notified hospitals of the reasons why the

changes were not accepted. This

procedure ensures that hospitals have

every opportunity to verify the data that

will be used to construct their wage

index values. We believe that fiscal

intermediaries are generally in the best

position to make evaluations regarding

the appropriateness of a particular cost

and whether it should be included in

the wage index data. However, if a

hospital disagrees with the

intermediary’s resolution of a requested

change, the hospital may contact HCFA

in an effort to resolve policy disputes.

We note that the April 6 deadline also

applies to these requested changes. We

will not consider factual determinations

at this time as these should have been

resolved earlier in the process.

We have created the process

described above to resolve all

substantive wage data correction

disputes before we finalize the wage

data for the FY 1999 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 note that, beginning this year with

the FY 1999 wage index, the final wage

index that is published August 1 will

incorporate all corrections, including

those to correct data entry or tabulation

errors of the final wage data by the

intermediary or HCFA. The final wage

data public use file will be released by

May 7, 1998. Hospitals will have until

June 5, 1998, to submit requests to

correct errors in the final wage data due

to data entry or tabulation errors by the

intermediary or HCFA. The correction

requests that will be considered after the

March 9 deadline will be limited to

errors in the entry or tabulation of the

final wage data which the hospital

could not have known about prior to

March 9, 1998.

The final wage data file released in

early May 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 February,

HCFA will make the final wage data file

released in May available to hospital

associations and the public (on the

Internet). This 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 correction

process described above (with the

March 9 deadline), not for the initiation

of new wage data correction requests.

Hospitals are encouraged to review their

hospital wage data promptly after the

release of the final file.

If, after reviewing the final file, a

hospital believes that its wage data are

incorrect due to a fiscal intermediary or

HCFA error in the entry or tabulation of

the final wage data, it should send a

letter to both its fiscal intermediary and

HCFA. The letters should outline why

the hospital believes an error exists and

provide all supporting information,

including dates. These requests must be

received by HCFA and the

intermediaries no later than June 5,

1998. Requests mailed to HCFA should

be sent to: Health Care Financing

Administration; Center for Health Plans

and Providers; Attention: Stephen

Phillips, Technical Advisor; Division of

Acute Care; 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.

At this time, changes to the hospital

wage data will be made only in those

very limited situations involving an

error by the intermediary or HCFA that

the hospital could not have known

about before its review of the final wage

data file. Specifically, neither the

intermediary nor HCFA will accept the

following types of requests at this stage

of the process:

• Requests for wage data corrections

that were submitted too late to be

included in the data transmitted to

HCRIS on or before April 6, 1998.

• Requests for correction of errors

that were not, but could have been,

identified during the hospital’s review

of the February 1998 wage data file.

• Requests to revisit factual

determinations or policy interpretations

made by the intermediary or HCFA

during the wage data correction process.

Verified corrections to the wage index

received timely (that is, by June 5, 1998)

will be incorporated into the final wage

index to be published by August 1,

1998, and effective October 1, 1998.

Again, we believe the wage data

correction process described above

provides hospitals with sufficient

opportunity to bring errors in their wage

data to the intermediary’s attention.

Moreover, because hospitals will have

access to the final wage data by early

May, they will have the opportunity to

detect any data entry or tabulation

errors made by the intermediary or

HCFA before the development and

publication of the FY 1999 wage index

by August 1, 1998, and the

implementation of the FY 1999 wage

index on October 1, 1998. 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

errors should occur after that date, we

retain the right to make midyear

changes to the wage index under very

limited circumstances.

Specifically, in accordance with

§ 412.63(w)(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 1999 (that is, by the June 5, 1998

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.

IV.–V. Other Decisions and Changes to

the Prospective Payment System for

Inpatient Operating Costs

A. Definition of Transfers (§ 412.4)

Pursuant to section 1886(d)(5)(I) of

the Act, the prospective payment system

distinguishes between ‘‘discharges,’’

situations in which a patient leaves an

acute care (prospective payment)

hospital after receiving complete acute

care treatment, and ‘‘transfers,’’

situations in which the patient is

transferred to another acute care

hospital for related care. If a full DRG

payment were made to each hospital

involved in a transfer situation,

irrespective of the length of time the

patient spent in the ‘‘sending’’ hospital

prior to transfer, a strong incentive to

increase transfers would be created,

thereby unnecessarily endangering
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25591

patients’ health. Therefore, our policy,

which is set forth in the regulations at

§ 412.4, provides that, in a transfer

situation, full payment is made to the

final discharging hospital and each

transferring hospital is paid a per diem

rate for each day of the stay, not to

exceed the full DRG payment that

would have been made if the patient

had been discharged without being

transferred.

Currently, the per diem rate paid to a

transferring hospital is determined by

dividing the full DRG payment that

would have been paid in a nontransfer

situation by the geometric mean length

of stay for the DRG into which the case

falls. Hospitals receive twice the per

diem for the first day of the stay and the

per diem for every following day up to

the full DRG amount. Transferring

hospitals are also eligible for outlier

payments for cases that meet the cost

outlier criteria established for all other

cases (nontransfer and transfer cases

alike) classified to the DRG. Two

exceptions to the transfer payment

policy are transfer cases classified into

DRG 385 (Neonates, Died or Transferred

to Another Acute Care Facility) and

DRG 456 (Burns, Transferred to Another

Acute Care Facility), which receive the

full DRG payment instead of being paid

on a per diem basis.

Under section 1886(d)(5)(J) of the Act,

which was added by section 4407 of the

Balanced Budget Act of 1997, a

‘‘qualified discharge’’ from one of 10

DRGs selected by the Secretary to a

postacute care provider will be treated

as a transfer case beginning with

discharges on or after October 1, 1998.

Section 1886(d)(5)(J)(iii) confers broad

authority on the Secretary to select 10

DRGs ‘‘based upon a high volume of

discharges classified within such group

and a disproportionate use of’’ certain

post discharge services. Section

1886(d)(5)(J)(ii) defines a ‘‘qualified

discharge’’ as a discharge from a

prospective payment hospital of an

individual whose hospital stay is

classified in one of the 10 selected DRGs

if, upon such discharge, the

individual—

• Is admitted to a hospital or hospital

unit that is not a prospective payment

system hospital;

• Is admitted to a skilled nursing

facility; or

• Is provided home health services by

a home health agency if the services

relate to the condition or diagnosis for

which the individual received inpatient

hospital services and if these services

are provided within an appropriate

period as determined by the Secretary.

The Conference Agreement that

accompanied the law noted that ‘‘(t)he

Conferees are concerned that Medicare

may in some cases be overpaying

hospitals for patients who are

transferred to a post acute care setting

after a very short acute care hospital

stay. The Conferees believe that

Medicare’s payment system should

continue to provide hospitals with

strong incentives to treat patients in the

most effective and efficient manner,

while at the same time, adjust PPS

[prospective payment system] payments

in a manner that accounts for reduced

hospital lengths of stay because of a

discharge to another setting.’’ (H.R. Rep.

No. 105–217, 740.) In its March 1, 1997

report, ProPAC expressed similar

concerns: ‘‘* * * length of stay declines

have been greater in DRGs associated

with substantial postacute care use,

suggesting a shift in care from hospital

inpatient to postacute settings’’ (pp. 21–

22).

In fact, based on the latest available

data, overall Medicare hospital costs per

case have decreased during FYs 1994

and 1995. This unprecedented real

decline in costs per case has led to

historically high Medicare operating

margins (over 10 percent on average).

Along with these declining lengths of

stay and costs per case, there has been

an increase in the utilization of

postacute care. In 1990, the rate of

skilled nursing facility services per

1,000 Medicare enrollees was 19. By

1995, it had grown to 33. Corresponding

numbers for home health agency

services are 58 per 1,000 Medicare

enrollees during 1990 and 93 per 1,000

enrollees during 1995. Although home

health services are not always directly

related to a hospitalization episode,

there does appear to be a trend toward

increased use of home health for the

provision of postacute care

rehabilitation services. Previous

analysis of the percentage of hospital

discharges that receive postacute home

health care showed a 10.3 percent

increase in 1994 compared to 1992.

Our proposals to implement section

1886(d)(5)(J) of the Act are set forth

below.

1. Selection of 10 DRGs

Section 1886(d)(5)(J)(iii)(I) of the Act

provides that the Secretary select 10

DRGs based on a high volume of

discharges to postacute care and a

disproportionate use of postacute care

services. Therefore, in order to select the

DRGs to be paid as transfers, we first

identified those DRGs with the highest

percentage of postacute care.

We used the FY 1996 MedPAR file

because the complete FY 1997 MedPAR

file was not available at the time we

conducted our analysis. To identify

postacute care utilization, we merged

hospital inpatient bill files with

postacute care bill files matching

beneficiary identification numbers and

discharge and admission dates. We

created this file rather than depend on

information concerning discharge

destination on the inpatient bill because

we have found that the discharge

destination codes included on the

hospital bills are often inaccurate in

identifying discharges to a facility other

than another prospective payment

hospital.

Section 1886(d)(5)(J)(ii)(III) of the Act

requires the Secretary to choose an

appropriate window of days in which

the home health services start in order

for the discharge to meet the definition

of a transfer. In order to include

postdischarge home health utilization in

our analysis, we identified all hospital

discharges for patients who received

any home health care within 7 days

after the date of discharge. (As described

below in section IV.A.2., we ultimately

decided to propose 3 days as the

window for home health services.)

Starting with the DRG with the

highest percentage of postacute care

discharges and continuing in

descending order, we selected the first

20 DRGs that had a relatively large

number of discharges to postacute care

(our lower limit was 14,000 cases). In

order to select 10 DRGs from the 20

DRGs on our list, for each of the DRGs

we considered the volume and percent

age of discharges to postacute care that

occurred before the mean length of stay

and whether the discharges occurring

early in the stay were more likely to

receive postacute care. The following

table lists the 10 DRGs we are proposing

to include under our expanded transfer

definition, their percentage of postacute

utilization compared to total cases, and

the total number of cases identified as

going to postacute care.
25592 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

DRG Title and type of DRG (surgical or medical)

Percent of

postacute

utilization

Number of

postacute

cases

14 ............. Specific Cerebrovascular Disorders Except Transient Ischemic Attack (Medical) ................................... 49.5 186,845

113 ........... Amputation for Circulatory System Disorders Excluding Upper Limb and Toe (Surgical) ....................... 59.0 28,402

209 ........... Major Joint Limb Reattachment Procedures of Lower Extremity (Surgical) ............................................. 71.9 257,875

210 ........... Hip and Femur Procedures Except Major Joint Age >17 With CC (Surgical) .......................................... 77.8 111,799

211 ........... Hip and Femur Procedures Except Major Joint Age >17 Without CC (Surgical) ..................................... 74.2 19,548

236 ........... Fractures of Hip and Pelvis (Medical) ....................................................................................................... 61.2 24,498

263 ........... Skin Graft and/or Debridement for Skin Ulcer or Cellulitis With CC (Surgical) ........................................ 49.4 14,499

264 ........... Skin Graft and/or Debridement for Skin Ulcer or Cellulitis W/O CC (Surgical) ........................................ 39.3 1,328

429 ........... Organic Disturbances and Mental Retardation (Medical) ......................................................................... 45.4 19,314

483 ........... Tracheostomy Except for Face, Mouth and Neck Diagnoses (Surgical) .................................................. 45.3 18,254

We included DRG 263 on the list

because of its ranking in the top 20

DRGs in terms of postacute utilization

and volume of discharges to postacute

care. DRGs 263 and 264 are paired

DRGS; that is, the only difference in the

cases assigned to DRG 263 as opposed

to DRG 264 is that the patient has a

complicating or comorbid condition. If

we included only DRG 263 in the list,

it would be possible for a transfer case

with a relatively short length of stay that

should be assigned to DRG 263 and

receive a relatively small transfer

payment to be assigned instead to DRG

264, and receive the full DRG payment,

simply by failing to include the CC

diagnosis code on the bill. Therefore,

our choice was to either delete DRG 263

from the list or add DRG 264. We

decided to include DRG 264 in the

proposed list because DRG 263 fully

meets all the conditions for inclusion on

the list of 10 DRGS.

2. Postacute Care Settings

Section 1886(d)(5)(J)(ii) of the Act

requires the Secretary to define and pay

as transfers cases from one of 10 DRGs

selected by the Secretary if the

individual is discharged to one of the

following settings:

• A hospital or hospital unit that is

not a subsection [1886](d) hospital, that

is a hospital or unit excluded from the

inpatient prospective payment system.

• A skilled nursing facility that is, a

facility that meets the definition of a

skilled nursing facility set forth at

section 1819 of the Act.

• Home health services provided by a

home health agency, if the services are

related to the condition or diagnosis for

which the individual received inpatient

hospital services, and if the home health

services are provided within an

appropriate period (as determined by

the Secretary).

Section 1886(d)(1)(B) of the Act

defines the hospitals and hospital units

that are excluded from the prospective

payment system as the following:

psychiatric, rehabilitation, childrens’,

long-term care, and cancer hospitals and

psychiatric and rehabilitation distinct

part units of a hospital. Therefore, any

discharge from a prospective payment

hospital from one of the 10 proposed

DRGS that is admitted to one of these

types of facilities on the date of

discharge from the acute hospital, on or

after October 1, 1998, would be

considered a transfer and paid

accordingly under the prospective

payment systems (operating and capital)

for inpatient hospital services.

A discharge from a prospective

payment hospital to a skilled nursing

facility would include cases discharged

from one of the 10 DRGS from an

inpatient bed in the hospital to a bed in

the same hospital that has been

designated for the provision of skilled

nursing care (a ‘‘swing’’ bed). The swing

bed provision allows certain small rural

hospitals to furnish services in inpatient

beds which, if furnished by a skilled

nursing facility, would constitute

extended care services. In addition, any

patient who receives swing-bed services

is deemed to have received extended

care services as if furnished by a skilled

nursing facility. Thus, if swing beds are

not included in the transfer policy,

those hospitals with swing bed

agreements could move patients

assigned to one of the 10 selected DRGs

as if it were a discharge from an

inpatient bed to a swing bed and receive

payment. We do not believe that this

would be a fair policy in that it would

create a payment advantage for swing

bed hospitals. Therefore, we are

providing in the regulations that a

discharge to a swing bed will be paid as

a transfer when the patient is classified

to one of the 10 selected DRGs.

Section 1886(d)(5)(J)(ii)(III) of the Act

states that the discharge of an individual

who receives home health services upon

discharge will be treated as a transfer if

‘‘such services are provided within an

appropriate period (as determined by

the Secretary) * * *.’’ As discussed

above in section IV.A.1, we began our

analysis using 7 days (one week) as the

time period we would consider. We

now believe that 3 days after the date of

discharge is a more appropriate

timeframe. Based on our analysis of the

FY 1996 bills, approximately 90 percent

of patients began receiving home health

care within 3 days. We are particularly

interested in receiving comments on the

appropriate period of time in which

home health services should begin in

the context of the transfer policy.

With regard to an appropriate

definition of ‘‘home health services

* * * relate[d] to the condition or

diagnosis for which the individual

received inpatient hospital services

* * *’’, we considered several possible

approaches. Under one approach we

could compare the principal diagnosis

of the inpatient stay to the diagnosis

code indicated on the home health bill,

similar to our policy on the 3-day

payment window for preadmission

services. However, we believe that is far

too restrictive in terms of qualifying

discharges for transfer payment. In

addition, a hospital will not know when

it discharges a patient to home health

what diagnosis code the home health

agency will put on the bill. Therefore,

the hospital would not be able to

correctly code the inpatient bill as a

transfer or discharge.

We also considered proposing that

any home health care that begins within

the designated timeframe be included

‘‘as related’’ in our definition. However,

this definition might be too broad and

the hospital would not be able to predict

which cases should be coded as

transfers because the hospital often may

not know about home health services

that are provided upon discharge but

were not ordered or planned for as part

of the hospital discharge plan.

We are proposing that home health

services would be considered related to

the hospital discharge if the patient is

discharged from the hospital with a

written plan of care for the provision of

home health care services from a home

health agency. In this way, the hospital

would be fully aware of the status of the

patient when discharged and could be

held responsible for correctly coding the
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25593

discharge as a transfer on the inpatient

bill. In general, this would mean that

the home health service would qualify

as a Part A home health benefit under

section 1861(tt) of the Act as added by

section 4611(b) of the BBA.

We note, however, that we plan to

compare inpatient bills with home

health service bills for care provided

within 3 days after discharge, similar to

our current claims edit for hospital to

hospital transfers. If we find that home

health services were provided within

the postdischarge window, the hospital

will be notified and the hospital

payment adjusted unless the hospital

can submit documentation verifying the

discharge status of the patient. This will

alert hospitals if there are problems with

their discharge/transfer billing and

allow them to adjust their discharge

planning process and billing practices.

If we find a continued pattern of a

hospital billing for cases from the 10

DRGs as discharges and our records

indicate that the patients are receiving

postacute care services from an

excluded hospital, a skilled nursing

facility, or within the 3-day home health

service window, the hospitals may be

investigated for fraudulent or abusive

billing practices.

3. Payment Methodology

The statute does not dictate the

payment methodology we must use for

these transfer cases. However, section

1886(d)(5)(J)(i) of the Act provides that

the payment amount for a case may not

exceed the sum of half the full DRG

payment amount and half of the

payment amount under the current per

diem payment methodology.

Based on our analysis comparing the

costs per case for the transfers in the 10

DRGs with payments under our current

transfer payment methodology, we

found that most of the 10 DRGs are

appropriately paid using our current

methodology (that is, twice the per diem

for the first day and the per diem for

each subsequent day). In fact, this

payment would, on average, slightly

exceed costs. However, this is not true

of DRGs 209, 210, and 211. For those

three DRGs, a disproportionate

percentage (about 50 percent) of the

costs of the case are incurred on the first

day of the stay. Therefore, we are

proposing to pay DRGs 209, 210, and

211 based on 50 percent of the DRG

payment for the first day of the stay and

50 percent of the per diem for the

remaining days of the stay. The other

seven DRGs would be paid under the

current transfer payment methodology.

In Appendix E to this proposed rule,

we have included tables that illustrate,

for 9 of the 10 DRGs, the number of total

and postacute discharges by length of

stay, the geometric mean lengths of stay

from FY 1983 through FY 1997, and the

estimated average costs and transfer

payments by length of stay. (The

summary information for DRG 264 was

not available at the time of publication

because it was not included in the

original data file of 20 DRGs used for

our analysis.) For DRGs 209, 210, and

211, the payment line is determined on

the basis of the alternative payment

formula described above.

These tables demonstrate that a very

large number of discharges from these

10 DRGs receive postacute care. In

addition, the length of stay for these

DRGs has decreased sharply over the

last several years. We believe that this

proposed policy will both decrease the

hospitals’ financial incentive to

discharge patients very early in the stay,

often before the full course of acute care

treatment has ended, as well as pay the

hospital at an appropriate level when it

does move patients into postacute care.

We would revise § 412.4 to reflect

these proposed policies. In addition, we

would delete the reference in current

§ 412.4(d)(2) to DRG 456 (Burns,

Transferred to Another Acute Care

Facility) because we are proposing to

replace that DRG, as discussed in

section II.B.3 of this preamble. There

would no longer be any burn DRG with

a transfer designation.

B. Rural Referral Centers (§ 412.96)

Under the authority of section

1886(d)(5)(C)(i) of the Act, § 412.96 sets

forth the criteria a hospital must meet in

order to receive special treatment under

the prospective payment system as a

rural referral center. For discharges

occurring before October 1, 1994, rural

referral centers received the benefit of

payment based on the other urban rather

than the rural standardized amount. As

of that date, the other urban and rural

standardized amounts were the same.

However, rural referral centers continue

to receive special treatment under both

the disproportionate share hospital

payment adjustment and the criteria for

geographic reclassification.

One of the criteria under which a

rural hospital may qualify as a rural

referral center is to have 275 or more

beds available for use. A rural hospital

that does not meet the bed size criterion

can qualify as a rural referral center if

the hospital meets two mandatory

criteria (specifying a minimum case-mix

index and a minimum number of

discharges) and at least one of the three

optional criteria (relating to specialty

composition of medical staff, source of

inpatients, or volume of referrals). With

respect to the two mandatory criteria, a

hospital may be classified as a rural

referral center if its—

• Case-mix index is at least equal to

the lower of the median case-mix index

for urban hospitals in its census region,

excluding hospitals with approved

teaching programs, or the median casemix index for all urban hospitals

nationally; and

• Number of discharges is at least

5,000 discharges per year or, if fewer,

the median number of discharges for

urban hospitals in the census region in

which the hospital is located. (The

number of discharges criterion for an

osteopathic hospital is at least 3,000

discharges per year.)

1. Case-Mix Index

Section 412.96(c)(1) provides that

HCFA will establish updated national

and regional case-mix index values in

each year’s annual notice of prospective

payment rates for purposes of

determining rural referral center status.

The methodology we use to determine

the proposed national and regional casemix index values, is set forth in

regulations at § 412.96(c)(1)(ii). The

proposed national case-mix index value

includes all urban hospitals nationwide,

and the proposed regional values are the

median values of urban hospitals within

each census region, excluding those

with approved teaching programs (that

is, those hospitals receiving indirect

medical education payments as

provided in § 412.105).

These values are based on discharges

occurring during FY 1997 (October 1,

1996 through September 30, 1997) and

include bills posted to HCFA’s records

through December 1997. Therefore, in

addition to meeting other criteria, for

hospitals with fewer than 275 beds, we

are proposing that to qualify for initial

rural referral center status for cost

reporting periods beginning on or after

October 1, 1998, a hospital’s case-mix

index value for FY 1997 would have to

be at least—

• 1.3578; or

• Equal to the median case-mix index

value for urban hospitals (excluding

hospitals with approved teaching

programs as identified in § 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:

Region

Case-mix

index

value

1. New England (CT, ME, MA,

NH, RI, VT) ............................. 1.2533

2. Middle Atlantic (PA, NJ, NY) .. 1.2499

3. South Atlantic (DE, DC, FL,

GA, MD, NC, SC, VA, WV) ..... 1.3468
25594 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

Region

Case-mix

index

value

4. East North Central (IL, IN, MI,

OH, WI) ................................... 1.2717

5. East South Central (AL, KY,

MS, TN) ................................... 1.2965

6. West North Central (IA, KS,

MN, MO, NE, ND, SD) ............ 1.2264

7. West South Central (AR, LA,

OK, TX) ................................... 1.3351

8. Mountain (AZ, CO, ID, MT,

NV, NM, UT, WY) ................... 1.3752

9. Pacific (AK, CA, HI, OR, WA) 1.3405

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 March

31, 1997.

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 1997

case-mix index value in Table 3C in

section IV. of the Addendum to this

proposed rule. In keeping with our

policy on discharges, these case-mix

index values are computed based on all

Medicare patient discharges subject to

DRG-based payment.

2. Discharges

Section 412.96(c)(2)(i) provides that

HCFA will set forth the national and

regional numbers of discharges in each

year’s annual notice of prospective

payment rates for purposes of

determining referral center status. As

specified in section 1886(d)(5)(C)(ii) of

the Act, the national standard is set at

5,000 discharges. 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 1996 (that is,

October 1, 1995 through September 30,

1996). 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 for cost reporting periods

beginning on or after October 1, 1998,

the number of discharges a hospital

must have for its cost reporting period

that began during FY 1997 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.

Region Number of

discharges

1. New England (CT, ME, MA,

NH, RI, VT) ............................. 6658

2. Middle Atlantic (PA, NJ, NY) .. 8477

3. South Atlantic (DE, DC, FL,

GA, MD, NC, SC, VA, WV) ..... 7505

4. East North Central (IL, IN, MI,

OH, WI) ................................... 7273

5. East South Central (AL, KY,

MS, TN) ................................... 6852

6. West North Central (IA, KS,

MN, MO, NE, ND, SD) ............ 5346

7. West South Central (AR, LA,

OK, TX) ................................... 5179

8. Mountain (AZ, CO, ID, MT,

NV, NM, UT, WY) ................... 7926

9. Pacific (AK, CA, HI, OR, WA) 5945

We note that the number of discharges

for hospitals in each census region is

greater than the national standard of

5,000 discharges. Therefore, 5,000

discharges is the minimum criteria for

all hospitals. These numbers will be

revised in the final rule based on the

latest FY 1996 cost report data.

We reiterate that, to qualify for rural

referral center status for cost reporting

periods beginning on or after October 1,

1998, 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.

C. Payments to Disproportionate Share

Hospitals: Conforming Change

Regarding Interpretation of Medicaid

Patient Days Included in

Disproportionate Patient Percentage

(§ 412.106)

Effective for discharges beginning on

or after May 1, 1986, hospitals that treat

a disproportionately large number of

low-income patients receive additional

payments through the disproportionate

share (DSH) adjustment. One means of

determining a hospital’s DSH payment

adjustment for a cost reporting period

requires calculation of its

disproportionate patient percentage for

the period. The disproportionate patient

percentage is the sum of a prescribed

Medicare fraction and a Medicaid

fraction for the hospital’s fiscal period.

Under clause (I) of section

1886(d)(5)(F)(vi) of the Act and

§ 412.106(b)(2), the Medicare fraction is

determined by dividing the number of

the hospital’s patient days for patients

who were entitled (for such days) to

benefits under both Medicare Part A and

Supplemental Security Income (SSI)

under Title XVI of the Act, by the total

number of the hospital’s patient days for

the patients who were entitled to

Medicare Part A. The Medicaid fraction

is determined, in accordance with

clause (II) of section 1886(d)(5)(F)(vi) of

the Act and § 412.106(b)(4), by dividing

the number of the hospital’s patient

days for patients who (for such days)

were eligible for medical assistance

under a State Medicaid plan approved

under Title XIX of the Act but who were

not entitled to Medicare Part A, by the

total number of the hospital’s patient

days for that period.

Initially, HCFA calculated the

Medicaid fraction by interpreting

section 1886(d)(5)(F)(vi)(II) of the Act to

recognize as Medicaid patient days only

those days for which the hospital

received Medicaid payment for

inpatient hospital services. See 51 FR

31454, 31460 (1986). The agency’s

interpretation was declared invalid by

four Federal circuit courts of appeals.

See Cabell Huntington Hosp., Inc. v.

Shalala, 101 F.3d 984, 990–91 (4th Cir.

1996) (following three other circuits).

These courts held that the statute

requires, for purposes of calculating the

Medicaid fraction, inclusion of each

patient day of service for which a

patient was eligible on that day for

medical assistance under an approved

State Medicaid plan. Specifically, the

statute requires inclusion of each

hospital patient day for a patient eligible

for Medicaid on such day, regardless of

whether particular items or services

were covered or paid under the State

Medicaid plan.

On February 27, 1997, the HCFA

Administrator issued HCFA Ruling 97–

2, which acquiesced in the four adverse

appellate court decisions. The Ruling

changed the agency’s statutory

construction to comport with those

decisions, in order to facilitate

nationwide uniformity in the

calculation of the Medicaid fraction.

Like the court decisions, the Ruling

provides that a hospital’s Medicaid

patient days include each patient day of

service for which a patient was eligible

on such day for medical assistance

under an approved State Medicaid plan,

regardless of whether particular items or

services were covered or paid under the

State plan. The Ruling also reflects the

hospital’s burden of furnishing data

adequate to prove each claimed

Medicaid patient day, and of verifying

with the State that a patient was eligible

for Medicaid during each day of the

inpatient hospital stay.

The Ruling further provides that the

agency’s new interpretation is effective

February 27, 1997 for each cost

reporting period that: (1) Begins on or

after that effective date; (2) was not

settled, as of that date, on the Medicaid

patient days issue, by means of an

applicable notice of program

reimbursement (NPR) (see § 405.1803);

or (3) was settled through such an NPR
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25595

as of the Ruling’s effective date and is

the subject of a pending administrative

appeal or civil action that satisfies all

applicable jurisdictional requirements

of the Medicare statute and regulations.

The Ruling also provides, however, that

the change in statutory interpretation

effected by the Ruling is not a basis for

reopening a hospital cost reporting

period (see §§ 405.1885–405.1889) that

was finalized previously on the same

matter at issue.

We propose to revise § 412.106(b)(4)

in order to conform the Medicare

regulations to the new statutory

construction issued in HCFA Ruling 97–

2. The revisions are necessary to ensure

that the regulations comport with the

four appellate court decisions that

declared invalid the agency’s prior

interpretation and led to the issuance of

the HCFA Ruling. The proposed

revisions will further facilitate

nationwide uniformity in the

calculation of the Medicaid fraction.

Since the proposed revisions are

intended simply to conform the

regulations to HCFA Ruling 97–2 (and

hence to the four adverse court

decisions), revised § 412.106(b)(4)

would reiterate the Ruling’s change of

interpretation that the Medicaid fraction

under section 1886(d)(5)(F)(vi)(II) of the

Act includes each hospital patient day

for a patient eligible for Medicaid on

such day, regardless of whether

particular items or services were

covered or paid under the State

Medicaid Plan. Our proposed revisions

to § 412.106(b)(4), like the Ruling,

would continue to place on the hospital

the burdens of production, proof, and

verification as to each claimed Medicaid

patient day.

Under our proposal, revised

§ 412.106(b)(4) would apply to cost

reporting periods beginning on or after

October 1, 1998. HCFA Ruling 97–2,

which includes the same provisions as

proposed § 412.106(b)(4), would

continue to apply to any cost reporting

period beginning before October 1, 1998

provided that, as of February 27, 1997,

there is for such period: no submitted

cost report; no cost report settled on the

Medicaid patient days issue through an

applicable NPR; or a cost report settled

on that issue, which is also the subject

of a jurisdictionally proper

administrative appeal or civil action on

the issue.

D. Payment for Bad Debts (§ 413.80)

Section 4451 of the Balanced Budget

Act of 1997 reduces the payment for

enrollee bad debt for hospitals.

Specifically, this provision reduces the

amount of bad debts otherwise treated

as allowable costs, attributable to the

deductibles and coinsurance amounts

under this title, by 25 percent for cost

reporting periods beginning during

fiscal year 1998, by 40 percent for cost

reporting periods beginning during

fiscal year 1999, and by 45 percent for

cost reporting periods beginning during

a subsequent fiscal year. This proposed

rule would conform the regulations to

the statute.

Section 4451 of the Balanced Budget

Act of 1997 also provides that in

determining such reasonable costs for

hospitals, any copayments reduced

under the election available for hospital

outpatient services under section

1833(t)(5)(B) of the Act will not be

treated as a bad debt. This provision

will be implemented in the outpatient

prospective payment system regulation

that implements section 4521, 4522, and

4523 of the Balanced Budget Act of

1997, to be published later this year.

E. Payment for Direct Costs of Graduate

Medical Education to Hospitals and

Nonhospital Providers (§§ 405.2468,

413.85, and 413.86)

1. Introduction

Currently, under section 1886(h) of

the Act, Medicare pays only hospitals

for the costs of graduate medical

education (GME) training. We do not

pay nonhospital sites for the costs they

incur in training medical residents.

There has been a general trend to shift

patient care from the inpatient setting to

the less expensive nonhospital setting

where appropriate. Consistent with this

trend in patient care, the BBA allows for

direct GME payment to qualified

nonhospital providers to encourage

more training of future physicians in

nonhospital settings.

Under section 1886(k) of the Act, as

added by section 4625 of the BBA, the

Secretary is now authorized, but not

required, to pay qualified nonhospital

providers for the direct costs of GME

training. The Conference Report also

notes that the Conferees believe paying

nonhospital providers for GME costs

may help alleviate physician shortages

in underserved rural areas. We believe

that providing Medicare payment

directly to nonhospital providers may

facilitate more training and better

quality training in nonhospital sites.

2. Statutory Background

Section 1886(k) of the Act states: ‘‘For

cost reporting periods beginning on or

after October 1, 1997, the Secretary may

establish rules for payment to qualified

nonhospital providers for their direct

costs of medical education, if those

costs are incurred in the operation of an

approved medical residency training

programs described in subsection (h).’’

The statute further provides that, to the

extent the Secretary exercises this broad

discretionary authority, the rules ‘‘shall

specify the amounts, form, and manner

in which such payments will be made

and the portion of such payments that

will be made from each of the trust

funds under this title.’’

a. Payments Only to ‘‘Qualified

Nonhospital Providers’’. The statute

confers broad discretion on the

Secretary regarding whether and how to

pay nonhospital providers for direct

GME costs. However, the statute does

specify the entities whom the Secretary

can pay—‘‘qualified nonhospital

providers.’’ Section 1886(k)(2) of the Act

defines ‘‘qualified nonhospital

providers’’ to include: Federally

Qualified Health Centers (FQHCs), as

defined in section 1861(aa)(4); Rural

Health Centers (RHCs), as defined in

section 1861(aa)(2); Medicare+Choice

organizations; and such other providers

(other than hospitals) as the Secretary

determines to be appropriate.

b. Payments Only for the ‘‘Direct

Costs’’ of Training. The statute also

specifies the costs the Secretary can pay

for under section 1886(k) of the Act.

Medicare pays hospitals for both the

direct and indirect costs of medical

education under sections 1886(h) and

1886(d)(5)(B) of the Act respectively,

but section 1886(k) of the Act provides

for payment to nonhospital providers

only for the direct costs of medical

education.

In addition, section 1886(k) of the Act

provides for payment for the direct costs

of training medical residents only if

those costs are incurred in the operation

of an ‘‘approved medical residency

training program.’’ Section

1886(h)(5)(A) of the Act defines an

‘‘approved medical residency training

program’’ as a ‘‘residency or other

postgraduate medical training program

participation in which may be counted

toward certification in a specialty or

subspecialty and includes formal

postgraduate training programs in

geriatric medicine approved by the

Secretary.’’ Implementing regulations at

§ 413.86(b) state that an approved

medical residency training program

includes allopathic and osteopathic

training programs as well as training

programs for dentistry and podiatry.

Therefore, the statute authorizes

Medicare payments to nonhospital

providers only for the costs of training

medical residents, not for the costs of

training other health professionals.

In addition to adding section 1886(k)

of the Act, section 4625 of the BBA

amends section 1886(h)(3)(B) of the Act

to prohibit double payments for direct
25596 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

GME to a hospital and a qualified

nonhospital provider. This prohibition

on double payments requires that the

Secretary reduce a hospital’s GME

payments (the ‘‘aggregate approved

amount’’ as defined in section

1886(h)(3)(b) of the Act) to the extent we

pay a nonhospital provider for GME

under section 1886(k) of the Act.

3. Proposed Policies

Pursuant to section 4625 of the BBA,

we are proposing policies to provide

Medicare payment to nonhospital

providers for the direct costs of GME

training, effective for portions of cost

reporting periods occurring on or after

January 1, 1999. We believe that these

payments will serve the Congressional

intent to encourage and support training

in nonhospital settings.

a. Definition of ‘‘Qualified NonHospital Providers’’. Under our

proposed policy, Medicare would make

GME payments to the following

‘‘qualified nonhospital providers’’—

FQHCs, RHCs, and Medicare+Choice

organizations. Under the authority of

section 1886(k)(2)(D) of the Act, the

Secretary may expand the definition of

a ‘‘qualified nonhospital provider’’ to

include such other providers (other than

hospitals) as the Secretary determines to

be appropriate. Once we have gained

experience providing direct GME

payments to FQHCs, RHCs, and

Medicare+Choice organizations, we may

consider including other types of

nonhospital providers in the definition

of a ‘‘qualified nonhospital provider.’’

Additionally, we propose that, under

certain circumstances, a hospital may

continue to receive GME payments for

residents who train in the nonhospital

setting. In those instances where a

hospital is eligible to continue receiving

GME payments for residents who train

in the nonhospital setting, the

nonhospital provider could receive

payment from the hospital for costs they

incur in training medical residents.

Thus, our policy promotes the intent of

section 4625 of the BBA to provide

financial support, either directly from

Medicare or through the hospital, to

nonhospital providers for the direct

costs of training residents in the

nonhospital site.

b. Definition of ‘‘Direct Costs’’ of

Medical Education for Non-Hospital

Providers. Section 4625 of the BBA

provides for payment to nonhospital

providers only for the direct costs of

training residents. Our proposed

definition of ‘‘direct costs’’ for

nonhospital providers is comparable to

the direct costs for hospitals under

section 1886(h) of the Act. Under our

proposed policy, direct GME costs are

those costs that are incurred by the

nonhospital site for the education

activities of the approved program and

that are the proximate result of training

medical residents in the nonhospital

site. Direct costs for nonhospital

providers would include:

• Residents’ salaries and fringe

benefits (including related travel and

lodging expenses where applicable);

• That portion of costs of the teaching

physicians’ salaries and fringe benefits

that are related to the time spent in

teaching and supervision of residents;

and

• Other related GME overhead costs.

Consistent with our policies on direct

GME costs for hospitals, direct GME

costs for nonhospital providers would

not include normal operating costs or

the marginal increase in costs that the

nonhospital site experiences as a result

of having an approved medical

residency training program. For

example, a decrease in productivity and

increased intensity in treatment patterns

as the result of a training program do

not constitute ‘‘direct costs’’ of training

residents in the nonhospital setting;

rather, these are the ‘‘indirect costs’’ of

such training.

Also consistent with our policies for

direct GME payments to hospitals, we

propose to pay qualified nonhospital

providers only for training that is

related to the delivery of patient care

services. Sections 1886(h) (‘‘Payments

for Direct GME Costs’’) and

1886(h)(4)(E) of the Act (‘‘Counting

Time Spent in Outpatient Settings’’)

provide support continuing our

longstanding policy of paying only for

training that is associated with patient

care services. In particular, section

1886(h)(4)(E) of the Act states:

Such rules shall provide that only time

spent in activities relating to patient care

shall be counted and that all the time so

spent by a resident under an approved

medical residency training program shall be

counted towards the determination of fulltime equivalency, without regard to the

setting in which the activities are performed,

if the hospital incurs all, or substantially all,

of the costs for the training program in that

setting.

In addition, section 1861(b) of the Act

describes the types of patient care

services that are reimbursable.

Specifically, section 1861(b)(6) of the

Act indicates that the training of interns

or residents under an approved teaching

program are included as reimbursable

patient care costs.

Moreover, direct GME costs for

nonhospital providers, like direct GME

costs for hospitals, would include only

that portion of costs of the teaching

physicians’ salaries and fringe benefits

associated with time spent in teaching

and supervising residents. Specifically,

a teaching physician’s time spent on

teaching of a general nature would

constitute a direct GME cost, while

teaching of a patient-specific nature

would not constitute a direct cost. In

addition, direct costs in the nonhospital

setting would include that portion of

teaching physicians’ salaries and fringe

benefits associated with time spent

developing resident schedules and

evaluating or rating the residents. Direct

costs would also include a teaching

physician’s office costs allocated to

GME.

By contrast, direct GME costs for

nonhospital providers would not

include the following: A teaching

physician’s time spent in the care of

individual patients which results in

billable services; teaching physicians’

activities that are related to the

education of other health professionals

(i.e., classroom instruction in

connection with approved activities

other than GME such as provideroperated nursing programs); teaching

physicians’ time spent on

administrative and supervisory services

to the provider that are unrelated to

approved educational activities (i.e.

operating costs); and teaching physician

activities that involve nonallowable

costs such as research and medical

school activities that are not related to

patient care in the nonhospital setting.

GME overhead costs include only

those costs that are allocable to direct

GME and that are not used in patient

care. For example, a portion of

administrative and general costs could

be appropriately allocated to an RHC or

FQHC’s GME cost center. Similarly, a

conference room that is dedicated

specifically for the training of residents

could be appropriately allocated to an

RHC or FQHC’s GME cost center. By

contrast, patient care rooms added to an

RHC or an FQHC cannot be

appropriately allocated to an RHC or

FQHC’s GME cost center.

One of the advantages of our proposed

definition of ‘‘direct costs’’ is that it is

administratively feasible. Our definition

of ‘‘direct costs’’ for nonhospital

providers is comparable to the direct

costs that are included in the per

resident amount paid to hospitals under

section 1886(h) of the Act. At present,

there is limited information regarding

the actual costs of training residents in

nonhospital sites. After we gain

experience providing direct GME

payments to qualified nonhospital

providers and have reviewed the GME

costs separately reported by these

nonhospital providers, we may revise

the definition of ‘‘direct costs.’’ We are
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25597

soliciting comments on other elements

that may constitute direct costs of GME

in the nonhospital site that can be

identified, reported, and verified as

directly attributable to GME activities

through the cost reporting process. We

are interested in comments on whether

we should include other costs in the

definition of ‘‘direct costs’’ for

nonhospital providers and on the

administrative feasibility of identifying

the GME portion of those costs.

c. Determining Direct Costs. One of

our major concerns in developing

policies for paying nonhospital

providers for the direct costs of GME is

the administrative feasibility of

determining the amount of direct costs

incurred by the nonhospital provider. It

is our understanding that, currently,

hospitals and nonhospital sites often

share, to varying degrees, the costs of

training residents in the nonhospital

site. Because of the difficulty in

apportioning costs between the hospital

and the nonhospital for the training in

the nonhospital site, we believe that it

is not administratively feasible to pay

both the hospital and the nonhospital

site for the cost of training in the

nonhospital site. We have been unable

to devise a method for accurately

apportioning costs between the two

entities.

Furthermore, the potential for both

the hospital and the nonhospital site to

be paid for the same direct GME

expenses poses a significant problem for

complying with section 1886(h)(3)(B) of

the Act, as amended by the BBA, which

specifically prohibits double payments.

Under this provision, the Secretary shall

reduce the hospital’s GME payment (the

‘‘aggregate approved amount’’) to the

extent we pay nonhospital providers for

GME costs under section 1886(k) of the

Act. Consequently, our policy must

ensure that Medicare does not pay two

entities for the same training time in the

nonhospital site.

Given that the hospital’s per resident

amount can include, but is not

necessarily based on the costs of

training in the nonhospital site, we were

not able to devise an equitable way of

reducing the hospital’s per resident

payment to reflect payments made

under section 1886(k) of the Act. It

would not be equitable to subtract the

exact amount of payment made to the

qualified nonhospital provider from the

hospital’s per resident payment because

the payment made to the nonhospital

site is unrelated to the hospital’s per

resident amount. The hospital per

resident amount is based on specific

GME costs incurred by the hospital in

the 1984 base year. Those costs

included in the per resident amount

have no relevance to the costs incurred

in the nonhospital setting almost 15

years after the 1984 base year. We

believe that the residents’ salaries,

teaching physicians’ salaries, and

overhead costs for the nonhospital

setting will constitute a different

proportion of the total GME costs in the

nonhospital setting as compared with

the hospital setting. Rather, it would be

more equitable to determine the

proportion of costs incurred by each

entity and reduce the hospital’s per

resident payment by the proportion of

GME costs incurred by the nonhospital

site; however, since specific

components of the per resident amount

were not identified in the hospital’s

GME base year (1984), we cannot

accurately determine the appropriate

amount to reduce the current year

hospital per resident payment amount.

Moreover, to reduce the hospital’s GME

payments based solely on the amount

paid to the nonhospital site could result

in inequitable payments to the hospital,

which has ongoing costs even when the

resident is training in the nonhospital

site. In fact, it could leave the hospital

at risk of receiving no payment for the

GME costs it has incurred.

In order to encourage training in

nonhospital sites, it is important to

develop a policy that, while providing

payment to nonhospital providers,

would also be equitable to hospitals. We

believe that paying only the nonhospital

site for the training costs could result in

hospitals choosing not to rotate their

residents to the nonhospital site. We

have been unable to devise an equitable

and accurate method for dividing up the

GME payment for training in the

nonhospital site if neither the hospital,

nor the nonhospital site incurs ‘‘all or

substantially all’’ of the costs. As such,

we are soliciting comment on possible

methods for allocating the GME

payments for training in the nonhospital

site where neither the hospital nor the

nonhospital provider is incurring ‘‘all or

substantially all’’ of the costs for the

training program. We believe that the

proposed policies discussed below are

equitable to both hospital and

nonhospital providers and will achieve

Congress’ objective of encouraging and

supporting training in the nonhospital

setting.

Given our concerns about

administrative feasibility, the statutory

prohibition on double payments, and

developing policies that are equitable to

hospitals as well as nonhospital

providers, we believe the only feasible

way to pay for training in nonhospital

settings is to pay either the hospital or

the nonhospital provider. Currently,

hospitals may receive payment for the

time residents spend in the nonhospital

setting if the hospital incurs ‘‘all or

substantially all’’ of the training costs.

We propose to adopt a similar policy for

nonhospital providers; that is, a

qualified nonhospital provider may

receive payment for the direct costs of

GME if the nonhospital provider incurs

‘‘all or substantially all’’ of the training

costs.

d. Modifications of Policy To Pay

Hospitals For GME. In the course of

developing our policies for nonhospital

providers, we have reviewed our

method for paying hospitals for the

costs of training residents in the

nonhospital site. Accordingly, as part of

our policy to pay nonhospital providers

for the costs of training residents, we are

proposing necessary and appropriate

modifications to our current policy for

paying hospitals for such nonhospital

training. Specifically, as part of our

proposal to implement section 1886(k)

of the Act, we propose to modify the

regulations at § 413.86(f).

Presently, under sections

1886(d)(5)(B)(iv) and 1886(h)(4)(E) of

the Act, if a hospital incurs ‘‘all or

substantially all’’ of the costs of training

residents in the nonhospital site, then

the hospital may include the resident in

its indirect medical education (IME) and

direct GME full-time equivalent count.

Under § 413.86(f)(1)(iii), currently a

hospital incurs ‘‘all or substantially all’’

of the costs of training the resident in

the nonhospital site if the hospital pays

the residents’ salaries and fringe

benefits. Based on our review of data in

Medicare cost reports on the Hospital

Cost Reporting Information System

(HCRIS), we decided to reexamine the

issue of what constitutes ‘‘all or

substantially all’’ of the costs of training

the resident. In our analysis, we

determined that, on average, residents’

salaries and fringe benefits are less than

half of the total amount of the direct

costs of a hospital’s GME program.

Therefore, we are proposing to revise

the standard for incurring ‘‘all or

substantially all’’ of the costs for the

training program in the nonhospital

setting.

We propose to redefine ‘‘all or

substantially all’’ of the costs for the

training program in the nonhospital

setting to include at a minimum:

• the portion of costs of the teaching

physicians’ salaries and fringe benefits

that are related to the time spent in

teaching and supervision of residents;

and

• residents’ salaries and fringe

benefits (including travel and lodging

expenses where applicable).

e. Payment Proposal. In light of the

numerous considerations discussed
25598 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

above, we are proposing a system

whereby we will pay either the hospital

or the nonhospital site for the cost of

training in the nonhospital site,

depending on which entity incurs ‘‘all

or substantially all’’ of the costs of

training in the nonhospital site. An

entity incurs ‘‘all or substantially all’’ of

the costs for the training program in the

nonhospital setting if it pays for, at a

minimum: that portion of the costs of

the teaching physicians’ salaries and

fringe benefits that are related to the

time spent in teaching and supervision

of residents; and residents’ salaries and

fringe benefits (including travel and

lodging expenses where applicable).

Our proposal accommodates three

alternative payment scenarios that are

discussed below.

i. Payment to FQHCs and RHCs. In the

first payment scenario, if the FQHC or

RHC incurs ‘‘all or substantially all’’ of

the costs for the training program in the

nonhospital setting, we are proposing to

pay the nonhospital site cost-based

reimbursement for the direct costs of

training. By reporting these direct GME

costs in a reimbursable cost center on

the cost report, an FQHC or RHC would

be attesting that it is incurring ‘‘all or

substantially all’’ of the costs for the

training program in the nonhospital site.

Conversely, where an FQHC or RHC is

not incurring ‘‘all or substantially all’’ of

the costs of training residents in the

nonhospital site, the FQHC or RHC

would report these training costs in a

nonreimbursable cost center on the cost

report.

As previously stated, we propose to

define the direct costs of training to

include:

• Residents’ salaries and fringe

benefits (including related travel and

lodging expenses where applicable);

• That portion of the costs of teaching

physicians’ salaries and fringe benefits

that are related to the time spent in

teaching and supervision of residents;

and

• Other related overhead costs that

are allocated to GME.

We are proposing that the FQHC’s and

RHC’s allowable direct GME costs be

subject to reasonable cost principles in

42 CFR part 413 and other relevant

provisions referenced in part 413. As

such we are proposing to add language

to § 415.60 to make the reasonable cost

principles applicable to FQHC’s and

RHC’s. In addition, the FQHC’s and

RHC’s direct GME costs would be

subject to the Reasonable Compensation

Equivalency limits under §§ 415.60 and

415.70. Accordingly, we are proposing

to add language to § 415.70 to make the

reasonable compensation equivalency

limits applicable to FQHC’s and RHC’s.

Also, Medicare would pay only for

Medicare’s share of the direct costs of

training in the nonhospital site. We are

proposing that the FQHC’s and RHC’s

Medicare share equal the nonhospital

provider’s ratio of Medicare visits to

total visits. Thus, the amount of

Medicare payment would equal the

product of the clinic’s Medicare allowed

direct GME costs and the clinic’s ratio

of Medicare visits to total visits.

For FQHCs and RHCs that incur ‘‘all

or substantially all’’ of the costs for the

training program in the nonhospital

setting, the direct GME costs are not

subject to the existing per visit payment

caps for reimbursement under sections

505.1 and 505.2 of the Medicare Rural

Health Clinic and Federally Qualified

Health Centers Manual. Moreover, we

believe participation in GME training

should not affect any FQHCs or RHCs

ability to meet the productivity

standards outlined in section 503 of the

Medicare Rural Health Clinic and

Federally Qualified Health Centers

Manual. Therefore, we are proposing

that, where payment is available under

section 1886(k) of the Act for residents

working in either an FQHC or an RHC,

the FQHCs and RHCs do not need to

include residents as health care staff in

the calculation of productivity

standards under section 503 of the

Manual.

ii. Payment to Medicare+Choice

organizations. In the second payment

scenario, if a Medicare+Choice

organization incurs ‘‘all or substantially

all’’ of the costs for the training program

in the nonhospital setting, we propose

making the direct GME payment to the

Medicare+Choice organization. The

Medicare+Choice organization would be

eligible to receive cost-based

reimbursement for the residents’ salaries

and fringe benefits only for the time that

the resident spends in the nonhospital

setting. In addition, we are proposing

that the Medicare+Choice organization’s

allowed costs include only that portion

of the teaching physician salaries and

fringe benefits that is related to training

in the nonhospital setting.

Unlike our proposed policy in paying

FQHCs and RHCs for GME, at this time

we are not proposing to pay

Medicare+Choice organizations for the

costs of overhead that are directly

associated with a GME program. We

have no historical data on the GME

costs of managed care organizations and

the extent to which these costs are

incurred directly or indirectly under

contracts between the managed care

organization and physician groups or

other providers engaged in ambulatory

care. Moreover, we have an established

methodology for allocating and

reporting overhead costs for FQHCs and

RHCs on Medicare cost reports that does

not currently exist for Medicare+Choice

organizations. Since Medicare+Choice

organizations do not use the Medicare

cost report, there is currently no

mechanism to review and audit these

costs in the managed care context.

Because Medicare+Choice organizations

are paid on a capitated basis, we have

no method for paying Medicare+Choice

organizations for variable costs such as

GME overhead that require a

sophisticated cost allocation

methodology. By contrast, it is currently

feasible to pay Medicare+Choice

organizations for the costs of the

residents’ salaries and teaching

physicians’ salaries because those costs

are more readily documented and

auditable.

However, we are open to suggestions

about how we can create a methodology

for allocating and reporting overhead

costs for Medicare+Choice

organizations. Any comments should

include not only a proposed

methodology for paying

Medicare+Choice organizations for GME

overhead costs, but also proposed

mechanisms for the audit and review of

the costs of these organizations.

Similar to our proposed policy for

paying FQHCs and RHCs for direct costs

of GME, the Medicare+Choice

organization’s reimbursement for

residents’ salaries and fringe benefits

(including related travel and lodging

expenses where applicable) would be

subject to the reasonable cost principles

in 42 CFR part 413 and any other

relevant provisions referenced in part

413. As such we are proposing to add

language to § 415.60 to make the

reasonable cost principles applicable to

Medicare+Choice organizations. In

addition, the Medicare+Choice

organization’s GME reimbursement

would also be subject to the Reasonable

Compensation Equivalency limits under

§§ 415.60 and 415.70. Accordingly, we

are proposing to add language to

§ 415.70 to make reasonable

compensation equivalency limits

applicable to Medicare+Choice

organizations. While we would pay the

Medicare+Choice organization for

certain GME costs in nonhospital

settings under this proposal, the cost of

residents’ and teaching physicians’

salaries and fringe benefits in the

hospital setting would be paid to the

hospital, not the Medicare+Choice

organization.

The Medicare+Choice organization

would receive direct GME payment only

for the direct costs of training in the

nonhospital site that are associated with

the delivery of patient care services. In
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25599

determining the amount of direct GME

payments to Medicare+Choice

organizations, we must adjust for

Medicare’s share of those education

costs. Medicare’s share would equal the

ratio of the total number of Medicare

enrollees in the Medicare+Choice

organization to total enrollees in the

Medicare+Choice organization.

We are proposing that, in order to

receive the direct GME payment, the

Medicare+Choice organization must

produce a contractual agreement

between itself and the nonhospital

providers. Medicare+Choice

organizations may contract with any

nonhospital patient care site, including

freestanding clinics, nursing homes, and

physicians’ offices in connection with

approved programs. The contract

between the Medicare+Choice

organization and the nonhospital site

must indicate that, for the time that

residents spend in the nonhospital site,

the Medicare+Choice organization

agrees to pay for the cost of residents’

salaries and fringe benefits. In addition,

the contract must indicate that the

Medicare+Choice organization agrees to

pay the portion of the costs of teaching

physicians’ salaries and fringe benefits

that is related to the time spent in

teaching and supervision of residents

and that is unrelated to the volume of

services. The contract must stipulate the

portion of each teaching physician’s

time that will be spent training residents

in the nonhospital setting. Moreover,

the contract must indicate that the

Medicare+Choice organization agrees to

identify an amount for the cost of the

teaching physician’s salary based on the

time that the resident spends in the

nonhospital setting, not based upon a

capitated rate for the delivery of

physician services.

Under our proposed rule, we could

pay a Medicare+Choice organization for

the direct costs of training medical

residents in a physician’s office if such

office had a contractual agreement with

the organization whereby the

organization agrees to pay for ‘‘all or

substantially all’’ of the costs for the

training program in the nonhospital

setting. However, an independent

physician office would not be eligible to

receive payment directly from Medicare

for the cost of training residents because

it would not be a ‘‘qualified nonhospital

provider’’ under our proposed policy.

Similarly, if a hospital rotates a resident

through a physician’s office, the

hospital must pay for ‘‘all or

substantially all’’ of the costs of training

the resident in the physician’s office in

order to include that resident in its FTE

count for IME and direct GME purposes.

(In this instance, the hospital’s

responsibility in assuming ‘‘all or

substantially all’’ of the costs of training

the resident in the nonhospital site

would not be based on section 4625 of

BBA which permits payment to

nonhospital providers.) The hospital

would have to assume ‘‘all or

substantially all’’ of the training costs

for that nonhospital training time in

order to avail itself of the benefit of

including the resident in the hospital’s

FTE count for IME and direct GME

purposes based on the proposed

modifications to § 413.86.

iii. Payment to Hospitals. In the third

payment scenario, if the hospital itself

incurs ‘‘all or substantially all’’ of the

costs for the training program in the

nonhospital setting, then the hospital

may include the residents’ training time

in the nonhospital setting in the

hospital’s FTE counts for direct GME

and for IME. In order to include the

residents’ training in the nonhospital

site, the hospital must produce a

contractual agreement between the

hospital and the nonhospital provider.

Under § 413.86(f)(1)(iii), hospitals may

contract with any nonhospital patient

care provider such as freestanding

clinics, nursing homes, and physicians’

offices in connection with approved

programs.

Currently, a hospital must produce a

written agreement between the hospital

and the nonhospital provider that states

that the resident’s compensation for

training time spent outside of the

hospital setting is to be paid by the

hospital. Since this proposal changes

the definition of what constitutes ‘‘all or

substantially all’’ of the costs of training

in the nonhospital site, hospitals must

produce a written agreement that

demonstrates that they are assuming

responsibility for more of the costs of

training in the nonhospital site than had

previously been required.

In accordance with our proposed

definition of what constitutes ‘‘all or

substantially all’’ of the costs of training

while the resident is in the nonhospital

site, we are proposing that the contract

must indicate that the hospital is

assuming financial responsibility for, at

a minimum, the cost of residents’

salaries and fringe benefits (including

travel and lodging expenses where

applicable) and the costs for that portion

of teaching physicians’ salaries and

fringe benefits related to the time spent

in teaching and supervision of residents.

The contract must indicate that the

hospital is assuming financial

responsibility for these costs directly or

that the hospital agrees to reimburse the

nonhospital provider for such costs. The

contract must also contain an

acknowledgment on the part of the

nonhospital provider that, since the

residents’ time is being counted by the

hospital, the nonhospital site cannot

claim GME costs on their Medicare cost

report. The nonhospital provider must

agree to report its direct GME costs as

well as any money received from the

hospital for GME purposes in a

nonallowable cost center on its cost

report. In addition, in order to

determine teaching physician

compensation that may be allocated to

direct GME, the nonhospital provider

must specify the portion of the teaching

physicians’ time that will be spent

training residents in the nonhospital

setting. Finally, any payment to the

hospital for the direct costs of GME

training in the nonhospital setting will

continue to reflect Medicare’s share,

which equals the hospital’s ratio of

Medicare inpatient days to total

inpatient days.

Hospitals that have residents who

rotate to nonhospital sites are, like all

teaching hospitals, subject to an

institutional cap on the number of FTE

residents that may be counted for both

indirect and direct GME under sections

1886(d)(5)(B)(v) and 1886(h)(6)(F) of the

Act. For hospitals that have residents

who rotate to a nonhospital site, those

residents will be subject to the

hospital’s FTE caps.

f. Trust Funds. Under section

1886(k)(1) of the Act, the rules

established by the Secretary for paying

nonhospital providers for GME must

specify the portion of Medicare

payments that will be made from each

of the Medicare trust funds. We propose

that GME payments made directly to an

FQHC, RHC, or Medicare+Choice

organization would be made from the

Federal Supplementary Medical

Insurance Trust Fund.

g. Conclusion. Under this proposed

rule, clinics that are presently ineligible

to receive payments for direct GME may

now receive such payments. Moreover,

this proposal provides Medicare+Choice

organizations the opportunity to receive

direct GME payments for training

residents in the nonhospital setting. As

Medicare+Choice organizations,

managed care entities will, for the first

time, be eligible to receive direct GME

payments for training residents in

various types of nonhospital sites. This

proposed rule would help bridge the

disparity between hospital and

nonhospital providers in obtaining

payment for direct GME costs.

We believe this proposed rule may

encourage the development of new

programs in nonhospital settings.

Similarly, it may also encourage

approved residency training programs to
25600 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

rotate additional residents to

nonhospital sites.

In developing this proposed rule, we

considered establishing a fixed payment

rate for the direct costs of training

residents in the nonhospital setting. We

are not proposing a policy of a fixed

payment at this time because we

presently have no reliable data on the

direct costs of training residents in

nonhospital settings. Moreover, we are

concerned that a fixed payment for

these costs may not be appropriate if

there is significant variation in cost

among participating nonhospital sites.

Given these considerations, our policy

to pay FQHCs, RHCs, and

Medicare+Choice organizations on a

cost reimbursement basis may be

revised in the future. Once we have

acquired data such that we can estimate

the direct costs of training residents in

the nonhospital site, we will revisit our

payment methodology for paying

FQHCs, RHCs, and Medicare+Choice

organizations for direct GME. We

believe that ultimately it might be

appropriate to pay FQHCs, RHCs, and

Medicare+Choice organizations using a

national average per resident amount.

This national per resident amount

would be based on the national average

for the direct costs of training medical

residents in the nonhospital site. As

such, we are interested in receiving

comments on a fixed payment

methodology and on how to derive such

a payment. These comments should

include empirical data on training costs

in nonhospital sites.

The effective date of these provisions

for FQHCs, RHCs, Medicare+Choice

organizations, and hospitals will be

January 1, 1999. In particular, the

effective date for IME payments to

hospitals under this provision applies to

discharges occurring on or after January

1, 1999. In addition, the effective date

for direct medical education payments

to FQHCs, RHCs, Medicare+Choice

organizations, and hospitals applies to

that portion of cost reporting periods

occurring on or after January 1, 1999.

VI. Changes to the Prospective Payment

System for Capital-Related Costs

A. Proposed Cap on the Capital Indirect

Medical Education Adjustment Ratio

(§ 417.322)

Under section 1886(g) of the Act, the

Secretary has broad discretion in

implementing the capital prospective

payment system. Section 412.322 of the

regulations specifies the formula for the

capital indirect medical education (IME)

adjustment factor. The capital IME

adjustment is intended to pay the

capital prospective payment system

share of the indirect costs of medical

education to teaching hospitals. The

formula was adopted in the August 30,

1991 final rule for the capital

prospective payment system (56 FR

43380) and uses the ratio of interns and

residents to average daily census

(defined as total inpatient days divided

by the number of days in the cost

reporting period). Section 1886(d)(5)(B)

of the Act requires the use of the ratio

of residents-to-beds to calculate the IME

adjustment for the operating Prospective

payment system. However, pursuant to

our authority under section 1886(g) of

the Act, we adopted the resident to

average daily census ratio for the capital

prospective payment system because we

believed it was a more appropriate

method for measuring teaching intensity

and because we believed it was less

subject to manipulation.

The IME adjustment factor increases

by approximately 2.8 percentage points

for each .10 increase in the hospital’s

ratio of residents to average daily

census. The IME adjustment for

inpatient capital-related costs for

hospitals paid under the prospective

payment system takes the form of e

raised to the power (.2822 × ratio of

interns and residents to average daily

census)-1] where e is the natural

antilogy of 1, based on the total cost

regression results. In order to determine

the Federal rate portion of the hospital’s

payment, the IME adjustment factor is

multiplied by the standard federal rate,

the DRG weight, the geographic

adjustment factor, and any other

relevant payment adjustments such as

the DSH adjustment or the large urban

add-on. The formula is as follows:

(Standard Federal Rate) × (DRG weight)

× (GAF) × (Large Urban Add-on, if

applicable) × (COLA adjustment for

hospitals located in Alaska and Hawaii)

× (1 + Disproportionate Share

Adjustment Factor + IME Adjustment

Factor, if applicable).

It has come to our attention that

because of the application of the capital

IME adjustment, one hospital would

receive a capital IME payment greater

than its total hospital costs. We have

also recently learned that of the

approximately 1,200 teaching hospitals

in the United States, based on December

1997 data, 8 hospitals have a resident to

average daily census ratio of more than

1.5. A resident to average daily census

ratio of 1.5 results in a capital IME

adjustment factor of .53, which

increases the Federal rate portion of the

hospital’s capital payment by 53

percent.

To address this unintended effect of

the capital IME methodology, we are

proposing to cap the capital IME ratio at

1.5. A ratio greater than 1.5 means a

hospital has, on average, considerably

more residents than inpatients. Capping

the ratio at 1.5 would allow for one

resident per patient on the inpatient

side plus some outpatient training, and

would keep capital IME payments more

consistent with the costs incurred.

Because of the large number of

unoccupied beds in most hospitals, the

operating IME ratio has only slightly

exceeded 1.0 in two cases. This change

would ensure that the capital IME

adjustment is more in line with hospital

costs.

B. Payment Methodology for Mergers

Involving New Hospitals (§ 412.331)

The August 30, 1991 final rule (56 FR

43418), which implemented the capital

prospective payment system,

established special payment provisions

for new hospitals. Under § 412.324(b), a

new hospital is paid 85 percent of its

allowable Medicare capital-related costs

through its first cost reporting period

ending at least 2 years after the hospital

accepts its first patient. The first cost

reporting period beginning at least 1

year after the hospital accepts its first

patient is the hospital’s base year for

purposes of determining its hospitalspecific rate. Section 412.302(b) defines

a new hospital’s old capital costs as

allowable capital-related costs for land

and depreciable assets that were put in

use for patient care on or before the last

day of the hospital’s base year cost

reporting period. Beginning with the

third year, the hospital is paid under the

fully prospective or hold-harmless

payment methodology, as appropriate. If

the hospital is paid under the holdharmless payment methodology, the

hospital’s hold-harmless payments for

its old capital costs can continue for up

to 8 years.

In the August 30, 1991 final rule, we

defined a new hospital as one that had

operated (under previous or present

ownership) for less than 2 years and did

not have a 12-month cost reporting

period that ended on or before

December 31, 1990. In the September 1,

1992 final rule (57 FR 39789), as a result

of situations brought to our attention

after publication of the prospective

payment system final rule, we clarified

the new hospital exemption under the

capital prospective payment system. We

explained that the new hospital

exemption would not apply to a facility

that opened as an acute care hospital if

that hospital had previously operated

under current or prior ownership and

had a historic asset base. We also

clarified that a hospital that replaced its

entire facility (with or without a change

of ownership) would not qualify for a
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25601

new hospital exemption and that a

previously existing excluded hospital

(paid under section 1886(b) of the Act)

that became an acute care hospital (paid

under section 1886(d)) of the Act would

not qualify.

We explained our belief that the

reasonable cost payment protection

under the new hospital exemption

should only be available to those

hospitals that had not received

reasonable cost payments in the past

and needed special protection during

their initial period of operation. We also

stated in the June 4, 1992 proposed rule

(57 FR 23649) that we were clarifying

the new hospital exemption to ensure

that hospitals that had an existing asset

base before December 31, 1990 were not

provided with an extended transition

period and inappropriately higher

payments relative to other hospitals. We

also explained our belief that it was

essential to maintain the integrity of the

capital prospective payment system by

allowing only truly new providers of

hospital care to qualify for the new

hospital exemption.

Since publication of our last

clarification of the payment rules for

new hospitals, questions have arisen

regarding application of our rules for

payment of new hospitals in merger

situations. Consistent with our

previously stated policy that only truly

new hospitals without an existing asset

base should be eligible for the new

hospital exemption, we are further

clarifying the new hospital payment

provisions.

If during the period it is eligible for

payment as a new hospital (as defined

at § 412.300(b) and § 412.328(b)), a new

hospital merges with one or more

existing hospitals and the merger meets

the existing capital-related reasonable

cost rules regarding the criteria for

recognizing a merger at § 413.134 and

the new hospital is the surviving

corporation (as defined in

§ 413.134(l)(2)) we would treat as old

capital only those assets of the existing

hospital that met the definition of old

capital (as defined in § 412.302(b)) prior

to the merger, for purposes of

determining payments after the merger.

Any assets of the existing hospital

that were considered new capital prior

to the merger will still be considered

new capital after the merger. The merger

cannot be used to convert the existing

hospital’s new capital into old capital.

After the merger, the discharges of each

campus of the merged entity would

maintain their pre-merger payment

methodology until the end of the 2 year

period that the ‘‘new hospital’’ campus

was eligible for reasonable cost

reimbursement as defined at

§ 412.324(b). At the end of this period,

the intermediary would devise a

hospital specific rate for the ‘‘new’’

campus of the merged hospital. Finally,

the calculation methodology for hospital

mergers at new § 412.331(a)(1) and (2)

would be performed and a combined

hospital-specific rate would be

determined and a payment methodology

selected for the merged hospital as a

whole.

The calculation at § 412.331(a)(1) and

(2) uses each hospital’s base year old

capital costs. Any new capital of the

previously existing hospital would not

be used in the determination. If the new

merged entity qualifies for the holdharmless payment methodology, only

the capital which meets the definition of

old capital at § 412.302(b) would be

eligible for hold-harmless payments.

We note that this proposed change is

consistent with the principles

underlying existing § 412.331(a)(3),

which provides that in the case of a

merger only the existing capital-related

costs related to the assets of each

merged or consolidated hospital as of

December 31, 1990 are recognized as old

capital costs during the transition

period. If the hospital is paid under the

hold-harmless methodology after merger

or consolidation, only that original base

year old capital is eligible for holdharmless payments.

Example: Hospital A is a new hospital in

its first 2 years of operation and is being paid

85 percent of its allowable Medicare

inpatient hospital capital-related costs.

Hospital A’s base year for establishing its

hospital-specific rate will end September 30,

1998. Hospital B is an existing hospital

whose base year for capital prospective

payment system purposes was June 30, 1990.

Hospital B is a hold-harmless hospital paid

100 percent of the Federal rate. Hospital A

merged with Hospital B (in accordance with

to § 413.134(l)) on March 1, 1998, and

Hospital A is a new merged entity, with two

campuses: one which used to be the original

Hospital A—the ‘‘new’’ hospital, and one

which used to be hospital B—the ‘‘existing’’

hospital). The merged Hospital A retains the

corporate structure, provider number, and

cost reporting period of the original Hospital

A, which is the surviving hospital. The

merged Hospital A’s discharges will be paid

under two different payment methodologies

until the ‘‘new’’ campus completes its base

period under the payment rules for new

hospitals and a hospital-specific rate and a

payment methodology can be determined for

the merged Hospital A. Until that time, the

discharges of the ‘‘new’’ hospital campus

(previously the original Hospital A) will be

paid in accordance with § 412.324(b) as a

new hospital. Any capital that meets the

definition of old capital acquired by the

‘‘new’’ campus before the end of its base year

will be accorded old capital status in

accordance with § 412.302(b). The ‘‘existing’’

hospital campus (previously hospital B) will

continue to be paid on a hold-harmless basis.

Any capital acquired by the ‘‘existing’’

campus will be accorded new capital status

in accordance with section 2807.3A of the

Provider Reimbursement Manual (PRM). At

the end of the ‘‘new’’ campus’ base year, a

hospital-specific rate will be determined for

that campus. After a hospital specific rate is

determined, the calculation methodology for

hospital mergers at § 412.331(a)(1) and (2)

will be performed. As part of the calculation

and before combining the data, the base years

of the two hospitals used to establish the

hospital-specific rate are brought to the same

point by discharge-weighting and updating.

The calculation uses only the old capital

costs of each hospital in order to determine

a combined hospital-specific rate and

payment methodology. After a payment

methodology determination is made, the two

campuses will be paid using the same

payment methodology for all of their

discharges.

VII. Changes for Hospitals and Units

Excluded From the Prospective

Payment System

Limits on and Adjustments to the Target

Amounts for Excluded Hospitals and

Units (§ 413.40(g))

1. Updated Caps

Section 1886(b)(3) of the Act as

amended by section 4414 of the BBA

established caps on the target amounts

for excluded hospitals and units for cost

reporting periods beginning on or after

October 1, 1997, through September 30,

2002. The caps on the target amounts

apply to the following three categories

of excluded hospitals: psychiatric

hospitals and units, rehabilitation

hospitals and units, and long-term care

hospitals.

A discussion of how the caps on the

target amounts were calculated can be

found in the August 29, 1997 final rule

with comment period (62 FR 46018).

For purposes of calculating the caps for

cost reporting periods beginning during

FY 1999 through FY 2002, the statute

requires us to calculate the 75th

percentile of the target amounts for each

class of hospital (psychiatric,

rehabilitation, or long-term care) for cost

reporting periods ending during FY

1996. The resulting amounts are

updated by the market basket

percentage to the applicable fiscal year.

The projected market basket for

excluded hospitals and units for FY

1999 is 2.5 percent. Accordingly, the

caps on the target amount for FY 1999

as follows:

(1) Psychiatric hospitals and units:

$10,443

(2) Rehabilitation hospitals and units:

$18,938

(3) Long-term care hospitals: $37,360
25602 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

2. Classification of Hospitals and Units

Since publication of the August 29,

1997 final rule with comment period,

some excluded facilities have suggested

that if they are currently excluded as

one class of hospital or unit but also

qualify for exclusion as another class of

hospital, they should be permitted to

choose which classification applies for

purposes of applying the cap on target

amounts. For example, some hospitals

that participate in Medicare as

psychiatric hospitals (defined under

section 1861(f) of the Act, and the

special conditions of participation in 42

CFR part 482 subpart E) have noted that

they have average lengths of stay greater

than 25 days. Those hospitals have

asked to be ‘‘reclassified’’ as long-term

care hospitals and given the benefit of

the higher cap on target amounts

applicable to that hospital class.

We have considered these hospitals’

suggestions, but we believe it would not

be appropriate to adopt them. Section

1886(b)(3)(H)(iv) of Act makes it clear

that each category of hospital and

corresponding units—psychiatric

(section 1886(d)(1)(B)(I)), rehabilitation

(section 1886(d)(1)(B)(ii)), and long-term

care hospitals (section 1886(d)(1)(B)(iv))

is treated separately. We believe it is

consistent with effective

implementation of this provision to

prevent hospitals or units that could

potentially be assigned to more than one

category of excluded facility from

choosing the category to which they

wish to be assigned. Even though some

hospitals or units in one group might

potentially have been assigned to a

different group, each group has its own

limit based on the target amounts for

similarly classified facilities. It would

not be appropriate to apply a limit to a

hospital or unit based on the target

amount derived from the cost

experience of differently classified

hospitals and units.

In addition, there are a number of

hospitals that could potentially move

from the psychiatric hospital cap to the

long-term care hospital cap. This

movement would have a significant

impact on the appropriateness of both

caps. In the case of the psychiatric

hospitals, had those hospitals with the

longest lengths of stay and therefore

higher per discharge target amount been

excluded in the original calculation of

the caps, the cap for all remaining

psychiatric hospitals would invariably

have been lower. Furthermore, had

those psychiatric hospitals been

included in the calculation of the longterm care hospital cap, that cap could

also have been lower. To allow such a

significant change in the application of

the caps is to raise a serious question as

to the appropriateness of the current

caps for all psychiatric and long-term

care hospitals.

Thus, to clarify the application of the

caps, we propose to revise

§ 413.40(c)(4)(iii) to specify that, for

purposes of that paragraph, the

classification of a hospital that was

excluded from the prospective payment

system for its cost reporting period

ending in FY 1996 will be determined

by its classification (that is, the basis on

which it was excluded) in FY 1996. If

a hospital or unit was not excluded for

a cost reporting period ending in FY

1996 but could be excluded on more

than one basis (for example, as either a

rehabilitation or long-term care hospital)

it will be assigned to the classification

group with the lowest limit.

3. Exceptions

The August 29, 1997 final rule with

comment period (62 FR 46018) specified

that a hospital that has a target amount

that is capped at the 75th percentile

would not be granted an adjustment

payment to the target amount (also

referred to as an exception payment) as

governed by § 413.40(g) based solely on

a comparison of its costs or patient mix

in its base year to its costs or patient

mix in the payment year. Since the

hospital’s target amount would not be

determined based on its own experience

in a base year, any comparison of costs

or patient mix in its base year to costs

or patient mix in the payment year

would be irrelevant.

We propose to clarify that, to the

extent we grant an exception to a

hospital not affected by the cap, the

amount of the exception would be

limited to the cap on the hospital’s

target amount. This policy is consistent

with the caps. By establishing caps on

TEFRA target amounts, Congress has

limited payments to individual

hospitals based on amounts that reflect

the cost experience of other hospitals.

Therefore, in determining the extent of

any adjustment paid to a hospital as an

exception under our regulations at

§ 413.40(g)(3), we believe it is consistent

with Congressional intent to limit the

extent of the adjustment to the

hospital’s cap on its target amount.

We propose to revise § 413.40(g)(1) to

set forth the limitation on the

adjustment payments.

VIII. MedPAC Recommendations

We have reviewed the March 1998

report submitted by MedPAC to

Congress and have given its

recommendations careful consideration

in conjunction with the proposals set

forth in this document.

Recommendations concerning the

update factors for inpatient operating

costs and for hospitals and hospital

distinct-part units excluded from the

prospective payment system are

discussed in Appendix D, to this

proposed rule. The remaining

recommendations are discussed below.

A. Disproportionate Share Hospitals

(DSH)

Recommendation: The Medicare

Payment Advisory Commission

(MedPAC) made several

recommendations concerning the

Medicare disproportionate share

adjustment calculation. In general, the

Commission’s proposal would base the

amount of DSH payment each hospital

receives on its volume and mix of cases

paid under the prospective payment

system and its share of low-income

patients. The low-income share measure

would reflect the costs of care provided

to low-income individuals (Medicare

patients eligible for Supplemental

Security Income (SSI), Medicaid

patients, patients sponsored by local

indigent care programs, and patients

receiving uncompensated care) as a

proportion of total patient care

expenses. Both inpatient and outpatient

costs were included in the data used to

calculate the low-income shares,

although payment would be made only

on inpatient discharges.

The same formula would be applied

to all prospective payment hospitals.

Under the recommendation, there

would be a threshold or minimum lowincome share, that must be reached for

a hospital to receive any Medicare

disproportionate share adjustment. The

payment the hospital would receive is

proportionate to the segment of its lowincome share that lies above the

threshold. MedPAC simulated the

potential effects of applying their

approach on the distribution of

Medicare disproportionate share

payments made in 1995. For purposes of

MedPAC’s simulations, the threshold

was set at a level that would limit

payments to about 40 percent of

prospective payment hospitals—roughly

the same as under the current DSH

adjustment. MedPAC stated that this

proportion could be adjusted, or the

threshold could be set using a different

method, as deemed appropriate by

policy makers. (For more information

see Volume 1, chapter 6, page 63 of the

March 1998 report.)

Response: Section 1886(d)(5)(F) of the

Act, as amended by section 4403(b) of

the BBA, requires us to prepare a report

to Congress, due by August 5, 1998,

which will include our

recommendations for an appropriate
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25603

formula for determining DSH payments.

We appreciate MedPAC’s efforts to

assist HCFA in restructuring the

Medicare disproportionate share

adjustment and we will further examine

and consider their recommendations as

we develop our report to Congress.

B. Potential Effects of Target Amount

Caps

Recommendation: The wage-related

portion of the excluded hospital target

amount caps should be adjusted by the

appropriate hospital wage index to

account for geographic differences in

wages. (For more information see

Volume 1, chapter 7, page 71 of the

March 1998 report.)

Response: As MedPAC indicated in

its recommendation, legislation would

be required to adjust the target amount

caps in such a substantial manner as to

adjust for differences in area labor costs.

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

or cartridge format; however, some files

are available on diskette as well as on

the Internet at HTTP://

WWW.HCFA.GOV/STATS/

PUBFILES.HTML. Data files are listed

below with the cost of each. Anyone

wishing to purchase data tapes,

cartridges, or diskettes should submit a

written request along with a company

check or money order (payable to

HCFA–PUF) to cover the cost to the

following address: Health Care

Financing Administration, Public Use

Files, Accounting Division, P.O. Box

7520, Baltimore, Maryland 21207–0520,

(410) 786–3691. Files on the Internet

may be downloaded without charge.

1. Expanded Modified MEDPARHospital (National)

The Medicare Provider Analysis and

Review (MedPAR) file contains records

for 100 percent of Medicare

beneficiaries using hospital inpatient

services in the United States. (The file

is a Federal fiscal year file, that is,

discharges occurring October 1 through

September 30 of the requested year.)

The records are stripped of most data

elements that will permit identification

of beneficiaries. The hospital is

identified by the 6-position Medicare

billing number. The file is available to

persons qualifying under the terms of

the Notice of Proposed New Routine

Uses for an Existing System of Records

published in the Federal Register on

December 24, 1984 (49 FR 49941), and

amended by the July 2, 1985 notice (50

FR 27361). The national file consists of

approximately 11 million records.

Under the requirements of these notices,

an agreement for use of HCFA

Beneficiary Encrypted Files must be

signed by the purchaser before release of

these data. For all files requiring a

signed agreement, please write or call to

obtain a blank agreement form before

placing an order. Two versions of this

file are created each year. They support

the following:

• Notice of Proposed Rulemaking

(NPRM) published in the Federal

Register, usually available by the end of

May (April beginning in 1998). 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 (August beginning

with the FY 1999 final rule). For final

rules published before 1998, this file is

derived from the MedPAR file with a

cutoff of 9 months after the end of the

fiscal year (June file). The FY 1997

MedPar file used for the FY 1999 final

rule will have a cutoff of 6 months after

the end of the fiscal year (March file).

Media: Tape/Cartridge

File Cost: $3,415.00 per fiscal year

Periods Available: FY 1988 through FY

1997

2. Expanded Modified MedPARHospital (State)

The State MedPAR file contains

records for 100 percent of Medicare

beneficiaries using hospital inpatient

services in a particular State. The

records are stripped of most data

elements that will permit identification

of beneficiaries. The hospital is

identified by the 6-position Medicare

billing number. The file is available to

persons qualifying under the terms of

the Notice of Proposed New Routine

Uses for an Existing System of Records

published in the December 24, 1984

Federal Register notice, and amended

by the July 2, 1985 notice. This file is

a subset of the Expanded Modified

MedPAR-Hospital (National) as

described above. Under the

requirements of these notices, an

agreement for use of HCFA Beneficiary

Encrypted Files must be signed by the

purchaser before release of these data.

Two versions of this file are created

each year. They support the following:

• NPRM published in the Federal

Register, usually available by the end of

May (April beginning in 1998). 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 (August beginning

with the FY 1999 final rule). For final

rules published before 1998, this file is

derived from the MedPAR file with a

cutoff of 9 months after the end of the

fiscal year (June file). The FY 1997

MedPar file used for the FY 1999 final

rule will be cut off 6 months after the

end of the fiscal year (March file).

Media: Tape/Cartridge

File Cost: $1,050.00 per State per year

Periods Available: FY 1988 through FY

1997

3. HCFA Wage Data

This file contains the hospital hours

and salaries for 1995 used to create the

proposed FY 1999 prospective payment

system wage index. The file will be

available by the beginning of February

for the NPRM and the beginning of May

for the final rule.

Processing

year

Wage data

year

PPS fiscal

year

1998 1995 1999

1997 1994 1998

1996 1993 1997

1995 1992 1996

1994 1991 1995

1993 1990 1994

1992 1989 1993

1991 1988 1992

These files support the following:

• NPRM published in the Federal

Register, usually by the end of April.

• Final Rule published in the Federal

Register, usually by the first week of

August.

Media: Diskette/Internet

File Cost: $145.00 per year

Periods Available: FY 1999 PPS Update

4. HCFA Hospital Wages Indices

(Formally: Urban and Rural Wage Index

Values Only)

This file contains a history of all wage

indices since October 1, 1983.

Media: Diskette/Internet

File Cost: $145.00 per year

Periods Available: FY 1999 PPS Update

5. PPS SSA/FIPS MSA State and County

Crosswalk

This file contains a crosswalk of State

and county codes used by the Social

Security Administration (SSA) and the

Federal Information Processing

Standards (FIPS), county name, and a

historical list of Metropolitan Statistical

Area (MSA).

Media: Diskette/Internet
25604 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

File Cost: $145.00 per year

Periods Available: FY 1999 PPS Update

6. Reclassified Hospitals by Provider

Only

This file contains a list of hospitals

that were reclassified for the purpose of

the proposed FY 1999 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 April.

• Final Rule published in the Federal

Register, usually by the first week of

August.

Media: Diskette/Internet

File Cost: $145.00 per year

Periods Available: FY 1999 PPS Update

7. PPS–IV to PPS–XII Minimum Data

Sets

The Minimum Data Set contains cost,

statistical, financial, and other

information from Medicare hospital cost

reports. The data set includes only the

most current cost report (as submitted,

final settled, or reopened) submitted for

a Medicare participating hospital by the

Medicare Fiscal Intermediary to HCFA.

This data set is updated at the end of

each calendar quarter and is available

on the last day of the following month.

MEDIA: TAPE/CARTRIDGE

Periods beginning on

or after

and before

PPS IV .............. 10/01/86 10/01/87

PPS V ............... 10/01/87 10/01/88

PPS VI .............. 10/01/88 10/01/89

PPS VII ............. 10/01/89 10/01/90

PPS VIII ............ 10/01/90 10/01/91

PPS IX .............. 10/01/91 10/01/92

PPS X ............... 10/01/92 10/01/93

PPS XI .............. 10/01/93 10/01/94

PPS XII ............. 10/01/94 10/01/95

(Note: The PPS XIII Minimum Data Set

covering FY 1997 will not be available until

July 31, 1998.)

File Cost: $715.00 per year

8. PPS–IX to PPS–XII Capital Data Set

The Capital Data Set contains selected

data for capital-related costs, interest

expense and related information and

complete balance sheet data from the

Medicare hospital cost report. The data

set includes only the most current cost

report (as submitted, final settled or

reopened) submitted for a Medicare

certified hospital by the Medicare fiscal

intermediary to HCFA. This data set is

updated at the end of each calendar

quarter and is available on the last day

of the following month.

MEDIA: TAPE/CARTRIDGE

Periods beginning on

or after

and before

PPS IX .............. 10/01/91 10/01/92

PPS X ............... 10/01/92 10/01/93

PPS XI .............. 10/01/93 10/01/94

PPS XII ............. 10/01/94 10/01/95

(Note: The PPS XIII Capital Data Set covering

FY 1997 will not be available until July 31,

1998.)

File Cost: $715.00 per year

9. Provider-Specific File

This file is a component of the

PRICER program used in the fiscal

intermediary’s system to compute DRG

payments for individual bills. The file

contains records for all prospective

payment system eligible hospitals,

including hospitals in waiver States,

and data elements used in the

prospective payment system

recalibration processes and related

activities. Beginning with December

1988, the individual records were

enlarged to include pass-through per

diems and other elements.

Media: Diskette/Internet

File Cost: $265.00

Periods Available: FY 1998 PPS Update

10. HCFA Medicare Case-Mix Index File

This file contains the Medicare casemix 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

(April beginning in 1998).

• Final rule published in the Federal

Register, usually by the first week of

September (August beginning in 1998).

Media: Diskette/Internet

Price: $145.00 per year

Periods Available: FY 1985 through FY

1997 (Internet—FY 1997)

11. DRG Relative Weights (Formerly

Table 5 DRG)

This file contains a listing of DRGs,

DRG narrative description, relative

weights, and geometric and arithmetic

mean lengths of stay as published in the

Federal Register. The hardcopy image

has been copied to diskette. There are

two versions of this file as published in

the Federal Register:

a. NPRM, usually published by the

end of May (April beginning in 1998).

b. Final rule, usually published by the

first week of September (August

beginning in 1999).

Media: Diskette/Internet

File Cost: $145.00

Periods Available: FY 1999 PPS Update

12. 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 1999 PPS Update

13. 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 April.

• Final rule published in the Federal

Register, usually by the first week of

August.

Media: Diskette/Internet

File Cost: $145.00

Periods Available: FY 1999 PPS Update

For further information concerning

these data tapes, contact Mary R. White

at (410) 786–3691.

Commenters interested in obtaining or

discussing any other data used in

constructing this rule should contact

Stephen Phillips at (410) 786–4548.

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
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25605

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 1999 be published by August 1,

1998, we will consider only those

comments that deal specifically with the

matters discussed in this proposed rule.

List of Subjects

42 CFR Part 405

Administrative practice and

procedure, Health facilities, Health

professions, Kidney diseases, Medicare,

Reporting and recordkeeping

requirements, Rural areas, X-rays.

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 Chapter IV would be amended

as set forth below:

A. Part 405 is amended as follows:

PART 405—FEDERAL HEALTH

INSURANCE FOR THE AGED AND

DISABLED

1. The authority citation for part 405

is revised to read as follows:

Authority: Secs. 1102, 1861, 1862(a), 1871,

1874, 1881, and 1886(k) of the Social

Security Act (42 U.S.C. 1302, 1395x,

1395y(a), 1395hh, 1395kk, 1395rr and

1395ww(k)), and sec. 353 of the Public

Health Service Act (42 U.S.C. 263a), unless

otherwise noted.

Subpart X—Rural Health Clinic and

Federally Qualified Health Center

Services

§ 405.2468 [Amended]

2. In § 405.2468, a new paragraph (f)

is added to read as follows:

* * * * *

(f) Graduate medical education. (1)

Effective for that portion of cost

reporting periods occurring on or after

January 1, 1999, if an RHC or an FQHC

incurs ‘‘all or substantially all’’ of the

costs for the training program in the

nonhospital setting as defined in

§ 413.86(b) of this chapter, the RHC or

FQHC may receive direct graduate

medical education payment for those

residents.

(2) Direct graduate medical education

costs are not included as allowable cost

under § 405.2466(b)(1)(i); and therefore,

are not subject to the limit on the allinclusive rate for allowable costs.

(3) Allowable graduate medical

education costs must be reported on the

RHC’s or the FQHC’s cost report under

a separate cost center.

(4) Allowable direct graduate medical

education costs under paragraphs (f)(5)

and (6)(i) of this section, are subject to

reasonable cost principles under part

413 and the reasonable compensation

equivalency limits in §§ 415.60 and

415.70 of this chapter.

(5) The allowable direct graduate

medical education costs are those costs

incurred by the nonhospital site for the

educational activities associated with

patient care services of an approved

program, subject to the redistribution

and community support principles in

§ 413.85(c).

(i) The following costs are included in

allowable direct graduate medical

education costs to the extent that they

are reasonable—

(A) The costs of the residents’ salaries

and fringe benefits (including travel and

lodging expenses where applicable).

(B) The portion of teaching

physicians’ salaries and fringe benefits

that are related to the time spent

teaching and supervising residents.

(C) Facility overhead costs that are

allocated to direct graduate medical

education.

(ii) The following costs are not

included as allowable graduate medical

education costs—

(A) Costs associated with training, but

not related to patient care services.

(B) Normal operating and capitalrelated costs.

(C) The marginal increase in patient

care costs that the RHC or FQHC

experiences as a result of having an

approved program.

(D) The costs associated with

activities described in § 413.85(d) of this

chapter.

(6) Payment is equal to the product

of—

(i) The RHC’s or the FQHC’s allowable

direct graduate medical education costs;

and

(ii) Medicare’s share of the direct

graduate medical education payment

which is equal to the ratio of Medicare

visits to the total number of visits (as

defined in § 405.2463).

(7) Direct graduate medical education

payments to RHCs and FQHCs made

under this section are made from the

Federal Supplementary Medical

Insurance Trust Fund.

* * * * *

B. Part 412 is amended as set forth

below:

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

1895hh).

Subpart A—General Provisions

2. Section 412.4 is revised to read as

follows:

§ 412.4 Discharges and transfers.

(a) Discharges. Subject to the

provisions of paragraphs (b) and (c) of

this section, a hospital inpatient is

considered discharged from a hospital

paid under the prospective payment

system when —

(1) The patient is formally released

from the hospital; or

(2) The patient dies in the hospital.

(b) Transfer—Basic rule. A discharge

of a hospital inpatient is considered to

be a transfer for purposes of payment

under this part if the discharge is made

under any of the following

circumstances:

(1) From a hospital to the care of

another hospital that is—

(i) Paid under the prospective

payment system; or

(ii) Excluded from being paid under

the prospective payment system because

of participation in an approved

Statewide cost control program as

described in subpart C of part 403 of

this chapter.

(2) From one inpatient area or unit of

a hospital to another inpatient area or

unit of the hospital that is paid under

the prospective payment system.

(c) Transfers—Special 10 DRG rule.

For discharges occurring on or after

October 1, 1998, a discharge of a

hospital inpatient is considered to be a

transfer for purposes of this part when

the patient’s discharge is assigned, as

described in § 412.60(c), to one of the

qualifying diagnosis-related groups

(DRGs) listed in paragraph (d) of this

section and the discharge is made under

any of the following circumstances—

(1) To a hospital or distinct part

hospital unit excluded from the

prospective payment system under

subpart B of this part.

(2) To a skilled nursing facility or to

a swing bed in the hospital that meets

the provisions of § 482.66 of this

chapter.

(3) To home under a written plan of

care for the provision of home health

services from a home health agency and

those services begin within 3 days after

the date of discharge.
25606 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

(d) Qualifying DRGs. The qualifying

DRGs for purposes of paragraph (c) of

this section are DRGs 14, 113, 209, 210,

211, 236, 263, 264, 429, and 483.

(e) Payment for discharges. The

hospital discharging an inpatient (under

paragraph (a) of this section) is paid in

full, in accordance with § 412.2(b).

(f) Payment for transfers—(1) General

rule. Except as provided in paragraph

(f)(2) or (f)(3) of this section, a hospital

that transfers an inpatient under the

circumstances described in paragraph

(b) or (c) of this section, is paid a

graduated per diem rate for each day of

the patient’s stay in that hospital, not to

exceed the amount that would have

been paid under subparts D and M of

this part if the patient had been

discharged to another setting. The per

diem rate is determined by dividing the

appropriate prospective payment rates

(as determined under subparts D, and M

of this part) by the geometric mean

length of stay for the specific which the

case is assigned. Payment is graduated

by paying twice the per diem amount

for the first day of the stay, and the per

diem amount for each subsequent day,

up to the full DRG payment.

(2) Special rule for DRGs 209, 210,

and 211. A hospital that transfers an

inpatient under the circumstances

described in paragraph (c) of this

section and the transfer is assigned to

DRGs 209, 210 or 211 is paid as follows:

(i) 50 percent of the appropriate

prospective payment rate (as

determined under subparts D and M of

this part) for the first day of the stay;

and

(ii) 50 percent of the per diem amount

as calculated under paragraph (f)(1) of

this section for the remaining days of

the stay, up to the full DRG payment.

(3) Transfer assigned to DRG 385. If a

transfer is classified into DRG No. 385

(Neonates, died or transferred) the

transferring hospital is paid in

accordance with § 412.2(e).

(4) Outliers. Effective with discharges

occurring on or after October 1, 1994, a

transferring hospital may qualify for an

additional payment for extraordinarily

high-cost cases that meet the criteria for

cost outliers as described in subpart F

of this part.

Subpart G—Special Treatment of

Certain Facilities Under the

Prospective Payment System for

Inpatient Operating Costs

3. In § 412.106, paragraph (b)(4) is

revised to read as follows:

§ 412.106 Special treatment: Hospitals that

serve a disproportionate share of lowincome patients.

* * * * *

(b) * * *

(4) Second computation. The fiscal

intermediary determines, for the same

cost reporting period used for the first

computation, the number of the

hospital’s patient days of service for

which patients were eligible for

Medicaid but not entitled to Medicare

Part A, and divides that number by the

total number of patient days in the same

period.

(i) For purpose of paragraph (b)(4), a

patient is deemed eligible for Medicaid

on a given day if the patient is eligible

for medical assistance under an

approved State Medicaid plan on such

day, regardless of whether particular

items or services were covered or paid

under the State plan.

(ii) The hospital has the burden of

furnishing data adequate to prove

eligibility for each Medicaid patient day

claimed under this paragraph, and of

verifying with the State that a patient

was eligible for Medicaid during each

claimed patient hospital day.

* * * * *

Subpart M—Prospective Payment

System for inpatient Hospital Capital

Costs

4. In § 412.322, a new sentence is

added at the end of paragraph (a)(3) to

read as follows:

§ 412.322 Indirect medical education

adjustment factor.

(a) * * *

(3) * * * This ratio cannot exceed

1.5.

* * * * *

5. In § 412.331, paragraphs (a) and (b)

are redesignated as paragraphs (b) and

(c) respectively, a new paragraph (a) is

added, and the first sentences of new

paragraphs (b) introductory text and

(b)(2) are revised to read as follows:

§ 412.331 Determining hospital-specific

rates in cases of hospital merger,

consolidation, or dissolution.

(a) New hospital merger or

consolidation. If, after a new hospital

accepts its first patient but before the

end of its base year, it merges with one

or more existing hospitals, and two or

more separately located hospital

campuses are maintained, hospital

specific rate and payment determination

for the merged entity are determined as

follows—

(1) The ‘‘new’’ campus continues to

be paid based on reasonable costs until

the end of its base year. The existing

campus remains on its previous

payment methodology until the end of

the new campus’ base year. Effective

with the first cost reporting period

beginning after the ‘‘new’’ campus, the

intermediary determines a hospitalspecific rate applicable to the new

campus, and then determines a revised

hospital-specific rate for the merged

entity in accordance with paragraph(a)

of this section.

(2) Payment determination. To

determine the applicable payment

methodology under § 412.336 and for

payment purposes under § 412.340 or

§ 412.344, the discharge-weighted

hospital-specific rate is compared to the

Federal rate. The revised payment

methodology is effective on the first day

of the cost reporting period beginning

after the end of the ‘‘new’’ campus’’ base

year.

(b) Hospital merger or consolidation.

If, after the base year, two or more

hospitals merge or consolidate into one

hospital as provided for under

§ 413.134(k) of this chapter and are not

subject to the provisions of paragraph

(a) of this section, the intermediary

determines a revised hospital-specific

rate applicable to the combined facility

under § 412.328, which is effective

beginning with the date of merger or

consolidation. * * *

(2) Payment determination. To

determine the applicable payment

methodology under § 412.336 and for

payment purposes under § 412.340 or

§ 412.344, the discharge-weighted

hospital-specific rate is compared to the

Federal rate. * * *

* * * * *

C. 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 FOR SKILLED NURSING

FACILITIES

1. The authority citation for part 413

is revised to read as follows:

Authority: Secs. 1102, 1812(d), 1814(b),

1815, 1833(a), (I) and (n), 1861(v), 1871,

1881, 1883, and 1866 of the Social Security

Act (42 U.S.C. 1302, 1395f(b), 1395g, 1395l,

1395l(a), (I) and (n), 1395x(v), 1395hh,

1395rr, 1395tt, and 1395ww).

Subpart C—Limits on Cost

Reimbursement

2. In § 413.40, paragraph (c)(4)(iv) is

redesignated as paragraph (v), a new

paragraph (iv) is added, and paragraph

(g)(1) is revised to read as follows:

§ 413.40 Ceiling on the rate of increase in

hospital inpatient costs.

* * * * *

(c) * * *
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25607

(4) * * *

(iv) For purposes of the limits on

target amounts established under

paragraph (c)(4)(iii) of this section, each

hospital or unit that was excluded from

the prospective payment system for its

cost reporting period ending during FY

1996 will be classified in the same way

(that is, as a psychiatric hospital or unit,

or a long-term care hospital) as it was

classified under subpart B of part 412 of

this chapter for purposes of exclusion

from prospective payment systems for

its cost reporting period ending during

FY 1996. If a hospital or unit was not

excluded from the prospective payment

system for a cost reporting period

ending during FY 1996 but could

qualify to be classified in more than one

way under the exclusion criteria in

subpart B of part 412 of this chapter, the

hospital is assigned to the classification

group that has the lowest limit on its

target amounts.

* * * * *

(g) Adjustments—(1) General rule.

HCFA may adjust the amount of the

operating costs considered in

establishing the rate-of-increase ceiling

for one or more cost reporting periods,

including both periods subject to the

ceiling and the hospital’s base period,

under the circumstances specified

below. When an adjustment is requested

by the hospital, HCFA makes an

adjustment only to the extent that the

hospital’s operating costs are

reasonable, attributable to the

circumstances specified separately

identified by the hospital, and verified

by the intermediary. HCFA may grant an

adjustment requested by the hospital

only if the hospital’s operating costs

exceed the rate-of-increase ceiling

imposed under this section. In the case

of a psychiatric hospital or unit,

rehabilitation hospital or unit, or long

term care hospital, the amount of

payment made to a hospital after an

adjustment under paragraph (g)(3) of

this section may not exceed the 75th

percentile of the target amounts for

hospitals of the same class as described

in § 413.40(c)(4)(iii).

Subpart F—Specific Categories of

Costs

3. In § 413.80, paragraph (h) is

redesignated as paragraph (i), and a new

paragraph (h) is added to read as

follows:

§ 413.80 Bad debts, charity, and courtesy

allowances.

* * * * *

(h) Limitations on bad debts. In

determining reasonable costs for

hospitals, the amount of bad debts

otherwise treated as allowable costs (as

defined in paragraph (e) of this section)

is reduced—

(1) For cost reporting periods

beginning during fiscal year 1998, by 25

percent;

(2) For cost reporting periods

beginning during fiscal year 1999, by 40

percent; and

(3) For cost reporting periods

beginning during a subsequent fiscal

year, by 45 percent.

* * * * *

4. In § 413.85, a new paragraph (h) is

added to read as follows:

§ 413.85 Cost of educational activities.

* * * * *

(h) Medicare+Choice organizations.

(1) Effective for that portion of cost

reporting periods occurring on or after

January 1, 1999, Medicare+Choice

organizations may receive direct

graduate medical education payments

for the time that residents spend in

nonhospital provider settings such as

freestanding clinics, nursing homes, and

physicians’ offices in connection with

approved programs.

(2) Medicare+Choice organizations

may receive direct graduate medical

education payments if all of the

following conditions are met—

(i) The resident spends his or her time

in patient care activities.

(ii) The Medicare+Choice

organization incurs ‘‘all or substantially

all’’ of the costs for the training program

in the nonhospital setting as defined in

§ 413.86(b).

(iii) There is a written agreement

between the Medicare+Choice

organization and the nonhospital

provider that contains—

(A) A statement by the nonhospital

provider that, all or substantially all of

the direct graduate medical education

costs as defined in paragraph (f)(1)(ii) of

this section are being assumed by the

Medicare+Choice organization;

(B) A statement that the nonhospital

site agrees to offset the revenue received

from the Medicare+Choice organization.

(C) A statement that the nonhospital

site agrees to report its direct graduate

medical education costs in a

nonreimbursable cost center on its cost

report; and

(D) A statement indicating how much

time the teaching physicians will spend

training residents in the nonhospital

setting, subject to the provisions of

§§ 415.60 and 415.70 of this chapter.

(3) A Medicare+Choice organization’s

allowable direct graduate medical

education costs, subject to the

redistribution and community support

principles in § 413.85(c), consist of—

(i) Residents’ salaries and fringe

benefits (including travel and lodging

where applicable); and

(ii) The portion of teaching

physicians’ salaries and fringe benefits

that are related to the time spent in

teaching and supervising residents.

(4) Allowable direct graduate medical

education costs under paragraph (h)(3)

of this section are subject to the

reasonable cost principles of part 413

and the reasonable compensation

equivalency limits in §§ 415.60 and

415.70 of this chapter.

(5) The direct graduate medical

education payment is equal to the

product of—

(i) The Medicare+Choice

organization’s allowable direct graduate

medical education costs as defined in

paragraph (h)(3) of this section; and

(ii) Medicare’s share of the

Medicare+Choice organization’s direct

graduate medical education payment in

the nonhospital site which is equal to

the ratio of the number of Medicare

beneficiaries enrolled to the total

number of individuals enrolled in the

Medicare+Choice organization.

(6) Direct graduate medical education

payments made to Medicare+Choice

organizations under this section are

made from the Federal Supplementary

Medical Insurance Trust Fund.

* * * * *

5. In § 413.86, the introductory text of

paragraph (b) is republished, a new

definition in alphabetical order is added

to paragraph (b), paragraphs (i) and (j)

are redesignated as paragraphs (j) and

(k) respectively, paragraph (f)(2) is

redesignated as new paragraph (i),

paragraphs (f)(2)(i) through (vii) are

redesignated as paragraphs (i)(1)

through (7) respectively, the

introductory text of paragraph (f)(1) is

redesignated as the introductory text of

paragraph (f), paragraphs (f)(1)(i)

through (iii) are redesignated as

paragraphs (f)(1) through (3)

respectively, paragraphs (f)(1)(iii)(A)

and (B) are redesignated as (f)(3)(i) and

(ii) respectively, new paragraph (f)(2)

and the introductory text of new

paragraph (f)(3) are revised, and a new

paragraph (f)(4) is added to read as

follows:

§ 413.86 Direct graduate medical

education payments.

* * * * *

(b) Definitions. For purposes of this

section, the following definitions apply:

* * * * *

All or substantially all of the costs for

the training program in the nonhospital

setting means the residents’ salaries and

fringe benefits (including travel and

lodging where applicable) and the
25608 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

portion of the cost of teaching

physicians’ salaries and fringe benefits.

* * * * *

(f) * * *

(2) No individual may be counted as

more than one FTE. If a resident spends

time in more than one hospital or,

except as provided in paragraphs (f)(3)

and (4) of this section, in a nonprovider

setting, the resident counts as partial

FTE based on the proportion of time

worked at the hospital to the total time

worked. A part-time resident counts as

a partial FTE based on the proportion of

allowable time worked compared to the

total time necessary to fill a full-time

internship or residency slot.

(3) On or after July 1, 1987 and for the

portion of the cost reporting period

ocurring before January 1, 1999, the

time residents spend in nonprovider

settings such as freestanding clinics,

nursing homes, and physicians’ offices

in connection with approved programs

is not excluded in determining the

number of FTE residents in the

calculation of a hospital’s resident count

if the following conditions are met—

* * * * *

(4) On or after July 1, 1987 and for the

portion cost reporting period occurring

on or after January 1, 1999, the time

residents spend in nonprovider settings

such as freestanding clinics, nursing

homes, and physicians’ offices in

connection with approved programs is

not excluded in determining the number

of FTE residents in the calculation of a

hospital’s resident count if the following

conditions are met—

(i) The resident spends his or her time

in patient care activities.

(ii) The written agreement between

the hospital and the nonhospital

provider must contain—

(A) A statement by the nonhospital

provider that, all or substantially all of

the direct graduate medical education

costs as defined in paragraph (b) of this

section are being assumed by the

hospital;

(B) A statement that the nonhospital

site agrees to offset the revenue received

from the hospital;

(C) A statement that the nonhospital

site agrees to report its direct graduate

medical education costs on its cost

report in a graduate medical education

cost center; and

(D) A statement indicating how much

time the teaching physicians will spend

training residents in the nonhospital

setting, subject to the provisions of

§§ 415.60 and 415.70 of this chapter.

* * * * *

(Catalog of Federal Domestic Assistance

Program No. 93.773, Medicare—Hospital

Insurance; and Program No. 93.774,

Medicare—Supplementary Medical

Insurance)

Dated: April 28, 1998.

Nancy-Ann Min DeParle,

Administrator, Health Care Financing

Administration.

Dated: May 1, 1998.

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,

1998 and Update Factors and Rate-ofIncrease Percentages Effective With Cost

Reporting Periods Beginning On or After

October 1, 1998

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, 1998, except for sole

community hospitals, Medicaredependent, small rural hospitals, and

hospitals located in Puerto Rico, each

hospital’s payment per discharge under

the prospective payment system will be

based on 100 percent of the Federal

national rate.

Sole community hospitals are paid

based on whichever of the following

rates yield 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. Medicaredependent, small rural hospitals are

paid based on the Federal national rate

or, if higher, the Federal national rate

plus 50 percent of the difference

between the Federal national rate and

the updated hospital-specific rate based

on FY 1982 or FY 1987 cost per

discharge, whichever is higher. For

hospitals in Puerto Rico, the payment

per discharge is based on the sum of 50

percent of a Puerto Rico rate and 50

percent of a national rate.

As discussed below in section II, we

are proposing to make changes in the

determination of the prospective

payment rates for Medicare inpatient

operating costs. The changes, to be

applied prospectively, would affect the

calculation of the Federal rates. In

section III of this addendum, we discuss

our proposed changes for determining

the prospective payment rates for

Medicare inpatient capital-related costs.

Section IV of this addendum 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 1999

The basic methodology for

determining prospective payment rates

for inpatient operating costs is set forth

at § 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 §§ 412.210 and

412.212. Below, we discuss the

proposed factors used for determining

the prospective payment rates. The

Federal and Puerto Rico rate changes,

once issued as final, would be effective

with discharges occurring on or after

October 1, 1998. 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

1999.

In summary, the proposed

standardized amounts set forth in

Tables 1A and 1C of section V of this

addendum reflect—

• Updates of 0.7 percent for all areas

(that is, the market basket percentage

increase of 2.6 percent minus 1.9

percentage points);

• An adjustment to ensure budget

neutrality as provided for in sections

1886(d)(4)(C)(iii) and (d)(3)(E) of the Act

by applying new budget neutrality

adjustment factors to the large urban

and other standardized amounts;

• An adjustment to ensure budget

neutrality as provided for in section

1886(d)(8)(D) of the Act by removing the

FY 1998 budget neutrality factor and

applying a revised factor;

• An adjustment to apply the revised

outlier offset by removing the FY 1998

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.

The standardized amounts set forth in

Tables 1E and 1F of section V of this

addendum, which apply to ‘‘temporary

relief’’ hospitals (see 62 FR 46001 for a

discussion of these hospitals), reflect

updates of 1.0 percent for all areas but

otherwise reflect the same adjustments
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25609

as the national standardized amounts.

As described in § 412.107, these

hospitals receive an update that is 0.3

percentage points more than the update

factor applicable to all other prospective

payment hospitals for FY 1999.

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, 1997, when the market basket

was last revised, we have considered

71.1 percent of costs to be labor-related

for purposes of the prospective payment

system. We are revising the Puerto Rico

standardized amounts by the average

labor share in Puerto Rico of 71.3

percent. We are revising the dischargeweighted national standardized amount

for Puerto Rico to reflect the proportion

of discharges in large urban and other

areas from the FY 1997 MedPAR file.

2. Computing Large Urban and Other

Area Averages

Sections 1886(d) (2)(D) and (3) of the

Act require the Secretary to compute

two average standardized amounts for

discharges occurring in a fiscal year:

One for hospitals located in large urban

areas and one for hospitals located in

other areas. In addition, under sections

1886(d)(9)(B)(iii) and (C)(i) of the Act,

the average standardized amount per

discharge must be determined for

hospitals located in urban and other

areas in Puerto Rico. Hospitals in Puerto

Rico are paid a blend of 50 percent of

the applicable Puerto Rico standardized

amount and 50 percent of a national

standardized payment amount.

Section 1886(d)(2)(D) of the Act

defines ‘‘urban area’’ as those areas

within a Metropolitan Statistical Area

(MSA). A ‘‘large urban area’’ is defined

as an urban area with a population of

more than 1,000,000. In addition,

section 4009(i) of Public Law 100–203

provides that a New England County

Metropolitan Area (NECMA) with a

population of more than 970,000 is

classified as a large urban area. As

required by section 1886(d)(2)(D) of the

Act, population size is determined by

the Secretary based on the latest

population data published by the

Bureau of the Census. Urban areas that

do not meet the definition of a ‘‘large

urban area’’ are referred to as ‘‘other

urban areas.’’ Areas that are not

included in MSAs are considered ‘‘rural

areas’’ under section 1886(d)(2)(D) of

the Act. Payment for discharges from

hospitals located in large urban areas

will be based on the large urban

standardized amount. Payment for

discharges from hospitals located in

other urban and rural areas will be

based on the other standardized

amount.

Based on 1996 population estimates

published by the Bureau of the Census,

60 areas meet the criteria to be defined

as large urban areas for FY 1999. These

areas are identified by a footnote in

Table 4A.

3. Updating the Average Standardized

Amounts

Under section 1886(d)(3)(A) of the

Act, we update the area average

standardized amounts each year. In

accordance with section

1886(d)(3)(A)(iv) of the Act, we are

proposing to update the large urban and

the other areas average standardized

amounts for FY 1999 using the

applicable percentage increases

specified in section 1886(b)(3)(B)(i) of

the Act. Section 1886(b)(3)(B)(i)(XIV) of

the Act specifies that, for hospitals in all

areas, the update factor for the

standardized amounts for FY 1999 is

equal to the market basket percentage

increase minus 1.9 percentage points.

The ‘‘temporary relief’’ provision under

section 4401 of Public Law 105–33

provides for an update equal to the

market basket percentage increase

minus 1.6 percentage points for

hospitals that are not Medicaredependent, small rural hospitals, that

receive no IME or DSH payments, that

are located in a state in which aggregate

Medicare operating payments for such

hospitals were less than their aggregate

allowable Medicare operating costs for

their cost reporting periods beginning

during FY 1995, and whose Medicare

operating payments are less than their

allowable Medicare operating costs for

their cost reporting period beginning

during FY 1999.

The percentage change in the market

basket reflects the average change in the

price of goods and services purchased

by hospitals to furnish inpatient care.

The most recent forecast of the proposed

hospital market basket increase for FY

1999 is 2.6 percent. Thus, for FY 1999,

the proposed update to the average

standardized amounts equals 0.7

percent (1.0 percent for those hospitals

qualifying under the ‘‘temporary relief’’

provision of Public Law 105–33).

As in the past, we are adjusting the

FY 1998 standardized amounts to

remove the effects of the FY 1998

geographic reclassifications and outlier

payments before applying the FY 1999

updates. That is, we are increasing the

standardized amounts to restore the

reductions that were made for the

effects of geographic reclassification and

outliers. We then apply the new offsets

to the standardized amounts for outliers

and geographic reclassifications for FY

1999.

Although the update factor for FY

1999 is set by law, we are required by

section 1886(e)(3) of the Act to report to

Congress on our initial recommendation

of update factors for FY 1999 for both

prospective payment hospitals and

hospitals excluded from the prospective

payment system. For general

information purposes, we have included

the report to Congress as Appendix C to

this proposed rule. Our proposed

recommendation on the update factors

(which is required by sections

1886(e)(4)(A) and (e)(5)(A) of the Act),

as well as our responses to MedPAC’s

recommendation concerning the update

factor, are set forth as Appendix D to

this proposed rule.
25610 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

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 1998 relative

weights and wage index to aggregate

payments using the proposed FY 1999

relative weights and wage index. The

same methodology was used for the FY

1998 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

0.999227. We adjust the Puerto Ricospecific 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 0.998946. These budget

neutrality adjustment factors are applied

to the standardized amounts without

removing the effects of the FY 1998

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 1999

adjustment factor to the hospitalspecific rates that are effective for cost

reporting periods beginning on or after

October 1, 1998, 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 1999 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 0.994019 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 1998

budget neutrality adjustment factor. We

note that the proposed FY 1999

adjustment reflects wage index and

standardized amount reclassifications

approved by the MGCRB or the

Administrator as of February 27, 1998.

The effects of any additional

reclassification changes resulting from

appeals and reviews of the MGCRB

decisions for FY 1999 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 1999.

c. Outliers. Section 1886(d)(5)(A) of

the Act provides for payments in

addition to the basic prospective

payments for ‘‘outlier’’ cases, cases

involving extraordinarily high costs

(cost outliers). Section 1886(d)(3)(B) of

the Act requires the Secretary to adjust

both the large urban and other area

national standardized amounts by the

same factor to account for the estimated

proportion of total DRG payments made

to outlier cases. Similarly, section

1886(d)(9)(B)(iv) of the Act requires the

Secretary to adjust the large urban and

other standardized amounts applicable

to hospitals in Puerto Rico to account

for the estimated proportion of total

DRG payments made to outlier cases.

Furthermore, under section

1886(d)(5)(A)(iv) of the Act, outlier

payments for any year must be projected

to be not less than 5 percent nor more

than 6 percent of total payments based

on DRG prospective payment rates.

For FY 1998, the fixed loss cost

outlier threshold is equal to the

prospective payment for the DRG plus

$11,050 ($10,080 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 1998 standardized amounts of

0.948840 for the large urban and other

areas rates and 0.9382 for the capital

Federal rate.

We are proposing a fixed loss cost

outlier threshold in FY 1999 equal to

the prospective payment rate for the

DRG plus $11,350 ($10,355 for hospitals

that have not yet entered the

prospective payment system for capitalrelated 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 1999 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 1999 will

result in outlier payments equal to 5.1
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25611

percent of operating DRG payments and

6.2 percent of capital payments based

on the Federal rate.

The proposed outlier adjustment

factors applied to the standardized

amounts for FY 1999 are as follows:

Operating

standardized

amounts

Capital federal

rate

National ..... 0.948819 0.9378

Puerto Rico 0.972962 0.9626

We apply the proposed outlier

adjustment factors after removing the

effects of the FY 1998 outlier adjustment

factors on the standardized amounts.

Table 8A in section V of this

addendum contains the updated

Statewide average operating cost-tocharge 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 29, 1997 final

rule with comment period (62 FR

46113), effective October 1, 1998. 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 0.217279 or greater than

1.28985 and capital cost-to-charge ratios

lower than 0.01281 or greater than

0.18084. This range represents 3.0

standard deviations (plus or minus)

from the mean of the log distribution of

cost-to-charge ratios for all hospitals.

We note that the cost-to-charge ratios in

Tables 8A and 8B would be used during

FY 1999 when hospital-specific cost-tocharge ratios based on the latest settled

cost report are either not available or

outside the three standard deviations

range.

In the August 29, 1997 final rule with

comment period (62 FR 46041), we

stated that, based on available data, we

estimated that actual FY 1997 outlier

payments would be approximately 4.8

percent of actual total DRG payments.

This was computed by simulating

payments using actual FY 1996 bill data

available at the time. That is, the

estimate of actual outlier payments did

not reflect actual FY 1997 bills but

instead reflected the application of FY

1997 rates and policies to available FY

1996 bills. Our current estimate, using

available FY 1997 bills, is that actual

outlier payments for FY 1997 were

approximately 5.5 percent of actual total

DRG payments. We note that the

MedPAR file for FY 1997 discharges

continues to be updated.

We currently estimate that actual

outlier payments for FY 1998 will be

approximately 5.4 percent of actual total

DRG payments, slightly higher than the

5.1 percent we projected in setting

outlier policies for FY 1998. This

estimate is based on simulations using

the December 1997 update of the

provider-specific file and the December

1997 update of the FY 1997 MedPAR

file (discharge data for FY 1997 bills).

We used these data to calculate an

estimate of the actual outlier percentage

for FY 1998 by applying FY 1998 rates

and policies to available FY 1997 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.

For FY 1998, we used a cost inflation

factor of minus 2.005 percent (a cost per

case decrease of 2.005 percent). For FY

1999, based on more recent data, we are

proposing a cost inflation factor of

minus 1.831 percent to set outlier

thresholds. We will reevaluate this

factor when we develop the final rule

for FY 1999. At that time, more recent

data should be available for analysis,

specifically, cost report data for cost

reporting periods beginning in FY 1997.

5. FY 1999 Standardized Amounts

The adjusted standardized amounts

are divided into labor and nonlabor

portions. Table 1A (Table 1E for

‘‘temporary relief’’ hospitals) contains

the two national standardized amounts

that we are proposing to be applicable

to all hospitals, except for hospitals in

Puerto Rico. Under section

1886(d)(9)(A)(ii) of the Act, the Federal

portion of the Puerto Rico payment rate

is based on the discharge-weighted

average of the national large urban

standardized amount and the national

other standardized amount (as set forth

in Table 1A and 1E). The labor and

nonlabor portions of the national

average standardized amounts for

Puerto Rico hospitals are set forth in

Table 1C (Table 1F for ‘‘temporary

relief’’ hospitals). These tables also

include the Puerto Rico standardized

amounts.

B. Adjustments for Area Wage Levels

and Cost of Living

Tables 1A, 1C, 1E and 1F, 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 laborrelated 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. 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

1999, we propose to adjust the

payments for hospitals in Alaska and

Hawaii by multiplying the nonlabor

portion of the standardized amounts by

the appropriate adjustment factor

contained in the table below. If the

Office of Personnel Management

releases revised cost-of-living

adjustment factors before July 1, 1998,

we will publish them in the final rule

and use them in determining FY 1999

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
25612 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

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 1999. These factors have been

recalibrated as explained in section II of

the preamble.

D. Calculation of Prospective Payment

Rates for FY 1999

General Formula for Calculation of

Prospective Payment Rates for FY 1999

Prospective payment rate for all

hospitals located outside of Puerto Rico

except sole community hospitals and

Medicare-dependent, small rural

hospitals = Federal rate.

Prospective payment rate for sole

community hospitals = Whichever of

the following rates yields the greatest

aggregate payment: 100 percent of the

Federal rate, 100 percent of the updated

FY 1982 hospital-specific rate, or 100

percent of the updated FY 1987

hospital-specific rate.

Prospective payment rate for

Medicare-dependent, small rural

hospitals = 100 percent of the Federal

rate plus, if the greater of the updated

FY 1982 hospital-specific rate or the

updated FY 1987 hospital-specific rate

is higher than the Federal rate, 50

percent of the difference between the

applicable hospital-specific rate and the

Federal rate.

Prospective payment rate for Puerto

Rico = 50 percent of the Puerto Rico rate

+ 50 percent of a discharge-weighted

average of the national large urban

standardized amount and the national

other standardized amount.

1. Federal Rate

For discharges occurring on or after

October 1, 1998 and before October 1,

1999, except for sole community

hospitals, Medicare-dependent, small

rural hospitals, and hospitals in Puerto

Rico, the hospital’s payment is based

exclusively on the Federal national rate.

The payment amount is determined as

follows:

Step 1—Select the appropriate

national standardized amount

considering the type of hospital and

designation of the hospital as large

urban or other (see Tables 1A or 1E, in

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 and

Medicare-Dependent, Small Rural

Hospitals)

Sections 1886(d)(5)(D)(i) and (b)(3)(C)

of the Act provide that sole community

hospitals are paid based on whichever

of the following rates yields the greatest

aggregate payment: the Federal rate, the

updated hospital-specific rate based on

FY 1982 cost per discharge, or the

updated hospital-specific rate based on

FY 1987 cost per discharge.

Sections 1886(d)(5)(G) and (b)(3)(D) of

the Act provide that Medicaredependent, small rural hospitals are

paid based on whichever of the

following rates yields the greatest

aggregate payment: the Federal rate or

the Federal rate plus 50 percent of the

difference between the Federal rate and

the greater of the updated hospitalspecific rate based on FY 1982 and FY

1987 cost per discharge.

Hospital-specific rates have been

determined for each of these hospitals

based on both the FY 1982 cost per

discharge and the FY 1987 cost per

discharge. For a more detailed

discussion of the calculation of the FY

1982 hospital-specific rate and the FY

1987 hospital-specific rate, we refer the

reader to the September 1, 1983 interim

final rule (48 FR 39772); the April 20,

1990 final rule with comment (55 FR

15150); and the September 4, 1990 final

rule (55 FR 35994).

a. Updating the FY 1982 and FY 1987

Hospital-Specific Rates for FY 1999. We

are proposing to increase the hospitalspecific rates by 0.7 percent (the

hospital market basket percentage

increase of 2.6 percent minus 1.9

percentage points) for sole community

hospitals and Medicare-dependent,

small rural hospitals located in all areas

for FY 1999. Section 1886(b)(3)(C)(iv) of

the Act provides that the update factor

applicable to the hospital-specific rates

for sole community hospitals equals the

update factor provided under section

1886(b)(3)(B)(iv) of the Act, which, for

FY 1999, is the market basket rate of

increase minus 1.9 percentage points.

Section 1886(b)(3)(D) of the Act

provides that the update factor

applicable to the hospital-specific rates

for Medicare-dependent, small rural

hospitals equals the update factor

provided under section 1886(b)(3)(B)(iv)

of the Act, which, for FY 1999, is the

market basket rate of increase minus 1.9

percentage points.

b. Calculation of Hospital-Specific

Rate. For sole community hospitals and

Medicare-dependent, small rural

hospitals, the applicable FY 1999

hospital-specific rate would be

calculated by increasing the hospital’s

hospital-specific rate for the preceding

fiscal year by the applicable update

factor (0.7 percent), which is the same

as the update for all prospective

payment hospitals except ‘‘temporary

relief’’ hospitals. In addition, the

hospital-specific rate would be adjusted

by the budget neutrality adjustment

factor (that is, 0.999227) as discussed in

section II.A.4.a of this Addendum. This

resulting rate would be used in

determining under which rate a sole

community hospital or Medicaredependent, small rural hospital is paid

for its discharges beginning on or after

October 1, 1998, 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, 1998 and Before

October 1, 1999.

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

or 1F 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 50 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 or

1F 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.
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25613

Step 3—Multiply the result in Step 2 by

50 percent.

Step 4—Multiply the amount from

Step 3 by the appropriate DRG relative

weight (see Table 5 of section 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 1999

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 §§ 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 1999. The rates will be

effective for discharges occurring on or

after October 1, 1998.

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

§ 412.308(c)(1), to account for capital

input price increases and other factors.

Also, § 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, § 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 § 412.348.

Furthermore, § 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, § 412.352 required that

the Federal rate also be adjusted by a

budget neutrality factor so that aggregate

payments for inpatient hospital capital

costs were projected to equal 90 percent

of the payments that would have been

made for capital-related costs on a

reasonable cost basis during the fiscal

year. That provision expired in FY 1996.

Section 412.308(b)(2) describes the 7.4

percent reduction to the rate which was

made in FY 1994, and § 412.308(b)(3)

describes the 0.28 percent reduction to

the rate made in FY 1996 as a result of

the revised policy of paying for

transfers. In the FY 1998 final rule with

comment period (62 FR 45966) we

implemented section 4402 of the BBA,

which required that for discharges

occurring on or after October 1, 1997,

and before October 1, 2002, the

unadjusted standard Federal rate was

reduced by 17.78 percent. A small part

of that reduction will be restored

effective October 1, 2002.

For each hospital, the hospitalspecific 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 hospitalspecific 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.

In the FY 1998 final rule with comment

period (62 FR 46012) we implemented

section 4402 of the BBA, which required

that for discharges occurring on or after

October 1, 1997, and before October 1,

2002, the unadjusted hospital-specific

rate should be reduced by 17.78 percent.

A small part of that reduction will also

be restored effective October 1, 2002.

To determine the appropriate budget

neutrality adjustment factor and the

exceptions payment adjustment factor,

we developed a dynamic model of

Medicare inpatient capital-related costs,

that is, a model that projects changes in

Medicare inpatient capital-related costs

over time. With the expiration of the

budget neutrality provision, the model

is still used to estimate the exceptions

payment adjustment and other factors.

The model and its application are

described in greater detail in Appendix

B of this proposed rule.

In accordance with section

1886(d)(9)(A) of the Act, under the

prospective payment system for

inpatient operating costs, hospitals

located in Puerto Rico are paid for

operating costs under a special payment

formula. Prior to FY 1998, hospitals in

Puerto Rico were paid a blended rate

that consisted of 75 percent of the

applicable standardized amount specific

to Puerto Rico hospitals and 25 percent

of the applicable national average

standardized amount. However,

effective October 1, 1998, as a result of

section 4406 of the BBA, operating

payments to hospitals in Puerto Rico are

based on a blend of 50 percent of the

applicable standardized amount specific

to Puerto Rico hospitals and 50 percent

of the applicable national average

standardized amount. In conjunction

with this change to the operating blend

percentage, effective with discharges on

or after October 1, 1997, we compute

capital payments to hospitals in Puerto

Rico based on a blend of 50 percent of

the Puerto Rico rate and 50 percent of

the Federal rate. Section 412.374

provides for the use of this blended

payment system for payments to Puerto

Rico hospitals under the prospective

payment system for inpatient capitalrelated costs. Accordingly, for capitalrelated costs we compute a separate

payment rate specific to Puerto Rico

hospitals using the same methodology

used to compute the national Federal

rate for capital.

A. Determination of Federal Inpatient

Capital-Related Prospective Payment

Rate Update

For FY 1998, the Federal rate is

$371.51. With the changes we are

proposing to the factors used to

establish the Federal rate, the proposed

FY 1999 Federal rate is $377.25.

In the discussion that follows, we

explain the factors that were used to

determine the proposed FY 1999

Federal rate. In particular, we explain

why the proposed FY 1999 Federal rate

has increased 1.55 percent compared to

the FY 1998 Federal rate. Even though

we estimate that Medicare hospital

inpatient discharges will decline by

approximately 2.25 between FY 1998

and FY 1999, we also estimate that

aggregate capital payments will increase

by 2.60 percent during this same period.

This aggregate increase is primarily due

to the change in the federal rate blend

percentage from 70 percent to 80

percent, the 1.55 percent increase in the

rate, and a projected increase in case

mix.

The major factor contributing to the

increase in the proposed capital Federal

rate for FY 1999 relative to FY 1998 is
25614 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

that the proposed FY 1999 exceptions

reduction factor is 1.06 percent higher

than the factor for FY 1998. The

exceptions reduction factor equals 1

minus the projected percentage of

exceptions payments. We estimate that

the projected percentage of exceptions

payments for FY 1999 will be lower

than the projected percentage for FY

1998; accordingly, the proposed FY

1999 rate reflects less of a reduction to

account for exceptions than the FY 1998

rate.

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 1999

compared to FY 1998.

1. Standard Federal Rate Update

a. Description of the Update

Framework. Under section

412.308(c)(1), the standard Federal rate

is updated on the basis of an analytical

framework that takes into account

changes in a capital input price index

and other factors. The update

framework consists of a capital input

price index (CIPI) and several policy

adjustment factors. Specifically, we

have adjusted the projected CIPI rate of

increase as appropriate each year for

case-mix index related changes, for

intensity, and for errors in previous CIPI

forecasts. The proposed update factor

for FY 1999 under that framework is 0.2

percent. This proposal is based on a

projected 0.8 percent increase in the

CIPI, policy adjustment factors of -0.2,

and a forecast error correction of ¥0.4

percent. We explain the basis for the FY

1999 CIPI projection in section II.D of

this addendum. Here we describe the

policy adjustments.

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’’ casemix 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 casemix 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 1999, 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 1999.

Therefore, the proposed net adjustment

for case-mix change in FY 1999 is -0.2

percentage points.

We estimate that DRG reclassification

and recalibration result 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 capital update framework

contains an adjustment for forecast

error. The input price index forecast is

based on historical trends and

relationships ascertainable at the time

the update factor is established for the

upcoming year. In any given year there

may be unanticipated price fluctuations

that may result in differences between

the actual increase in prices 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 1997 through

an adjustment to the FY 1999 update.

Because we only introduced this

analytical framework in FY 1996, FY

1998 was the first year in which a

forecast error adjustment could be

required. We estimate that the FY 1997

CIPI was 0.4 percentage points higher

than our current data show, which

means that we estimate a forecast error

of -0.4 percentage points for FY 1997.

Therefore we are making an -0.4 percent

adjustment for forecast error in FY 1999.

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 1999, we have developed a

Medicare-specific intensity measure

based on a 5-year average using FY

1993–1997 data. In determining casemix constant intensity, we found that

observed case-mix increase was 0.9

percent in FY 1993, 0.8 percent in FY
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25615

1994, 1.7 percent in FY 1995, 1.6

percent in FY 1996, and 0.3 percent in

FY 1997. For FY 1995 and FY 1996, we

estimate that real case-mix increase was

1.0 to 1.4 percent each year. The

estimate for those years is supported by

past studies of case-mix change by the

RAND Corporation. The most recent

study was ‘‘Has DRG Creep Crept Up?

Decomposing the Case Mix Index

Change Between 1987 and 1988’’ by G.

M. Carter, J. P. Newhouse, and D. A.

Relles, R–4098–HCFA/ProPAC(1991).

The study suggested that real case-mix

change was not dependent on total

change, but was usually a fairly steady

1.0 to 1.5 percent per year. We use 1.4

percent as the upper bound because the

RAND study did not take into account

that hospitals may have induced doctors

to document medical records more

completely in order to improve

payment. Following that study, we

consider up to 1.4 percent of observed

case-mix change as real for FY 1992

through FY 1997. Based on this

analysis, we believe that all of the

observed case-mix increase for FY 1993,

FY 1994 and FY 1997 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 case-mix. Given

estimates of real case mix of 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, and 0.3 percent for FY 1997,

we estimate that case-mix constant

intensity declined by an average 1.5

percent during FYs 1993 through 1997,

for a cumulative decrease of 7.3 percent.

If we assume that real case-mix increase

was 0.9 percent for FY 1993, 0.8 percent

for FY 1994, 1.4 percent for FY 1995, 1.4

percent for FY 1996 and 0.3 percent for

FY 1997, we estimate that case-mix

constant intensity declined by an

average 1.6 percent during FYs 1993

through 1997, for a cumulative decrease

of 7.7 percent. Since we estimate that

intensity has declined during that

period, we are recommending a 0.0

percent intensity adjustment for FY

1999.

b. Comparison of HCFA and MedPAC

Update Recommendations. MedPAC

recommends a 0.0 to 0.7 percent update

to the standard Federal rate and we are

recommending a 0.2 percent update.

There are some significant differences

between the HCFA and MedPAC update

frameworks, which account for the

difference in the respective update

recommendations. A major difference is

the input price index which each

framework uses as a beginning point to

estimate the change in input prices

since the previous year. The HCFA

capital input price index (the CIPI)

includes price measures for interest

expense, which are an indicator of the

interest rates facing hospitals during

their capital purchasing decisions. The

MedPAC capital market basket does not

include interest expense; instead the

MedPAC update framework includes 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. MedPAC’s capital market basket

is not vintage-weighted, accounting only

for the current year price changes. This

year, due to the difference between

HCFA’s and MedPAC’s input price

index, the percentage change in HCFA’s

CIPI is 0.8 percent, and the percentage

change in MedPAC’s market basket is

2.4 percent.

MedPAC and HCFA also differ in the

adjustments they make to their price

indices. (See Table 1 for a comparison

of HCFA and MedPAC’s update

recommendations.) MedPAC makes an

adjustment for productivity, while

HCFA has not adopted an adjustment

for capital productivity or efficiency.

MedPAC employs the same productivity

adjustment in its operating and capital

framework. We have identified a total

intensity factor but have not identified

an adequate total productivity measure.

The Commission also includes a

product change adjustment to account

for changes in the service content of

hospital stays, which adjusts the base

payment rates to eliminate

overpayments in the future. MedPAC

recommends a ¥3.0 to a ¥1.0

adjustment for product change for FY

1999. For FY 1999 MedPAC

recommends a ¥0.7 to a ¥0.3

adjustment for productivity. 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

1999. MedPAC makes a two part

adjustment for case mix changes, which

takes into account changes in case mix

in the past year. They recommend a

¥0.2 to ¥0.0 adjustment for coding

change and an 0.0 to 0.2 adjustment for

within-DRG complexity change. We

recommend a ¥0.4 adjustment for

forecast error correction, and MedPAC

recommends a ¥0.4 adjustment for

forecast error correction.

The net result of these adjustments is

that MedPAC’s capital update

framework suggests a ¥1.9 to 1.4

percent update. MedPAC has

recommended a 0.0 to 0.7 percent

update to the rate for FY 1999. This

range is consistent with the PPS

operating update recommended by the

Commission. We describe the basis for

our proposed 0.2 percent total update in

the preceding section. HCFA and

MedPAC’s update recommendations are

quite close, with HCFA’s

recommendation within the range

recommended by MedPAC.

TABLE 1.—HCFA’S FY 1999 UPDATE FACTOR AND MEDPAC’S RECOMMENDATION

HCFA’s update

factor

MedPAC’s

recommenda

tion

Capital Input Price Index ................................................................................................................................. 0.8 2.4

Policy Adjustment Factors:

Productivity ............................................................................................................................................... .............................. ¥0.7 to ¥0.3

Intensity .................................................................................................................................................... 0.0

Science and Technology .................................................................................................................. .............................. 0.0 to 0.5

Intensity ............................................................................................................................................. .............................. (1)

Real within DRG Change ................................................................................................................. .............................. (2)

Product Change ....................................................................................................................................... .............................. ¥3.0 to ¥1.0

Subtotal ......................................................................................................................................... 0.0 ¥3.7 to ¥0.8

Case-Mix Adjustment Factors:

Projected Case-Mix Change .................................................................................................................... ¥1.0

Real Across DRG Change ....................................................................................................................... 0.8
25616 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 1.—HCFA’S FY 1999 UPDATE FACTOR AND MEDPAC’S RECOMMENDATION—Continued

HCFA’s update

factor

MedPAC’s

recommenda

tion

Coding Change ........................................................................................................................................ .............................. ¥0.2 to ¥0.0

Real within DRG Change ........................................................................................................................ (3) 0.0 to 0.2

Subtotal ......................................................................................................................................... ¥0.2 ¥0.2 to 0.2

Effect of FY 1996 Reclassification and Recalibration .................................................................................... 0.0

Forecast Error Correction ............................................................................................................................... ¥0.4 ¥0.4

Total Update ......................................................................................................................................... 0.2 ¥1.9 to 1.4

1 Included in MedPAC’s productivity measure.

2 Included in MedPAC’s case-mix adjustment.

3 Included in HCFA’s intensity factor.

2. Outlier Payment Adjustment Factor

Section 412.312(c) establishes a

unified outlier methodology for

inpatient operating and inpatient

capital-related costs. A single set of

thresholds is used to identify outlier

cases for both inpatient operating and

inpatient capital-related payments.

Outlier payments are made only on the

portion of the Federal rate that is used

to calculate the hospital’s inpatient

capital-related payments (for example,

80 percent for cost reporting periods

beginning in FY 1999 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 100 percent of the

Federal rate. For purposes of calculating

the outlier thresholds and the outlier

reduction factor, we model payments as

if all hospitals were paid 100 percent of

the Federal rate because, as explained

above, outlier payments are made only

on the portion of the Federal rate that

is included in the hospital’s inpatient

capital-related payments.

In the August 29, 1997 final rule with

comment period, we estimated that

outlier payments for capital in FY 1998

would equal 6.18 percent of inpatient

capital-related payments based on the

Federal rate. Accordingly, we applied

an outlier adjustment factor of 0.9382 to

the Federal rate. Based on the

thresholds as set forth in section II.A.4.d

of this Addendum, we estimate that

outlier payments for capital will equal

6.22 percent of inpatient capital-related

payments based on the Federal rate in

FY 1999. We are, therefore, proposing

an outlier adjustment factor of 0.9378 to

the Federal rate. Thus, estimated capital

outlier payments for FY 1999 represent

a higher percentage of total capital

standard payments than in FY 1998.

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

1999 is 0.9996 (0.9378/0.9382). Thus,

the outlier adjustment decreases the FY

1999 Federal rate by 0.04 percent

(0.9996—1) compared with the FY 1998

outlier adjustment.

3. Budget Neutrality Adjustment Factor

for Changes in DRG Classifications and

Weights and the Geographic Adjustment

Factor

Section 412.308(c)(4)(ii) requires that

the Federal rate be adjusted so that

aggregate payments for the fiscal year

based on the Federal rate after any

changes resulting from the annual DRG

reclassification and recalibration and

changes in the GAF are projected to

equal aggregate payments that would

have been made on the basis of the

Federal rate without such changes. We

use the actuarial model, described in

Appendix B of this proposed rule, to

estimate the aggregate payments that

would have been made on the basis of

the Federal rate without changes in the

DRG classifications and weights and in

the GAF. We also use the model to

estimate aggregate payments that would

be made on the basis of the Federal rate

as a result of those changes. We then use

these figures to compute the adjustment

required to maintain budget neutrality

for changes in DRG weights and in the

GAF.

For FY 1998, we calculated a GAF/

DRG budget neutrality factor of 0.9989.

For FY 1999, we are proposing a GAF/

DRG budget neutrality factor of 1.0032.

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 1998 to FY 1999 is 1.0032. The

proposed cumulative change in the rate

due to this adjustment is 1.0034 (the

product of the incremental factors for

FY 1993, FY 1994, FY 1995, FY 1996,

FY 1997, FY 1998, and the proposed

incremental factor for FY 1999: 0.9980

× 1.0053 × 0.9998 × 0.9994 × 0.9987 ×

0.9989 × 1.0032 = 1.0034).

This proposed factor accounts for

DRG reclassifications and recalibration

and for changes in the GAF. It also

incorporates the effects on the GAF of

FY 1999 geographic reclassification

decisions made by the MGCRB

compared to FY 1998 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 § 412.348 relative to

total payments under the hospitalspecific rate and Federal rate. We use

the model originally developed for

determining the budget neutrality

adjustment factor to determine the
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25617

exceptions payment adjustment factor.

We describe that model in Appendix B

to this proposed rule.

For FY 1998, we estimated that

exceptions payments would equal 3.41

percent of aggregate payments based on

the Federal rate and the hospitalspecific rate. Therefore, we applied an

exceptions reduction factor of 0.9659

(1–0.0341) in determining the Federal

rate. For this proposed rule, we estimate

that exceptions payments for FY 1999

will equal 2.39 percent of aggregate

payments based on the Federal rate and

the hospital-specific rate. Therefore, we

are proposing an exceptions payment

reduction factor of 0.9761 to the Federal

rate for FY 1999. The proposed

exceptions reduction factor for FY 1999

is 1.06 percent higher than the factor for

FY 1998.

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 1999 Federal rate

is 0.9761/0.9659, or 1.0106.

5. Standard Capital Federal Rate for FY

1999

For FY 1998, the capital Federal rate

was $371.51. With the changes we are

proposing to the factors used to

establish the Federal rate, the FY 1999

Federal rate would be $377.25. The

proposed Federal rate for FY 1999 was

calculated as follows:

• The proposed FY 1999 update

factor is 1.0020, that is, the proposed

update is 0.20 percent.

• The proposed FY 1999 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 1.0032.

• The proposed FY 1999 outlier

adjustment factor is 0.9378.

• The proposed FY 1999 exceptions

payments adjustment factor is 0.9761.

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 1999 affected the computation of

the proposed FY 1999 Federal rate in

comparison to the FY 1998 Federal rate.

The proposed FY 1999 update factor has

the effect of increasing the Federal rate

by 0.20 percent compared to the rate in

FY 1998, while the proposed geographic

and DRG budget neutrality factor has

the effect of increasing the Federal rate

by 0.32 percent. The proposed FY 1999

outlier adjustment factor has the effect

of decreasing the Federal rate by 0.04

percent compared to FY 1998. The

proposed FY 1999 exceptions reduction

factor has the effect of increasing the

Federal rate by 1.06 percent compared

to the exceptions reduction for FY 1998.

The combined effect of all the proposed

changes is to increase the proposed

Federal rate by 1.55 percent compared

to the Federal rate for FY 1998.

Comparison of Factors and Adjustments—FY 1998 Federal Rate and Proposed FY 1999 Federal Rate

FY 98 Proposed

FY 99 Change Percentchange

Update factor1 .................................................................................................................. 1.0090 1.0020 1.0020 0.20

GAF/DRG Adjustment Factor1 ......................................................................................... 0.9989 1.0032 1.0032 0.32

Outlier Adjustment Factor2 ............................................................................................... 0.9382 0.9378 0.9996 ¥0.04

Exceptions Adjustment Factor2 ........................................................................................ 0.9659 0.9761 1.0106 1.06

Federal Rate ..................................................................................................................... $371.51 $377.25 1.0155 1.55

1The update factor and the GAF/DRG budget neutrality factors are built permanently into the rates. Thus, for example, the incremental change

from FY 1998 to FY 1999 resulting from the application of the 1.0032 GAF/DRG budget neutrality factor for FY 1999 is 1.0032. 2The 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 1999 outlier reduction factor is

0.9378/0.9382, or 0.9996.

6. Special Rate for Puerto Rico Hospitals

As explained at the beginning of this

section, hospitals in Puerto Rico are

paid based on 50 percent of the Puerto

Rico rate and 50 percent of the Federal

rate. The Puerto Rico rate is derived

from the costs of Puerto Rico hospitals

only, while the Federal rate is derived

from the costs of all acute care hospitals

participating in the prospective

payment system (including Puerto

Rico). To adjust hospitals’ capital

payments for geographic variations in

capital costs, we apply a geographic

adjustment factor (GAF) to both portions

of the blended rate. The GAF is

calculated using the operating PPS wage

index and varies depending on the MSA

or rural area in which the hospital is

located. We use the Puerto Rico wage

index to determine the GAF for the

Puerto Rico part of the capital blended

rate and the national wage index to

determine the GAF for the national part

of the blended rate.

Since we implemented a separate

GAF for Puerto Rico, we also propose to

apply separate budget neutrality

adjustments for the national GAF and

for the Puerto Rico GAF. We propose to

apply the same budget neutrality factor

for DRG reclassifications and

recalibration nationally and for Puerto

Rico. Separate adjustments were

unnecessary for FY 1998 since the

Puerto Rico specific GAF was

implemented that year. The Puerto Rico

GAF budget neutrality factor is 0.9989,

while the DRG adjustment is 1.0033, for

a combined cumulative adjustment of

1.0022. (For a more detailed explanation

of this proposed change see Appendix

B.)

In computing the payment for a

particular Puerto Rico hospital, the

Puerto Rico portion of the rate (50%) is

multiplied by the Puerto Rico-specific

GAF for the MSA in which the hospital

is located, and the national portion of

the rate (50%) is multiplied by the

national GAF for the MSA in which the

hospital is located (which is computed

from national data for all hospitals in

the United States and Puerto Rico). In

FY 1998, we implemented a 17.78

percent reduction to the Puerto Rico rate

as a result of the BBA.

For FY 1998, before application of the

GAF, the special rate for Puerto Rico

hospitals was $177.57. With the changes

we are proposing to the factors used to

determine the rate, the proposed FY

1999 special rate for Puerto Rico is

$180.73.

B. Determination of Hospital-Specific

Rate Update

Section 412.328(e) of the regulations

provides that the hospital-specific rate

for FY 1999 be determined by adjusting
25618 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

the FY 1998 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 § 412.308(c)(1). For FY 1999, we

are proposing that the hospital-specific

rate be updated by a factor of 1.0020.

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

§ 412.348, determined as a proportion of

the total amount of payments under the

hospital-specific rate and the Federal

rate. For FY 1999, we estimate that

exceptions payments will be 2.39

percent of aggregate payments based on

the Federal rate and the hospitalspecific rate. Therefore, we propose that

the updated hospital-specific rate be

reduced by a factor of 0.9761. The

exceptions reduction factors are not

built permanently into the rates; that is,

the factors are not applied cumulatively

in determining the hospital-specific

rate. The proposed net adjustment to the

FY 1999 hospital-specific rate is 0.9761/

0.9659, or 1.0106.

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 1998

and FY 1999 and the net adjustment for

each factor. It also shows that the

proposed cumulative net adjustment

from FY 1998 to FY 1999 is 1.0126,

which represents a proposed increase of

1.26 percent to the hospital-specific

rate. For each hospital, the proposed FY

1999 hospital-specific rate is

determined by multiplying the FY 1998

hospital-specific rate by the cumulative

net adjustment of 1.0126.

PROPOSED FY 1999 UPDATE AND ADJUSTMENTS TO HOSPITAL-SPECIFIC RATES

FY 98 Proposed

FY 99

Net AdjustmentPercent

Change

Update Factor ................................................................................................................... 1.0090 1.0020 1.0020 0.20

Exceptions Payment Adjustment Factor .......................................................................... 0.9659 0.9761 1.0106 1.06

Cumulative Adjustments ................................................................................................... 0.9746 0.9869 1.0026 1.26

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 1998 to FY 1999 is 1.0020. In contrast, the exceptions payment adjustment factor is not applied cumulatively. Thus, for example, the incremental increase in the exceptions reduction factor from FY 1998 to FY 1999 is 0.9761/0.9659, or 1.0106.

C. Calculation of Inpatient CapitalRelated Prospective Payments for FY

1999

During the capital prospective

payment system transition period, a

hospital is paid for the inpatient capitalrelated costs under one of two payment

methodologies—the fully prospective

payment methodology or the holdharmless 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

redution factor for that fiscal year; and,

• For the payment adjustment factors

applicable to the hospital (that is, the

hospital’s GAF, the disproportionate

share adjustment factor, and the indirect

medical education adjustment factor,

when appropriate).

• If the hospital-specific rate is above

the applicable Federal rate, the hospital

is paid under the hold-harmless

methodology. If the hospital-specific

rate is below the applicable Federal rate,

the hospital is paid under the fully

prospective methodology.

For purposes of calculating payments

for each discharge under both the holdharmless payment methodology and the

fully prospective payment methodology,

the standard Federal rate is adjusted as

follows:

(Standard Federal Rate) x (DRG

weight) x (GAF) x (Large Urban Add-on,

if applicable) x (COLA adjustment for

hospitals located in Alaska and Hawaii)

x (1 + Disproportionate Share

Adjustment Factor + IME Adjustment

Factor, if applicable).

The result is the adjusted Federal rate.

Payments under the hold-harmless

methodology are determined under one

of two formulas. A hold-harmless

hospital is paid the higher of the

following:

• 100 percent of the adjusted Federal

rate for each discharge; or

• An old capital payment equal to 85

percent (100 percent for sole community

hospitals) of the hospital’s allowable

Medicare inpatient old capital costs per

discharge for the cost reporting period

plus a new capital payment based on a

percentage of the adjusted Federal rate

for each discharge. The percentage of

the adjusted Federal rate equals the ratio

of the hospital’s allowable Medicare

new capital costs to its total Medicare

inpatient capital-related costs in the cost

reporting period.

Once a hospital receives payment

based on 100 percent of the adjusted

Federal rate in a cost reporting period

beginning on or after October 1, 1994 (or

the first cost reporting period after

obligated capital that is recognized as

old capital under § 412.302(c) is put in

use for patient care, if later), the hospital

continues to receive capital prospective

payment system payments on that basis

for the remainder of the transition

period.

Payment for each discharge under the

fully prospective methodology is the

sum of the following:

• The hospital-specific rate

multiplied by the DRG relative weight

for the discharge and by the applicable

hospital-specific transition blend

percentage for the cost reporting period;

and

• The adjusted Federal rate

multiplied by the Federal transition

blend percentage.

• The blend percentages for cost

reporting periods beginning in FY 1999

are 80 percent of the adjusted Federal

rate and 20 percent of the hospitalspecific 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 80 percent of the Federal rate for
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25619

discharges occurring in cost reporting

periods beginning during FY 1999.

Thus, a fully prospective hospital will

receive 80 percent of the capital-related

outlier payment calculated for the case

for discharges occurring in cost

reporting periods beginning in FY 1999.

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 1999 are in section II.A.4.c of this

Addendum. For FY 1999, a case

qualifies as a cost outlier if the cost for

the case (after standardization for the

indirect teaching adjustment and

disproportionate share adjustment) is

greater than the prospective payment

rate for the DRG plus $11,350.

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 § 412.348.

The proposed minimum payment levels

for portions of cost reporting periods

occurring in FY 1999 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 § 412.106(c)(2),

80 percent; and

• All other hospitals, 70 percent.

Under § 412.348(d), the amount of the

exceptions payment is determined by

comparing the cumulative payments

made to the hospital under the capital

prospective payment system to the

cumulative minimum payment levels

applicable to the hospital for each cost

reporting period subject to that system.

Any amount by which the hospital’s

cumulative payments exceed its

cumulative minimum payment is

deducted from the additional payment

that would otherwise be payable for a

cost reporting period.

New hospitals are exempted from the

capital prospective payment system for

their first 2 years of operation and are

paid 85 percent of their reasonable costs

during that period. A new hospital’s old

capital costs are its allowable costs for

capital assets that were put in use for

patient care on or before the later of

December 31, 1990 or the last day of the

hospital’s base year cost reporting

period, and are subject to the rules

pertaining to old capital and obligated

capital as of the applicable date.

Effective with the third year of

operation, we will pay the hospital

under either the fully prospective

methodology, using the appropriate

transition blend in that Federal fiscal

year, or the hold-harmless methodology.

If the hold-harmless methodology is

applicable, the hold-harmless payment

for assets in use during the base period

would extend for 8 years, even if the

hold-harmless payments extend beyond

the normal transition period.

D. Capital Input Price Index

1. Background

Like the prospective payment hospital

operating input price index, the Capital

Input Price Index (CIPI) is a fixedweight price index that measures the

price changes associated with costs

during a given year. The CIPI differs

from the operating input price index in

one important aspect—the CIPI reflects

the vintage nature of capital, which is

the acquisition and use of capital over

time. Capital expenses in any given year

are determined by the stock of capital in

that year (that is, capital that remains on

hand from all current and prior capital

acquisitions). An index measuring

capital price changes needs to reflect

this vintage nature of capital. Therefore,

the CIPI was developed to capture the

vintage nature of capital by using a

weighted-average of past capital

purchase prices up to and including the

current year.

Using Medicare cost reports, AHA

data, and Securities Data Corporation

data, a vintage-weighted price index

was developed to measure price

increases associated with capital

expenses. We periodically update the

base year for the operating and capital

input prices to reflect the changing

composition of inputs for operating and

capital expenses. Currently, the CIPI is

based to FY 1992 and was last rebased

in 1997. The most recent explanation of

the CIPI was discussed in the final rule

with comment period for FY 1998

published in the August 29, 1997

Federal Register (62 FR 46050). The

following Federal Register documents

also describe development and revisions

of the methodology involved with the

construction of the CIPI: September 1,

1992 (57 FR 40016), May 26, 1993 (58

FR 30448), September 1, 1993 (58 FR

46490), May 27, 1994 (59 FR 27876),

September 1, 1994 (59 FR 45517), June

2, 1995 (60 FR 29229), and September

1, 1995 (60 FR 45815), May 31, 1996 (61

FR 27466), August 30, 1996 (61 FR

46196), and June 2, 1997 (62 FR 29953).

2. Forecast of the CIPI for Federal Fiscal

Year 1999

DRI forecasts a 0.8 percent increase in

the CIPI for FY 1999. This is the

outcome of a projected 2.0 percent

increase in vintage-weighted

depreciation prices (building and fixed

equipment, and movable equipment)

and a 2.6 percent increase in other

capital expense prices in FY 1999,

partially offset by a 2.7 percent decline

in vintage-weighted interest rates in FY

1999. The weighted average of these

three factors produces the 0.8 percent

increase for the CIPI as a whole.

IV. Proposed Changes to Payment Rates

for Excluded Hospitals and Hospital

Units: Rate-of-Increase Percentages

A. Rate-of-Increase Percentages for

Excluded Hospitals and Hospital Units

The inpatient operating costs of

hospitals and hospital units excluded

from the prospective payment system

are subject to rate-of-increase limits

established under the authority of

section 1886(b) of the Act, which is

implemented in § 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). In the case of a

psychiatric hospital or unit,

rehabilitation hospital or unit, or longterm care hospital, the target amount

may not exceed the 75th percentile of

target amounts for hospitals and units in

the same class (psychiatric,

rehabilitation, and long-term care). The

target amount is multiplied by the

number of Medicare discharges in a

hospital’s cost reporting period, yielding

the ceiling on aggregate Medicare

inpatient operating costs for the cost

reporting period.

Each hospital’s target amount is

adjusted annually, at the beginning of

its cost reporting period, by an

applicable update factor. Section

1886(b)(3)(B) of the Act provides that for

cost reporting periods beginning on or

after October 1, 1998 and before October

1, 1999, the update factor is the market

basket less a percentage point between

0 and 2.5 depending on the hospital’s or
25620 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

unit’s costs in relation to the ceiling. For

hospitals with costs exceeding the

ceiling by 10 percent or more, the

update factor is the market basket

increase. For hospitals with costs

exceeding the ceiling by less than 10

percent, the update factor is the market

basket minus .25 percent for each

percentage point by which costs are less

than 10 percent over the ceiling. For

hospitals with costs equal to or less than

the ceiling but greater than 66.7 percent

of the ceiling, the update factor is the

greater of 0 percent or the market basket

minus 2.5 percent. For hospitals with

costs that do not exceed 66.7 percent of

the ceiling, the update factor is 0.

The most recent forecast of the market

basket increase for FY 1999 for hospitals

and hospital units excluded from the

prospective payment system is 2.5

percent; therefore, the update to a

hospital’s target amount for its cost

reporting period beginning in FY 1999

would be between 0 and 2.5 percent.

In addition, section 1886(b)(3)(H) of

the Act provides that for cost reporting

periods beginning on or after October 1,

1998 and before October 1, 1999, the

target amount for psychiatric hospitals

and units, rehabilitation hospitals and

units, and long-term care hospitals will

be the lower of the hospital’s specific

target amount or the 75th percentile

target amount for hospitals in the same

class. The FY 1998 75th percentile

target amounts were $10,534 for

psychiatric hospitals and units, $19,104

for rehabilitation hospital and units, and

$37,688 for long-term care hospitals. For

1999, these 75th percentile figures must

be updated by the market basket

increase. Section 1886(b) of the Act was

revised to change the formulas for

determining bonus and relief payments

for excluded hospitals and also

establishes an additional bonus

payment for continuous improvement,

for cost reporting periods on or after

October 1, 1997. Finally, a new statutory

payment methodology for new hospitals

and units (psychiatric, rehabilitation,

and long-term care) was effective

October 1, 1997 as governed by section

1886(b)(7) of the Act.

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, 1E, 1F, 3C,

4A, 4B, 4C, 4D, 4E, 4F, 5, 6A, 6B, 6C,

6D, 6E, 6F, 6G, 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 1E—National Adjusted Operating

Standardized Amounts for

‘‘Temporary Relief’’ Hospitals,

Labor/Nonlabor

Table 1F—Adjusted Operating

Standardized Amounts for

‘‘Temporary Relief’’ Hospitals in

Puerto Rico, Labor/Nonlabor

Table 3C—Hospital Case Mix Indexes

for Discharges Occurring in Federal

Fiscal Year 1997 and Hospital

Average Hourly Wage for Federal

Fiscal Year 1999 Wage Index

Table 4A—Wage Index and Capital

Geographic Adjustment Factor

(GAF) for Urban Areas

Table 4B—Wage Index and Capital

Geographic Adjustment Factor

(GAF) for Rural Areas

Table 4C—Wage Index and Capital

Geographic Adjustment Factor

(GAF) for Hospitals That Are

Reclassified

Table 4D—Average Hourly Wage for

Urban Areas

Table 4E—Average Hourly Wage for

Rural Areas

Table 4F—Puerto Rico Wage Index and

Capital Geographic Adjustment

Factor (GAF)

Table 5—List of Diagnosis Related

Groups (DRGs), Relative Weighting

Factors, Geometric Mean Length of

Stay, and Arithmetic Mean Length

of Stay Points Used in the

Prospective Payment System

Table 6A—New Diagnosis Codes

Table 6B—New Procedure Codes

Table 6C—Invalid Diagnosis Codes

Table 6D—Invalid Procedure Codes

Table 6E—Revised Diagnosis Code

Titles

Table 6F—Additions to the CC

Exclusions List

Table 6G—Deletions to the CC

Exclusions List

Table 7A—Medicare Prospective

Payment System Selected Percentile

Lengths of Stay FY 97 MEDPAR

Update 12/97 GROUPER V15.0

Table 7B—Medicare Prospective

Payment System Selected Percentile

Lengths of Stay FY 97 MEDPAR

Update 12/97 GROUPER V16.0

Table 8A—Statewide Average Operating

Cost-to-Charge Ratios for Urban and

Rural Hospitals (Case Weighted)

March 1998

Table 8B—Statewide Average Capital

Cost-to-Charge Ratios (Case

Weighted) March 1998

TABLE 1A.—NATIONAL ADJUSTED OPERATING STANDARDIZED AMOUNTS, LABOR/NONLABOR

Large urban areas Other areas

Labor-related Nonlabor-related Labor-related Nonlabor-related

2,776.21 1,128.44 2,732.26 1,110.58

TABLE 1C.—ADJUSTED OPERATING STANDARDIZED AMOUNTS FOR PUERTO RICO, LABOR/NONLABOR

Large urban areas Other areas

Labor Nonlabor Labor Nonlabor

National ............................................................................................................................. 2,752.36 1,118.74 2,752.36 1,118.74

Puerto Rico ....................................................................................................................... 1,323.01 532.55 1,302.07 524.11
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25621

TABLE 1D.—CAPITAL STANDARD FEDERAL PAYMENT RATE

Rate

National .................................................................................................................................................................................................... 371.51

Puerto Rico .............................................................................................................................................................................................. 177.57

TABLE 1E.—NATIONAL ADJUSTED OPERATING STANDARDIZED AMOUNTS FOR ‘‘TEMPORARY RELIEF’’ HOSPITALS, LABOR/

NONLABOR

Large urban areas Other areas

Labor-related Nonlabor-related Labor-related Nonlabor-related

2,790.09 1,134.08 2,745.92 1,116.13

TABLE 1F.—ADJUSTED OPERATING STANDARDIZED AMOUNTS FOR ‘‘TEMPORARY RELIEF’’ HOSPITALS IN PUERTO RICO,

LABOR/NONLABOR

Large urban areas Other areas

Labor Nonlabor Labor Nonlabor

National ............................................................................................................................. 2,766.12 1,124.33 2,766.12 1,124.33

Puerto Rico ....................................................................................................................... 1,329.63 535.21 1,308.58 526.73
25622 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 3C.—HOSPITAL CASE MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 1997; HOSPITAL

AVERAGE HOURLY WAGE FOR FEDERAL FISCAL YEAR 1999 WAGE INDEX

PAGE 1 OF 15

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

010001 ..... 01.4634 15.97 010097 ..... 00.9183 14.87 030006 ..... 01.5689 18.22 040005 ..... 01.0400 13.38 040118 ..... 01.3520 15.27

010004 ..... 01.0055 13.79 010098 ..... 01.1894 13.02 030007 ..... 01.3034 17.95 040007 ..... 01.8696 18.99 040119 ..... 01.1640 15.33

010005 ..... 01.1699 15.89 010099 ..... 01.1010 09.13 030008 ..... 02.2412 14.19 040008 ..... 01.0301 13.20 040124 ..... 01.0549 16.23

010006 ..... 01.4636 16.19 010100 ..... 01.3314 15.67 030009 ..... 01.2640 17.83 040010 ..... 01.3262 16.83 040126 ..... 00.9551 13.26

010007 ..... 01.1300 14.09 010101 ..... 01.0382 14.69 030010 ..... 01.4386 20.05 040011 ..... 00.9590 11.65 040134 ..... 02.6975 ..........

010008 ..... 01.0838 13.76 010102 ..... 00.9504 12.71 030011 ..... 01.4734 19.48 040014 ..... 01.2138 18.12 050002 ..... 01.5241 27.86

010009 ..... 01.1456 17.50 010103 ..... 01.8119 17.65 030012 ..... 01.2358 18.04 040015 ..... 01.1668 14.80 050006 ..... 01.5662 20.69

010010 ..... 01.0888 15.40 010104 ..... 01.6869 18.66 030013 ..... 01.2951 20.90 040016 ..... 01.6762 16.66 050007 ..... 01.5312 27.11

010011 ..... 01.6411 20.28 010108 ..... 01.2192 16.69 030014 ..... 01.5263 19.07 040017 ..... 01.2700 14.62 050008 ..... 01.4438 25.60

010012 ..... 01.2728 17.45 010109 ..... 01.1224 13.41 030016 ..... 01.1871 19.00 040018 ..... 01.2583 18.08 050009 ..... 01.6484 24.26

010015 ..... 01.1428 14.04 010110 ..... 01.0248 14.97 030017 ..... 01.4718 19.72 040019 ..... 01.1438 12.08 050013 ..... 01.8476 23.25

010016 ..... 01.2538 17.40 010112 ..... 01.1997 14.59 030018 ..... 01.8083 27.57 040020 ..... 01.5404 15.42 050014 ..... 01.1816 23.57

010018 ..... 00.9607 17.72 010113 ..... 01.6522 15.97 030019 ..... 01.2636 23.65 040021 ..... 01.2056 16.15 050015 ..... 01.3820 24.35

010019 ..... 01.2435 15.00 010114 ..... 01.3201 16.49 030022 ..... 01.4160 18.79 040022 ..... 01.5321 23.41 050016 ..... 01.1889 18.74

010021 ..... 01.2461 15.83 010115 ..... 00.8706 08.92 030023 ..... 01.4822 20.04 040024 ..... 01.0031 13.38 050017 ..... 02.0973 24.47

010022 ..... 01.0069 18.25 010117 ..... 00.8624 .......... 030024 ..... 01.6963 20.87 040025 ..... 00.9000 12.48 050018 ..... 01.2579 17.02

010023 ..... 01.6877 16.06 010118 ..... 01.3033 28.66 030025 ..... 01.0483 14.97 040026 ..... 01.5700 17.88 050021 ..... 01.4154 24.41

010024 ..... 01.4236 15.62 010119 ..... 00.8398 16.57 030027 ..... 01.0392 17.17 040027 ..... 01.2930 13.77 050022 ..... 01.5819 23.22

010025 ..... 01.3834 14.53 010120 ..... 01.0107 16.62 030030 ..... 01.7154 18.21 040028 ..... 01.0462 14.24 050024 ..... 01.3639 20.68

010027 ..... 00.8180 36.37 010121 ..... 01.3471 13.03 030033 ..... 01.2640 15.67 040029 ..... 01.2975 17.64 050025 ..... 01.8279 21.99

010029 ..... 01.6109 17.24 010123 ..... 01.2883 16.28 030034 ..... 01.0795 17.44 040030 ..... 00.8325 12.20 050026 ..... 01.5433 28.62

010031 ..... 01.2801 17.36 010124 ..... 01.2886 16.44 030035 ..... 01.2315 17.93 040032 ..... 00.9669 11.81 050028 ..... 01.3707 15.51

010032 ..... 00.9803 13.81 010125 ..... 01.0743 15.15 030036 ..... 01.2603 20.35 040035 ..... 00.9837 10.12 050029 ..... 01.4900 21.71

010033 ..... 01.9671 18.82 010126 ..... 01.2171 18.91 030037 ..... 02.0594 20.18 040036 ..... 01.5104 17.85 050030 ..... 01.3267 20.82

010034 ..... 01.1086 14.54 010127 ..... 01.3575 18.07 030038 ..... 01.6264 20.57 040037 ..... 01.1061 12.40 050032 ..... 01.2557 19.03

010035 ..... 01.1827 17.08 010128 ..... 00.9738 .......... 030040 ..... 01.1572 14.74 040039 ..... 01.2394 13.39 050033 ..... 01.4502 24.74

010036 ..... 01.1899 17.99 010129 ..... 01.0590 12.94 030041 ..... 00.9538 14.31 040040 ..... 00.9817 15.09 050036 ..... 01.6546 15.95

010038 ..... 01.3028 19.03 010130 ..... 00.9980 15.85 030043 ..... 01.2213 17.92 040041 ..... 01.2978 17.08 050038 ..... 01.4456 29.35

010039 ..... 01.7055 17.67 010131 ..... 01.3864 17.25 030044 ..... 00.9736 16.04 040042 ..... 01.2567 15.12 050039 ..... 01.6097 21.59

010040 ..... 01.6110 18.52 010134 ..... 00.8391 10.86 030047 ..... 00.9401 18.63 040044 ..... 01.0524 13.02 050040 ..... 01.2411 32.71

010043 ..... 01.0489 11.63 010137 ..... 01.2373 18.84 030049 ..... 00.9939 20.75 040045 ..... 01.0079 17.86 050042 ..... 01.2889 22.76

010044 ..... 01.1028 15.92 010138 ..... 00.9399 12.43 030054 ..... 00.8332 14.41 040047 ..... 01.1013 15.48 050043 ..... 01.5649 31.83

010045 ..... 01.2056 14.77 010139 ..... 01.6766 20.38 030055 ..... 01.2012 17.65 040050 ..... 01.1795 12.44 050045 ..... 01.2364 18.69

010046 ..... 01.5054 17.67 010143 ..... 01.2743 15.07 030059 ..... 01.3005 22.74 040051 ..... 01.1670 13.51 050046 ..... 01.1880 22.24

010047 ..... 00.9884 12.14 010144 ..... 01.3459 16.59 030060 ..... 01.1528 17.75 040053 ..... 01.1178 15.65 050047 ..... 01.5646 34.07

010049 ..... 01.1575 13.82 010145 ..... 01.3390 16.15 030061 ..... 01.6564 20.08 040054 ..... 01.0532 13.50 050051 ..... 01.1348 20.91

010050 ..... 01.1489 14.17 010146 ..... 01.2470 16.83 030062 ..... 01.2455 16.61 040055 ..... 01.4655 15.78 050054 ..... 01.1263 18.44

010051 ..... 00.9234 11.17 010148 ..... 00.9483 .......... 030064 ..... 01.7664 18.45 040058 ..... 01.0463 15.12 050055 ..... 01.3276 22.45

010052 ..... 01.0479 13.68 010149 ..... 01.3349 17.75 030065 ..... 01.7843 19.91 040060 ..... 00.9290 11.03 050056 ..... 01.3074 24.36

010053 ..... 01.0750 08.17 010150 ..... 01.1552 15.82 030067 ..... 01.0939 16.99 040062 ..... 01.6786 15.55 050057 ..... 01.5828 20.60

010054 ..... 01.1995 17.28 010152 ..... 01.2892 16.12 030068 ..... 01.1092 15.82 040064 ..... 01.0657 13.92 050058 ..... 01.4871 25.22

010055 ..... 01.4737 16.47 010155 ..... 01.0788 10.90 030069 ..... 01.4037 21.66 040066 ..... 01.1801 16.36 050060 ..... 01.5008 18.49

010056 ..... 01.3306 19.46 020001 ..... 01.5208 27.19 030071 ..... 01.0057 .......... 040067 ..... 01.2165 12.63 050061 ..... 01.3507 22.13

010058 ..... 00.9765 13.47 020002 ..... 01.0595 24.09 030072 ..... 00.8620 .......... 040069 ..... 01.1095 15.47 050063 ..... 01.4701 23.89

010059 ..... 01.0774 15.44 020004 ..... 01.1712 25.49 030073 ..... 01.0041 .......... 040070 ..... 00.9098 14.25 050065 ..... 01.7005 21.95

010061 ..... 01.1893 15.80 020005 ..... 00.9285 28.73 030074 ..... 00.9408 .......... 040071 ..... 01.6234 16.49 050066 ..... 01.2265 19.77

010062 ..... 01.0206 13.27 020006 ..... 01.1834 25.07 030075 ..... 00.8242 .......... 040072 ..... 01.0982 15.41 050067 ..... 01.3204 21.48

010064 ..... 01.7552 20.86 020007 ..... 00.9834 25.64 030076 ..... 00.9614 .......... 040074 ..... 01.2503 16.30 050068 ..... 01.1315 19.98

010065 ..... 01.3692 15.35 020008 ..... 01.1238 30.06 030077 ..... 00.8060 .......... 040075 ..... 01.0369 12.15 050069 ..... 01.6246 24.57

010066 ..... 00.9184 10.89 020009 ..... 00.8881 25.77 030078 ..... 01.0727 .......... 040076 ..... 01.0407 16.99 050070 ..... 01.3716 31.44

010068 ..... 01.2837 17.18 020010 ..... 01.0169 25.93 030079 ..... 00.8528 .......... 040077 ..... 01.0621 12.57 050071 ..... 01.3791 33.07

010069 ..... 01.1851 12.84 020011 ..... 00.9299 25.75 030080 ..... 01.5008 19.77 040078 ..... 01.5099 22.64 050072 ..... 01.4414 32.14

010072 ..... 01.1579 15.22 020012 ..... 01.2746 26.15 030083 ..... 01.3763 22.10 040080 ..... 01.0790 16.38 050073 ..... 01.3063 33.68

010073 ..... 01.0650 11.04 020013 ..... 01.0266 26.76 030084 ..... 01.1228 .......... 040081 ..... 00.9679 10.85 050075 ..... 01.3412 32.86

010078 ..... 01.2573 17.97 020014 ..... 01.1152 22.90 030085 ..... 01.4617 18.59 040082 ..... 01.2191 14.71 050076 ..... 01.9181 32.26

010079 ..... 01.2411 14.42 020017 ..... 01.4752 25.14 030086 ..... 01.4318 20.19 040084 ..... 01.1006 16.62 050077 ..... 01.6304 24.52

010081 ..... 01.8296 17.69 020018 ..... 00.9680 .......... 030087 ..... 01.6536 19.77 040085 ..... 01.1954 15.29 050078 ..... 01.3632 25.59

010083 ..... 01.0337 15.64 020019 ..... 00.9067 .......... 030088 ..... 01.4231 19.42 040088 ..... 01.4395 13.39 050079 ..... 01.5434 31.90

010084 ..... 01.5048 18.27 020020 ..... 00.7369 .......... 030089 ..... 01.6391 19.70 040090 ..... 00.9349 14.77 050080 ..... 01.4214 19.44

010085 ..... 01.2796 17.32 020021 ..... 00.8551 .......... 030092 ..... 01.6833 21.25 040091 ..... 01.1266 18.55 050082 ..... 01.6661 21.99

010086 ..... 01.0395 15.44 020024 ..... 01.1349 22.66 030093 ..... 01.3770 18.77 040093 ..... 00.9413 13.01 050084 ..... 01.6759 22.53

010087 ..... 01.6587 16.36 020025 ..... 01.0164 26.32 030094 ..... 01.2784 19.19 040100 ..... 01.2392 12.91 050088 ..... 00.9877 19.55

010089 ..... 01.2392 18.50 020026 ..... 01.2873 .......... 030095 ..... 01.0461 18.85 040105 ..... 01.0353 13.05 050089 ..... 01.3688 18.85

010090 ..... 01.6235 17.44 020027 ..... 01.0891 .......... 030099 ..... 00.9439 .......... 040106 ..... 01.0675 13.53 050090 ..... 01.2668 23.85

010091 ..... 01.0247 13.51 030001 ..... 01.3399 19.87 040001 ..... 01.1079 13.42 040107 ..... 01.1428 16.75 050091 ..... 01.1370 21.99

010092 ..... 01.4011 15.82 030002 ..... 01.7944 20.96 040002 ..... 01.1468 13.33 040109 ..... 01.1342 13.95 050092 ..... 00.9386 16.26

010094 ..... 01.2128 16.01 030003 ..... 02.0396 22.65 040003 ..... 01.0880 13.97 040114 ..... 01.8758 17.98 050093 ..... 01.5500 23.90

010095 ..... 00.9779 12.73 030004 ..... 01.1011 12.52 040004 ..... 01.6709 17.69 040116 ..... 01.2656 16.72 050096 ..... 01.2374 21.29
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25623

PAGE 2 OF 15

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

050097 ..... 01.3873 18.48 050204 ..... 01.5825 24.52 050313 ..... 01.2044 22.00 050443 ..... 00.9057 18.82 050571 ..... 01.5096 20.05

050099 ..... 01.4747 23.55 050205 ..... 01.2709 21.52 050315 ..... 01.3579 20.47 050444 ..... 01.2967 22.54 050573 ..... 01.6294 28.41

050100 ..... 01.6983 33.49 050207 ..... 01.2640 20.02 050317 ..... 01.2655 21.86 050446 ..... 00.9770 10.06 050575 ..... 01.1367 ..........

050101 ..... 01.4168 31.68 050211 ..... 01.3186 30.67 050320 ..... 01.2324 27.70 050447 ..... 01.0672 18.58 050577 ..... 01.4644 20.19

050102 ..... 01.3532 17.01 050213 ..... 01.5794 22.96 050324 ..... 01.9664 26.19 050448 ..... 01.0974 20.95 050578 ..... 01.4689 30.62

050103 ..... 01.5661 23.46 050214 ..... 01.4659 21.31 050325 ..... 01.2308 21.08 050449 ..... 01.3366 21.14 050579 ..... 01.4970 28.52

050104 ..... 01.4815 23.94 050215 ..... 01.5572 29.63 050327 ..... 01.5599 18.67 050454 ..... 01.8425 25.82 050580 ..... 01.4380 27.74

050107 ..... 01.4511 23.02 050217 ..... 01.3457 19.08 050329 ..... 01.2928 19.88 050455 ..... 01.7746 16.56 050581 ..... 01.3930 24.39

050108 ..... 01.8295 23.87 050219 ..... 01.1139 18.83 050331 ..... 01.4843 24.20 050456 ..... 01.1694 16.92 050583 ..... 01.6266 21.88

050110 ..... 01.1656 20.59 050222 ..... 01.6256 31.91 050333 ..... 01.1427 24.96 050457 ..... 02.0310 31.03 050584 ..... 01.1966 20.18

050111 ..... 01.3578 20.16 050224 ..... 01.5705 23.23 050334 ..... 01.7269 34.59 050459 ..... 01.2985 29.51 050585 ..... 01.2772 27.19

050112 ..... 01.4824 19.36 050225 ..... 01.6075 22.02 050335 ..... 01.4534 21.39 050464 ..... 01.8738 22.01 050586 ..... 01.3490 20.52

050113 ..... 01.3756 31.25 050226 ..... 01.4119 24.79 050336 ..... 01.3695 20.14 050468 ..... 01.3879 19.71 050588 ..... 01.3220 24.70

050114 ..... 01.3693 23.13 050228 ..... 01.2880 30.89 050342 ..... 01.3706 17.71 050469 ..... 01.0972 16.63 050589 ..... 01.2474 24.07

050115 ..... 01.5640 20.46 050230 ..... 01.3342 25.40 050343 ..... 01.0225 14.95 050470 ..... 01.1474 18.51 050590 ..... 01.3578 24.92

050116 ..... 01.4487 23.36 050231 ..... 01.6681 25.54 050348 ..... 01.6579 25.44 050471 ..... 01.8883 23.41 050591 ..... 01.3784 22.87

050117 ..... 01.4515 20.79 050232 ..... 01.7123 21.50 050349 ..... 00.8825 14.57 050476 ..... 01.3512 21.10 050592 ..... 01.3661 18.46

050118 ..... 01.1901 23.81 050234 ..... 01.2536 30.23 050350 ..... 01.3957 24.28 050477 ..... 01.4936 26.90 050593 ..... 01.1846 ..........

050121 ..... 01.3531 24.60 050235 ..... 01.6014 24.55 050351 ..... 01.4653 32.84 050478 ..... 00.9635 21.11 050594 ..... 01.6739 19.05

050122 ..... 01.5966 26.85 050236 ..... 01.4693 25.40 050352 ..... 01.3034 19.07 050481 ..... 01.4648 27.13 050597 ..... 01.2665 21.36

050124 ..... 01.3182 17.12 050238 ..... 01.5517 24.76 050353 ..... 01.6669 24.77 050482 ..... 01.0978 16.07 050598 ..... 01.3875 32.07

050125 ..... 01.3970 27.55 050239 ..... 01.5877 21.67 050355 ..... 00.9808 16.04 050483 ..... 01.1821 22.22 050599 ..... 01.6318 23.23

050126 ..... 01.5414 24.94 050240 ..... 01.4863 21.17 050357 ..... 01.4011 23.77 050485 ..... 01.6561 23.81 050601 ..... 01.6150 32.05

050127 ..... 01.3406 24.15 050241 ..... 01.2337 26.32 050359 ..... 01.2854 19.11 050486 ..... 01.3493 23.00 050603 ..... 01.4035 22.60

050128 ..... 01.6211 21.63 050242 ..... 01.4284 29.91 050360 ..... 01.4136 31.05 050488 ..... 01.3349 32.94 050604 ..... 01.5622 37.27

050129 ..... 01.6194 14.25 050243 ..... 01.5930 22.58 050366 ..... 01.3455 22.32 050491 ..... 01.1935 21.97 050607 ..... 01.1545 20.69

050131 ..... 01.3023 29.90 050245 ..... 01.4385 23.33 050367 ..... 01.2485 27.64 050492 ..... 01.4113 22.37 050608 ..... 01.3080 15.26

050132 ..... 01.4257 23.74 050248 ..... 01.2618 27.54 050369 ..... 01.2376 21.58 050494 ..... 01.2167 26.20 050609 ..... 01.4505 32.31

050133 ..... 01.2911 25.55 050251 ..... 01.0989 14.91 050373 ..... 01.4446 24.31 050496 ..... 01.7259 31.88 050613 ..... 01.0696 31.83

050135 ..... 01.3964 25.36 050253 ..... 01.2992 25.63 050376 ..... 01.3991 26.32 050497 ..... 00.8270 10.59 050615 ..... 01.6042 23.31

050136 ..... 01.4011 24.04 050254 ..... 01.2141 14.11 050377 ..... 00.9333 19.49 050498 ..... 01.2434 24.96 050616 ..... 01.3591 22.85

050137 ..... 01.4012 30.81 050256 ..... 01.7518 23.91 050378 ..... 01.1364 20.86 050502 ..... 01.7222 22.74 050618 ..... 01.1163 22.63

050138 ..... 01.9630 33.22 050257 ..... 01.1275 19.38 050379 ..... 00.9589 15.15 050503 ..... 01.3400 23.15 050623 ..... 02.0034 27.05

050139 ..... 01.2532 31.55 050260 ..... 01.0044 24.07 050380 ..... 01.6867 29.30 050506 ..... 01.4395 27.49 050624 ..... 01.3554 22.18

050140 ..... 01.2757 31.54 050261 ..... 01.2723 18.81 050382 ..... 01.3984 23.86 050510 ..... 01.3791 31.86 050625 ..... 01.6074 25.23

050144 ..... 01.6355 29.12 050262 ..... 01.8576 27.43 050385 ..... 01.4021 26.64 050512 ..... 01.5743 33.03 050630 ..... 01.3401 23.93

050145 ..... 01.3861 31.48 050264 ..... 01.3335 27.45 050388 ..... 00.9019 20.64 050515 ..... 01.3473 32.36 050633 ..... 01.3131 21.95

050146 ..... 01.4762 .......... 050267 ..... 01.6544 27.78 050390 ..... 01.1857 16.75 050516 ..... 01.5400 26.16 050636 ..... 01.5051 26.10

050148 ..... 01.1151 21.00 050270 ..... 01.3573 24.13 050391 ..... 01.3292 21.68 050517 ..... 01.1822 19.69 050638 ..... 01.1025 24.90

050149 ..... 01.4748 22.78 050272 ..... 01.3703 21.55 050392 ..... 00.9917 18.42 050522 ..... 01.2252 30.95 050641 ..... 01.2588 14.88

050150 ..... 01.2678 23.95 050274 ..... 00.9903 21.63 050393 ..... 01.4860 17.95 050523 ..... 01.2384 28.96 050643 ..... 00.8426 ..........

050152 ..... 01.3850 23.39 050276 ..... 01.2072 33.01 050394 ..... 01.5488 20.22 050526 ..... 01.3236 13.42 050644 ..... 01.0506 22.44

050153 ..... 01.6231 28.40 050277 ..... 01.4723 19.05 050396 ..... 01.6148 24.12 050528 ..... 01.2785 19.70 050660 ..... 01.4613 ..........

050155 ..... 01.0917 22.33 050278 ..... 01.5669 22.63 050397 ..... 00.9890 20.00 050531 ..... 01.1762 20.18 050661 ..... 00.8186 20.05

050158 ..... 01.3649 27.94 050279 ..... 01.3441 19.04 050401 ..... 01.1257 19.64 050534 ..... 01.4679 23.66 050662 ..... 00.8651 33.41

050159 ..... 01.2998 19.09 050280 ..... 01.7639 25.90 050404 ..... 01.0765 15.96 050535 ..... 01.3453 23.23 050663 ..... 01.1547 24.12

050167 ..... 01.2885 21.83 050281 ..... 01.5490 33.56 050406 ..... 01.0708 19.56 050537 ..... 01.3680 18.57 050666 ..... 00.9460 34.46

050168 ..... 01.5276 22.07 050282 ..... 01.3068 23.58 050407 ..... 01.3597 29.45 050539 ..... 01.2567 19.52 050667 ..... 01.0189 28.01

050169 ..... 01.4399 24.49 050283 ..... 01.5231 27.35 050410 ..... 01.0632 13.08 050541 ..... 01.5665 33.44 050668 ..... 01.1332 39.35

050170 ..... 01.4906 21.04 050286 ..... 00.8525 18.46 050411 ..... 01.3589 33.17 050542 ..... 01.1186 14.45 050670 ..... 00.7487 20.84

050172 ..... 01.2523 19.87 050289 ..... 01.6964 30.78 050414 ..... 01.3074 23.74 050543 ..... 00.9409 23.72 050674 ..... 01.3219 32.55

050173 ..... 01.3729 21.72 050290 ..... 01.6895 33.81 050417 ..... 01.3155 20.45 050545 ..... 00.8583 27.87 050675 ..... 01.9709 14.65

050174 ..... 01.6799 29.40 050291 ..... 01.1544 30.54 050419 ..... 01.4360 16.25 050546 ..... 00.6946 31.14 050676 ..... 00.9474 16.75

050175 ..... 01.3660 23.84 050292 ..... 01.0469 22.19 050420 ..... 01.3375 23.41 050547 ..... 00.8417 36.25 050677 ..... 01.3998 32.89

050177 ..... 01.2731 16.69 050293 ..... 01.1254 20.70 050423 ..... 01.0173 19.31 050549 ..... 01.7120 26.33 050678 ..... 01.2229 ..........

050179 ..... 01.3003 21.22 050295 ..... 01.4947 21.01 050424 ..... 01.8153 23.48 050550 ..... 01.4607 22.49 050680 ..... 01.1971 28.94

050180 ..... 01.6017 32.17 050296 ..... 01.1902 23.74 050425 ..... 01.3094 34.22 050551 ..... 01.3289 24.83 050682 ..... 00.8928 22.32

050183 ..... 01.1126 19.44 050298 ..... 01.3275 22.54 050426 ..... 01.3708 25.47 050552 ..... 01.2293 20.52 050684 ..... 01.2450 17.19

050186 ..... 01.2933 27.51 050299 ..... 01.3607 20.49 050427 ..... 00.9189 19.93 050557 ..... 01.5109 21.78 050685 ..... 01.2468 28.37

050188 ..... 01.4286 26.90 050300 ..... 01.4936 19.23 050430 ..... 01.0555 19.53 050559 ..... 01.3996 23.82 050686 ..... 01.3134 32.42

050189 ..... 01.0831 22.39 050301 ..... 01.2481 24.81 050432 ..... 01.6129 22.37 050561 ..... 01.1996 32.15 050688 ..... 01.2792 25.15

050191 ..... 01.4729 20.67 050302 ..... 01.3482 27.55 050433 ..... 01.1058 20.42 050564 ..... 01.3309 06.57 050689 ..... 01.4155 30.16

050192 ..... 01.1901 20.19 050305 ..... 01.5457 29.10 050434 ..... 01.1365 19.87 050565 ..... 01.3544 13.81 050690 ..... 01.5124 32.17

050193 ..... 01.3308 22.67 050307 ..... 01.3027 19.99 050435 ..... 01.2208 29.08 050566 ..... 00.9061 13.99 050693 ..... 01.3049 29.48

050194 ..... 01.2435 27.41 050308 ..... 01.4832 27.92 050436 ..... 00.9412 15.20 050567 ..... 01.6269 24.54 050694 ..... 01.3586 18.36

050195 ..... 01.5834 33.92 050309 ..... 01.3376 24.61 050438 ..... 01.8098 19.83 050568 ..... 01.3990 19.06 050695 ..... 01.0960 28.46

050196 ..... 01.3052 15.36 050310 ..... 01.0912 20.24 050440 ..... 01.3403 18.63 050569 ..... 01.3783 23.26 050696 ..... 02.3021 26.75

050197 ..... 01.8716 30.49 050312 ..... 01.9222 24.66 050441 ..... 02.0343 26.41 050570 ..... 01.7110 23.79 050697 ..... 01.4515 20.60
25624 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

PAGE 3 OF 15

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

050698 ..... 00.9075 .......... 060073 ..... 01.0655 16.43 100009 ..... 01.4921 21.67 100102 ..... 01.0245 18.11 100210 ..... 01.6031 18.18

050699 ..... 00.6236 20.97 060075 ..... 01.3102 24.34 100010 ..... 01.5263 24.50 100103 ..... 00.9830 16.14 100211 ..... 01.3282 20.20

050700 ..... 01.5678 31.31 060076 ..... 01.3829 19.28 100012 ..... 01.6950 16.74 100105 ..... 01.4360 21.03 100212 ..... 01.6623 20.46

050701 ..... 01.3360 30.27 060085 ..... 00.9348 12.76 100014 ..... 01.4918 21.94 100106 ..... 01.0823 16.69 100213 ..... 01.5199 18.60

050704 ..... 01.1294 15.23 060087 ..... 01.6777 21.08 100015 ..... 01.4344 17.47 100107 ..... 01.3253 18.60 100217 ..... 01.3379 18.88

050707 ..... 01.0702 27.09 060088 ..... 00.9931 23.16 100017 ..... 01.4976 17.71 100108 ..... 01.0633 14.31 100220 ..... 01.7265 26.34

050708 ..... 01.2629 22.59 060090 ..... 00.9777 13.54 100018 ..... 01.5086 21.03 100109 ..... 01.3838 18.97 100221 ..... 01.7374 25.21

050709 ..... 01.3280 18.88 060096 ..... 01.0685 21.94 100019 ..... 01.5290 19.50 100110 ..... 01.4040 20.80 100222 ..... 01.4127 20.13

050710 ..... 01.3480 26.13 060100 ..... 01.5060 .......... 100020 ..... 01.3336 23.86 100112 ..... 00.9244 12.57 100223 ..... 01.4858 18.81

050713 ..... 00.8060 .......... 060103 ..... 01.2902 23.16 100022 ..... 01.9055 24.49 100113 ..... 02.1161 19.93 100224 ..... 01.4049 20.57

050714 ..... 01.3480 .......... 060104 ..... 01.2502 21.91 100023 ..... 01.4358 17.35 100114 ..... 01.4078 18.20 100225 ..... 01.4014 20.59

050715 ..... 01.7138 .......... 060107 ..... 01.1286 .......... 100024 ..... 01.3638 19.67 100117 ..... 01.3161 19.37 100226 ..... 01.4003 18.53

050716 ..... 03.8652 .......... 070001 ..... 01.7599 25.86 100025 ..... 01.8449 18.06 100118 ..... 01.2409 19.51 100228 ..... 01.3287 20.31

050717 ..... 00.8003 .......... 070002 ..... 01.8086 24.34 100026 ..... 01.5872 18.06 100121 ..... 01.2121 16.03 100229 ..... 01.3032 18.10

050718 ..... 00.9336 .......... 070003 ..... 01.1454 25.30 100027 ..... 00.9920 15.86 100122 ..... 01.3058 16.67 100230 ..... 01.3648 22.35

050899 ..... 00.5288 .......... 070004 ..... 01.2352 24.34 100028 ..... 01.2339 18.03 100124 ..... 01.3284 14.64 100231 ..... 01.7051 16.97

060001 ..... 01.6504 20.31 070005 ..... 01.4131 24.84 100029 ..... 01.4199 19.56 100125 ..... 01.3273 18.00 100232 ..... 01.3660 19.83

060003 ..... 01.3293 18.91 070006 ..... 01.4122 27.20 100030 ..... 01.3066 19.01 100126 ..... 01.4408 18.89 100234 ..... 01.5349 18.94

060004 ..... 01.2793 20.57 070007 ..... 01.3912 24.35 100032 ..... 01.8893 17.78 100127 ..... 01.6387 19.58 100235 ..... 01.5525 17.92

060006 ..... 01.1829 18.36 070008 ..... 01.2534 22.94 100034 ..... 01.7634 19.44 100128 ..... 02.1517 21.53 100236 ..... 01.4246 19.87

060007 ..... 01.1389 15.33 070009 ..... 01.2944 24.56 100035 ..... 01.6050 17.98 100129 ..... 01.2696 17.72 100237 ..... 02.2024 23.28

060008 ..... 01.1684 15.83 070010 ..... 01.6774 20.35 100038 ..... 01.5798 18.23 100130 ..... 01.2454 18.62 100238 ..... 01.5894 13.88

060009 ..... 01.4660 21.35 070011 ..... 01.4579 23.69 100039 ..... 01.5397 21.36 100131 ..... 01.3794 20.96 100239 ..... 01.4442 19.35

060010 ..... 01.5585 22.31 070012 ..... 01.2488 23.36 100040 ..... 01.7626 17.97 100132 ..... 01.3098 19.53 100240 ..... 00.7775 15.37

060011 ..... 01.3645 22.12 070015 ..... 01.4162 24.05 100043 ..... 01.3643 15.33 100134 ..... 00.9935 13.03 100241 ..... 00.9329 13.90

060012 ..... 01.4391 18.62 070016 ..... 01.3810 23.00 100044 ..... 01.4082 21.18 100135 ..... 01.6123 17.62 100242 ..... 01.4132 16.91

060013 ..... 01.3221 16.29 070017 ..... 01.3702 24.60 100045 ..... 01.4052 19.25 100137 ..... 01.3170 18.60 100243 ..... 01.4048 24.16

060014 ..... 01.7402 .......... 070018 ..... 01.4229 28.54 100046 ..... 01.4822 20.36 100138 ..... 01.0153 10.76 100244 ..... 01.4078 19.39

060015 ..... 01.5816 21.13 070019 ..... 01.2953 24.83 100047 ..... 01.7725 18.92 100139 ..... 01.1145 15.04 100246 ..... 01.4106 17.86

060016 ..... 01.2616 17.07 070020 ..... 01.3139 24.55 100048 ..... 00.9695 13.58 100140 ..... 01.2249 17.48 100248 ..... 01.6271 18.75

060018 ..... 01.2400 17.15 070021 ..... 01.2930 24.85 100049 ..... 01.3276 17.97 100142 ..... 01.2594 18.68 100249 ..... 01.3503 18.84

060020 ..... 01.6773 17.56 070022 ..... 01.8192 23.48 100050 ..... 01.1456 15.90 100144 ..... 01.2818 19.61 100252 ..... 01.2846 21.94

060022 ..... 01.6160 19.49 070024 ..... 01.3153 23.84 100051 ..... 01.2118 19.11 100146 ..... 01.0877 16.15 100253 ..... 01.5082 20.97

060023 ..... 01.6591 17.02 070025 ..... 01.8600 19.43 100052 ..... 01.4303 16.90 100147 ..... 01.0605 14.54 100254 ..... 01.5827 18.66

060024 ..... 01.7966 22.84 070026 ..... 01.1616 18.55 100053 ..... 01.2198 18.09 100150 ..... 01.3984 19.96 100255 ..... 01.2900 24.34

060027 ..... 01.6866 21.24 070027 ..... 01.2854 23.11 100054 ..... 01.3283 17.76 100151 ..... 01.7240 18.08 100256 ..... 02.0081 18.90

060028 ..... 01.4966 21.55 070028 ..... 01.5443 24.77 100055 ..... 01.3757 17.93 100154 ..... 01.5955 19.74 100258 ..... 01.6280 21.07

060029 ..... 00.9005 15.35 070029 ..... 01.3587 21.95 100056 ..... 01.4068 19.38 100156 ..... 01.2007 19.92 100259 ..... 01.4194 18.73

060030 ..... 01.3241 19.00 070030 ..... 01.2292 25.18 100057 ..... 01.4184 18.63 100157 ..... 01.5860 21.06 100260 ..... 01.4513 21.73

060031 ..... 01.6355 19.53 070031 ..... 01.2535 23.12 100060 ..... 01.7365 21.02 100159 ..... 00.9550 11.69 100262 ..... 01.3943 21.16

060032 ..... 01.4770 20.78 070033 ..... 01.4122 26.38 100061 ..... 01.4813 21.68 100160 ..... 01.2495 18.43 100263 ..... 01.2482 18.64

060033 ..... 01.0722 13.41 070034 ..... 01.3825 29.05 100062 ..... 01.7465 18.11 100161 ..... 01.7073 21.30 100264 ..... 01.4012 17.62

060034 ..... 01.5666 .......... 070035 ..... 01.4072 22.69 100063 ..... 01.2890 18.31 100162 ..... 01.4540 19.83 100265 ..... 01.3352 15.01

060036 ..... 01.1694 15.76 070036 ..... 01.5709 27.95 100067 ..... 01.4095 16.81 100165 ..... 01.1337 13.18 100266 ..... 01.3566 18.10

060037 ..... 01.0286 13.56 070038 ..... 01.0707 .......... 100068 ..... 01.3733 17.72 100166 ..... 01.4808 19.75 100267 ..... 01.3379 19.83

060038 ..... 01.0310 13.78 070039 ..... 00.9302 23.64 100069 ..... 01.3153 15.88 100167 ..... 01.4454 20.58 100268 ..... 01.2241 22.61

060041 ..... 00.9383 14.14 080001 ..... 01.7025 27.32 100070 ..... 01.4966 18.19 100168 ..... 01.3650 19.91 100269 ..... 01.4247 20.37

060042 ..... 01.0363 14.73 080002 ..... 01.2023 15.33 100071 ..... 01.2953 16.97 100169 ..... 01.8710 20.54 100270 ..... 00.8682 20.06

060043 ..... 00.9025 12.99 080003 ..... 01.3849 20.16 100072 ..... 01.2360 23.32 100170 ..... 01.4100 15.49 100271 ..... 01.7428 20.02

060044 ..... 01.1085 16.07 080004 ..... 01.3094 19.45 100073 ..... 01.7511 20.04 100172 ..... 01.3995 14.68 100275 ..... 01.4146 20.36

060046 ..... 01.0901 18.50 080006 ..... 01.4184 21.83 100075 ..... 01.6523 18.22 100173 ..... 01.6957 17.25 100276 ..... 01.2702 22.13

060047 ..... 00.9872 13.98 080007 ..... 01.4486 16.75 100076 ..... 01.3180 17.07 100174 ..... 01.3787 17.95 100277 ..... 01.0519 15.24

060049 ..... 01.3479 20.25 090001 ..... 01.5888 27.79 100077 ..... 01.3753 16.82 100175 ..... 01.2198 15.49 100279 ..... 01.3775 12.47

060050 ..... 01.2593 16.03 090002 ..... 01.3122 19.74 100078 ..... 01.1969 16.33 100176 ..... 02.0937 23.45 100280 ..... 01.3550 16.99

060052 ..... 01.0840 13.49 090003 ..... 01.3697 25.82 100079 ..... 01.6561 19.15 100177 ..... 01.3473 18.58 100281 ..... 01.3003 22.78

060053 ..... 01.1047 14.93 090004 ..... 01.7397 24.43 100080 ..... 01.6318 22.70 100179 ..... 01.7319 19.47 100282 ..... 01.1124 17.70

060054 ..... 01.3319 18.61 090005 ..... 01.3450 23.71 100081 ..... 01.0539 14.21 100180 ..... 01.4631 19.43 110001 ..... 01.3047 15.63

060056 ..... 00.9946 15.37 090006 ..... 01.3214 20.39 100082 ..... 01.4614 18.91 100181 ..... 01.2111 21.61 110002 ..... 01.3058 16.54

060057 ..... 01.0133 23.55 090007 ..... 01.3635 19.38 100084 ..... 01.4186 20.77 100183 ..... 01.2830 18.48 110003 ..... 01.3845 15.24

060058 ..... 00.9506 15.60 090008 ..... 01.4969 20.72 100085 ..... 01.3915 21.33 100187 ..... 01.4150 19.92 110004 ..... 01.3881 18.05

060060 ..... 00.9769 14.53 090010 ..... 01.0223 17.93 100086 ..... 01.2392 21.23 100189 ..... 01.3952 24.14 110005 ..... 01.1802 17.38

060062 ..... 00.9096 16.53 090011 ..... 02.0090 25.70 100087 ..... 01.8553 21.28 100191 ..... 01.2949 20.19 110006 ..... 01.4001 19.78

060064 ..... 01.4880 21.56 100001 ..... 01.4825 16.62 100088 ..... 01.6726 21.08 100199 ..... 01.3616 19.76 110007 ..... 01.6056 16.12

060065 ..... 01.3260 22.85 100002 ..... 01.4763 19.92 100090 ..... 01.3888 17.89 100200 ..... 01.3456 21.55 110008 ..... 01.2651 18.30

060066 ..... 01.0226 15.09 100004 ..... 01.0119 13.82 100092 ..... 01.5281 19.47 100204 ..... 01.6026 19.37 110009 ..... 01.1532 15.80

060068 ..... 01.0475 18.74 100006 ..... 01.6406 20.10 100093 ..... 01.5080 15.93 100206 ..... 01.3988 19.96 110010 ..... 02.1459 24.74

060070 ..... 01.1221 17.17 100007 ..... 01.8866 20.87 100098 ..... 01.1552 19.33 100208 ..... 01.5848 22.72 110011 ..... 01.2262 16.24

060071 ..... 01.2194 16.52 100008 ..... 01.7096 20.20 100099 ..... 01.2922 13.50 100209 ..... 01.5855 17.58 110013 ..... 01.1130 16.61
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25625

PAGE 4 OF 15

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

110014 ..... 01.0448 16.21 110101 ..... 01.1323 12.27 110198 ..... 01.3303 25.48 130048 ..... 01.0690 14.17 140081 ..... 01.0654 14.36

110015 ..... 01.1788 19.15 110103 ..... 00.9185 11.59 110200 ..... 01.8824 19.23 130049 ..... 01.2597 19.05 140082 ..... 01.4505 22.85

110016 ..... 01.2943 16.27 110104 ..... 01.0983 15.18 110201 ..... 01.5092 18.30 130054 ..... 00.8904 17.88 140083 ..... 01.3069 18.82

110017 ..... 00.8766 13.46 110105 ..... 01.2904 15.96 110203 ..... 00.9956 20.45 130056 ..... 00.8204 17.37 140084 ..... 01.2298 19.27

110018 ..... 01.1447 18.80 110107 ..... 01.8386 18.54 110204 ..... 00.8148 18.89 130060 ..... 01.3078 20.72 140086 ..... 01.1655 15.72

110020 ..... 01.3285 18.61 110108 ..... 00.9689 17.58 110205 ..... 01.0763 22.85 130061 ..... 00.9403 09.29 140087 ..... 01.3956 17.07

110023 ..... 01.2840 18.65 110109 ..... 01.0955 15.30 110207 ..... 01.1607 12.46 130063 ..... 01.1768 .......... 140088 ..... 01.7029 21.97

110024 ..... 01.4669 19.21 110111 ..... 01.1955 15.74 110208 ..... 00.9903 15.74 140001 ..... 01.3044 15.14 140089 ..... 01.2384 17.29

110025 ..... 01.4282 17.90 110112 ..... 01.1297 18.83 110209 ..... 00.7381 16.57 140002 ..... 01.3201 18.33 140090 ..... 01.4953 23.24

110026 ..... 01.2060 14.58 110113 ..... 01.1014 14.21 110211 ..... 00.9586 .......... 140003 ..... 01.0457 15.69 140091 ..... 01.8169 18.10

110027 ..... 01.1287 15.90 110114 ..... 01.0561 15.10 110212 ..... 01.1651 .......... 140004 ..... 01.0989 16.55 140093 ..... 01.1840 18.79

110028 ..... 01.6783 20.65 110115 ..... 01.6734 22.60 110213 ..... 00.7480 .......... 140005 ..... 00.9503 10.22 140094 ..... 01.3097 20.06

110029 ..... 01.3697 20.27 110118 ..... 01.0544 11.38 120001 ..... 01.8279 27.25 140007 ..... 01.4925 21.24 140095 ..... 01.3835 20.89

110030 ..... 01.2736 17.81 110120 ..... 01.0683 12.89 120002 ..... 01.2601 23.99 140008 ..... 01.5269 20.27 140097 ..... 00.9245 15.85

110031 ..... 01.2780 19.47 110121 ..... 01.2134 14.59 120003 ..... 01.1064 24.14 140010 ..... 01.3777 23.35 140100 ..... 01.3042 20.50

110032 ..... 01.3079 15.70 110122 ..... 01.3699 18.25 120004 ..... 01.2164 24.55 140011 ..... 01.1962 16.35 140101 ..... 01.2281 18.42

110033 ..... 01.4405 21.48 110124 ..... 01.3180 14.58 120005 ..... 01.2966 21.62 140012 ..... 01.2712 18.24 140102 ..... 01.1167 15.46

110034 ..... 01.6284 18.31 110125 ..... 01.2718 16.36 120006 ..... 01.3249 24.64 140013 ..... 01.5981 16.59 140103 ..... 01.4637 15.98

110035 ..... 01.4374 23.29 110127 ..... 00.9214 14.72 120007 ..... 01.6729 21.82 140014 ..... 01.2346 18.98 140105 ..... 01.3523 20.16

110036 ..... 01.7729 .......... 110128 ..... 01.1853 18.34 120009 ..... 00.9647 19.58 140015 ..... 01.2859 14.77 140107 ..... 01.0723 14.19

110038 ..... 01.4872 17.19 110129 ..... 01.6924 17.61 120010 ..... 01.8131 23.76 140016 ..... 00.9826 12.09 140108 ..... 01.3529 22.83

110039 ..... 01.3748 19.83 110130 ..... 01.0679 11.85 120011 ..... 01.3231 32.97 140018 ..... 01.3572 19.73 140109 ..... 01.2235 14.65

110040 ..... 01.1392 17.40 110132 ..... 01.1281 13.98 120012 ..... 00.8889 21.42 140019 ..... 01.0877 14.26 140110 ..... 01.2260 18.89

110041 ..... 01.1919 16.68 110134 ..... 00.9052 12.22 120014 ..... 01.3437 23.53 140024 ..... 00.9826 13.82 140112 ..... 01.1475 14.27

110042 ..... 01.2326 16.85 110135 ..... 01.3155 17.76 120015 ..... 00.8945 23.63 140025 ..... 01.0844 16.04 140113 ..... 01.5963 18.16

110043 ..... 01.8013 16.83 110136 ..... 01.1358 15.43 120016 ..... 01.0773 26.99 140026 ..... 01.2533 16.60 140114 ..... 01.3451 19.18

110044 ..... 01.1835 15.11 110140 ..... 01.0384 15.81 120018 ..... 01.0119 22.29 140027 ..... 01.3199 17.12 140115 ..... 01.3318 19.21

110045 ..... 01.2010 19.00 110141 ..... 01.0430 13.17 120019 ..... 01.2134 20.93 140029 ..... 01.4133 20.69 140116 ..... 01.2572 20.69

110046 ..... 01.2702 19.27 110142 ..... 00.9278 10.94 120021 ..... 00.8363 19.89 140030 ..... 01.7236 21.88 140117 ..... 01.5466 20.39

110048 ..... 01.2958 14.77 110143 ..... 01.4312 20.93 120022 ..... 01.6938 17.36 140031 ..... 01.1981 14.47 140118 ..... 01.6712 23.20

110049 ..... 01.0595 12.66 110144 ..... 01.1053 18.09 120026 ..... 01.2420 24.30 140032 ..... 01.3088 17.51 140119 ..... 01.7295 21.17

110050 ..... 01.2663 17.24 110146 ..... 01.1084 16.74 120027 ..... 01.4788 22.77 140033 ..... 01.2949 22.13 140120 ..... 01.4493 16.54

110051 ..... 01.0328 13.87 110149 ..... 01.1383 18.93 120028 ..... 01.2495 .......... 140034 ..... 01.1849 18.25 140121 ..... 01.4033 14.91

110052 ..... 01.1633 08.57 110150 ..... 01.3908 18.34 130001 ..... 00.9237 20.88 140035 ..... 01.0753 13.77 140122 ..... 01.5946 22.76

110054 ..... 01.3234 18.80 110152 ..... 01.0769 15.05 130002 ..... 01.3874 15.94 140036 ..... 01.2318 17.01 140124 ..... 01.2207 25.20

110056 ..... 01.1047 16.02 110153 ..... 01.0943 18.60 130003 ..... 01.3296 19.77 140037 ..... 01.0362 13.33 140125 ..... 01.3391 16.31

110059 ..... 01.3075 12.05 110154 ..... 01.0296 13.75 130005 ..... 01.4326 19.70 140038 ..... 01.2131 14.65 140127 ..... 01.4371 18.66

110061 ..... 01.0818 13.87 110155 ..... 01.1450 14.18 130006 ..... 01.8387 19.10 140040 ..... 01.3081 15.90 140128 ..... 01.0565 16.08

110062 ..... 00.8961 14.52 110156 ..... 01.0223 15.53 130007 ..... 01.6496 19.28 140041 ..... 01.1977 16.33 140129 ..... 01.1941 16.61

110063 ..... 01.1382 15.19 110161 ..... 01.3086 20.74 130008 ..... 00.9899 12.07 140042 ..... 01.0291 13.94 140130 ..... 01.2719 24.16

110064 ..... 01.3862 18.18 110162 ..... 00.8099 .......... 130009 ..... 00.9347 15.62 140043 ..... 01.1678 17.93 140132 ..... 01.5121 23.60

110065 ..... 01.0241 12.93 110163 ..... 01.5208 18.71 130010 ..... 00.9101 19.08 140045 ..... 01.0478 15.21 140133 ..... 01.3440 20.51

110066 ..... 01.4714 20.37 110164 ..... 01.4277 21.27 130011 ..... 01.3476 19.35 140046 ..... 01.3159 15.70 140135 ..... 01.2990 16.16

110069 ..... 01.2824 18.52 110165 ..... 01.4010 18.70 130012 ..... 01.0020 22.02 140047 ..... 01.1731 16.57 140137 ..... 01.0428 17.24

110070 ..... 01.1006 17.18 110166 ..... 01.5150 18.65 130013 ..... 01.3101 19.25 140048 ..... 01.3315 21.58 140138 ..... 01.0982 14.18

110071 ..... 01.1356 11.04 110168 ..... 01.7223 20.47 130014 ..... 01.3693 17.03 140049 ..... 01.5511 20.89 140139 ..... 01.1145 15.86

110072 ..... 01.0173 12.51 110169 ..... 01.1931 18.66 130015 ..... 00.9264 17.50 140051 ..... 01.5114 19.42 140140 ..... 01.1906 18.58

110073 ..... 01.2272 14.32 110171 ..... 01.4942 20.46 130016 ..... 00.9173 17.25 140052 ..... 01.3990 17.19 140141 ..... 01.3059 14.79

110074 ..... 01.4541 17.24 110172 ..... 01.4235 21.34 130017 ..... 01.1709 16.55 140053 ..... 02.0119 18.24 140143 ..... 01.1514 17.94

110075 ..... 01.3591 16.51 110174 ..... 00.9675 15.24 130018 ..... 01.7382 17.35 140054 ..... 01.3761 22.90 140144 ..... 01.0424 17.37

110076 ..... 01.5073 20.04 110176 ..... 02.5217 20.96 130019 ..... 01.1641 17.99 140055 ..... 00.9267 13.99 140145 ..... 01.1604 16.19

110078 ..... 01.7630 21.73 110177 ..... 01.5788 19.87 130021 ..... 00.9692 15.30 140058 ..... 01.2943 16.54 140146 ..... 01.0612 16.77

110079 ..... 01.3856 19.30 110178 ..... 02.9393 16.83 130022 ..... 01.2437 18.53 140059 ..... 01.2264 15.77 140147 ..... 01.3933 15.62

110080 ..... 01.2083 18.22 110179 ..... 01.1105 20.42 130024 ..... 01.0773 18.00 140061 ..... 01.1070 14.15 140148 ..... 01.8210 17.46

110082 ..... 02.1044 21.81 110181 ..... 00.9493 14.70 130025 ..... 01.1043 14.20 140062 ..... 01.2892 26.44 140150 ..... 01.5671 25.02

110083 ..... 01.7148 20.98 110183 ..... 01.3855 21.18 130026 ..... 01.1592 19.63 140063 ..... 01.4336 22.90 140151 ..... 01.0723 19.64

110086 ..... 01.2336 13.04 110184 ..... 01.2704 19.37 130027 ..... 00.8923 19.57 140064 ..... 01.3056 17.80 140152 ..... 01.1727 21.63

110087 ..... 01.3469 20.67 110185 ..... 01.1237 15.51 130028 ..... 01.2366 16.83 140065 ..... 01.5316 24.12 140155 ..... 01.3024 17.47

110089 ..... 01.2215 17.12 110186 ..... 01.3551 15.59 130029 ..... 01.1095 17.62 140066 ..... 01.2213 15.60 140158 ..... 01.3851 22.91

110091 ..... 01.3195 19.73 110187 ..... 01.3406 19.18 130030 ..... 00.8668 18.40 140067 ..... 01.7964 17.99 140160 ..... 01.2137 16.52

110092 ..... 01.1612 15.18 110188 ..... 01.3408 18.49 130031 ..... 00.9616 16.44 140068 ..... 01.2411 18.98 140161 ..... 01.2198 18.07

110093 ..... 00.9463 11.69 110189 ..... 01.1257 17.51 130034 ..... 01.0096 19.35 140069 ..... 01.0622 16.04 140162 ..... 01.7869 17.93

110094 ..... 01.0827 14.08 110190 ..... 01.0981 15.41 130035 ..... 01.0090 19.47 140070 ..... 01.2423 17.31 140164 ..... 01.4470 20.29

110095 ..... 01.3819 14.69 110191 ..... 01.3627 17.96 130036 ..... 01.3025 13.66 140074 ..... 01.0465 17.25 140165 ..... 01.1078 13.70

110096 ..... 01.1427 14.85 110192 ..... 01.4687 21.41 130037 ..... 01.2910 16.97 140075 ..... 01.4117 14.13 140166 ..... 01.3247 17.54

110097 ..... 01.0561 14.44 110193 ..... 01.2426 17.89 130043 ..... 00.9508 15.79 140077 ..... 01.2351 16.89 140167 ..... 01.1271 15.06

110098 ..... 00.9804 15.28 110194 ..... 00.9257 14.21 130044 ..... 01.1952 10.50 140079 ..... 01.2417 17.22 140168 ..... 01.1771 16.36

110100 ..... 01.0482 16.39 110195 ..... 01.1159 13.34 130045 ..... 00.9956 15.28 140080 ..... 01.6294 20.58 140170 ..... 01.0929 13.81
25626 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

PAGE 5 OF 15

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

140171 ..... 00.9828 12.95 140300 ..... 01.5868 23.72 150074 ..... 01.6442 19.08 160030 ..... 01.3920 18.00 160109 ..... 01.0993 14.76

140172 ..... 01.6579 18.91 150001 ..... 01.1146 19.10 150075 ..... 01.1491 15.63 160031 ..... 01.1010 14.50 160110 ..... 01.5914 15.04

140173 ..... 00.9180 16.52 150002 ..... 01.5657 18.51 150076 ..... 01.1723 21.36 160032 ..... 01.1307 16.27 160111 ..... 01.0133 12.29

140174 ..... 01.5914 20.01 150003 ..... 01.6957 19.07 150077 ..... 01.1446 17.40 160033 ..... 01.8232 17.57 160112 ..... 01.4106 16.06

140176 ..... 01.2364 19.89 150004 ..... 01.5034 19.60 150078 ..... 01.0704 17.34 160034 ..... 01.1382 15.15 160113 ..... 01.0099 13.35

140177 ..... 01.3461 17.27 150005 ..... 01.1843 18.97 150079 ..... 01.2096 15.90 160035 ..... 01.0002 16.77 160114 ..... 01.0199 15.40

140179 ..... 01.3420 20.09 150006 ..... 01.2849 18.75 150082 ..... 01.5715 18.22 160036 ..... 00.9948 19.22 160115 ..... 01.0123 15.21

140180 ..... 01.4432 20.79 150007 ..... 01.2112 23.06 150084 ..... 01.9333 21.85 160037 ..... 01.0667 17.12 160116 ..... 01.1438 16.05

140181 ..... 01.4074 19.27 150008 ..... 01.4533 20.34 150086 ..... 01.3607 16.73 160039 ..... 01.0325 17.49 160117 ..... 01.4481 16.57

140182 ..... 01.4406 15.18 150009 ..... 01.3592 17.29 150088 ..... 01.3868 18.67 160040 ..... 01.3654 17.43 160118 ..... 01.0367 15.14

140184 ..... 01.2681 15.18 150010 ..... 01.3797 16.85 150089 ..... 01.4239 19.56 160041 ..... 01.1128 14.40 160120 ..... 01.0155 11.33

140185 ..... 01.5341 17.64 150011 ..... 01.2435 18.61 150090 ..... 01.2347 18.94 160043 ..... 01.0103 14.43 160122 ..... 01.0901 18.27

140186 ..... 01.3891 20.30 150012 ..... 01.6411 21.50 150091 ..... 01.0113 16.53 160044 ..... 01.2318 15.75 160124 ..... 01.2824 16.47

140187 ..... 01.4964 16.84 150013 ..... 01.1763 15.74 150092 ..... 01.0684 14.87 160045 ..... 01.7278 18.63 160126 ..... 01.0538 15.68

140188 ..... 00.9537 13.20 150014 ..... 01.5052 18.35 150094 ..... 00.9903 17.59 160046 ..... 00.9983 11.21 160129 ..... 01.0655 15.03

140189 ..... 01.1992 17.72 150015 ..... 01.2408 20.85 150095 ..... 01.0953 18.41 160047 ..... 01.3985 16.53 160130 ..... 01.2040 14.80

140190 ..... 01.1009 16.47 150017 ..... 01.8553 19.45 150096 ..... 01.0629 17.95 160048 ..... 01.0493 13.27 160131 ..... 01.0625 14.49

140191 ..... 01.4397 22.26 150018 ..... 01.3501 18.66 150097 ..... 01.1098 17.18 160049 ..... 00.9436 12.67 160134 ..... 00.9376 12.70

140193 ..... 01.1059 14.46 150019 ..... 01.1845 14.94 150098 ..... 01.1241 16.63 160050 ..... 01.0811 15.90 160135 ..... 01.0142 15.11

140197 ..... 01.2541 16.79 150020 ..... 01.1512 13.22 150099 ..... 01.2843 17.66 160051 ..... 00.9312 13.79 160138 ..... 01.0655 14.59

140199 ..... 01.1100 17.14 150021 ..... 01.6165 18.36 150100 ..... 01.6568 17.51 160052 ..... 01.0078 14.41 160140 ..... 01.1400 16.69

140200 ..... 01.4621 21.75 150022 ..... 01.1136 17.58 150101 ..... 01.1211 19.95 160054 ..... 01.0121 13.35 160142 ..... 01.1009 15.31

140202 ..... 01.3111 21.58 150023 ..... 01.6061 19.97 150102 ..... 01.1598 12.14 160055 ..... 00.9931 13.61 160143 ..... 00.9819 15.10

140203 ..... 01.1647 22.19 150024 ..... 01.3888 18.92 150103 ..... 00.9512 19.44 160056 ..... 01.1741 14.54 160145 ..... 01.1407 14.85

140205 ..... 00.9675 15.10 150025 ..... 01.4888 17.26 150104 ..... 01.0823 16.22 160057 ..... 01.3770 17.28 160146 ..... 01.4416 16.29

140206 ..... 01.2352 20.80 150026 ..... 01.2078 18.81 150105 ..... 01.3386 17.27 160058 ..... 01.7722 19.62 160147 ..... 01.3353 17.49

140207 ..... 01.3748 20.67 150027 ..... 01.0411 17.50 150106 ..... 01.0981 15.15 160060 ..... 01.1076 15.15 160151 ..... 01.1079 16.09

140208 ..... 01.6884 24.61 150029 ..... 01.3890 20.73 150109 ..... 01.4355 18.03 160061 ..... 01.1171 16.03 160152 ..... 01.0039 14.39

140209 ..... 01.6540 14.76 150030 ..... 01.2567 17.00 150110 ..... 01.0392 15.28 160062 ..... 00.9454 15.66 160153 ..... 01.8054 18.68

140210 ..... 01.0799 14.99 150031 ..... 01.0946 15.03 150111 ..... 01.1656 15.08 160063 ..... 01.1546 16.85 170001 ..... 01.1951 16.74

140211 ..... 01.2061 19.50 150032 ..... 01.8612 19.41 150112 ..... 01.3267 18.92 160064 ..... 01.6269 18.72 170004 ..... 01.0677 13.57

140213 ..... 01.3176 21.25 150033 ..... 01.5986 21.73 150113 ..... 01.2282 18.52 160065 ..... 01.0220 16.04 170006 ..... 01.1576 15.84

140215 ..... 01.0859 14.05 150034 ..... 01.4872 21.18 150114 ..... 01.0692 17.02 160066 ..... 01.1481 15.76 170008 ..... 00.9797 13.42

140217 ..... 01.3129 22.52 150035 ..... 01.5616 19.66 150115 ..... 01.3601 17.18 160067 ..... 01.4072 17.52 170009 ..... 01.2006 17.07

140218 ..... 01.0528 15.20 150036 ..... 01.0369 18.92 150122 ..... 01.1376 18.53 160068 ..... 01.0212 15.43 170010 ..... 01.3037 16.52

140220 ..... 01.1009 17.26 150037 ..... 01.2481 18.31 150123 ..... 01.0540 14.07 160069 ..... 01.4919 17.39 170012 ..... 01.4254 15.95

140223 ..... 01.6061 23.21 150038 ..... 01.4463 18.74 150124 ..... 01.1303 15.08 160070 ..... 00.9590 14.55 170013 ..... 01.3060 16.49

140224 ..... 01.3499 22.21 150039 ..... 00.9739 16.62 150125 ..... 01.4487 19.02 160072 ..... 01.0768 14.19 170014 ..... 01.0310 17.45

140228 ..... 01.6505 17.83 150042 ..... 01.2851 16.54 150126 ..... 01.4679 20.96 160073 ..... 00.9704 13.66 170015 ..... 00.9909 15.23

140230 ..... 00.9336 15.97 150043 ..... 01.0389 16.96 150127 ..... 01.0314 15.89 160074 ..... 01.0474 15.71 170016 ..... 01.6836 22.29

140231 ..... 01.5659 21.90 150044 ..... 01.2351 18.03 150128 ..... 01.2813 18.07 160075 ..... 01.1806 15.77 170017 ..... 01.2077 18.08

140233 ..... 01.8328 18.16 150045 ..... 01.1303 16.21 150129 ..... 01.1222 24.48 160076 ..... 01.0409 17.07 170018 ..... 01.1380 14.10

140234 ..... 01.2359 17.76 150046 ..... 01.4926 16.66 150130 ..... 01.3484 16.53 160077 ..... 01.0730 11.38 170019 ..... 01.2203 16.42

140236 ..... 01.0046 14.29 150047 ..... 01.6176 19.11 150132 ..... 01.4914 18.89 160079 ..... 01.4250 17.85 170020 ..... 01.2910 15.58

140239 ..... 01.7410 18.31 150048 ..... 01.2267 18.58 150133 ..... 01.1644 17.44 160080 ..... 01.2026 17.07 170022 ..... 01.1333 16.84

140240 ..... 01.4331 22.78 150049 ..... 01.1415 15.37 150134 ..... 01.1629 17.56 160081 ..... 01.0971 15.21 170023 ..... 01.3998 17.38

140242 ..... 01.6616 22.15 150050 ..... 01.2343 16.20 150136 ..... 00.8607 20.95 160082 ..... 01.9400 17.26 170024 ..... 01.1587 13.03

140245 ..... 01.2200 15.19 150051 ..... 01.4673 18.63 150145 ..... 03.7024 .......... 160083 ..... 01.6760 17.94 170025 ..... 01.1942 16.10

140246 ..... 01.1107 12.78 150052 ..... 01.1526 14.50 160001 ..... 01.2869 18.91 160085 ..... 00.9877 15.41 170026 ..... 01.1060 13.45

140250 ..... 01.3085 23.24 150053 ..... 01.0122 18.92 160002 ..... 01.1579 14.48 160086 ..... 00.9510 15.78 170027 ..... 01.3149 15.96

140251 ..... 01.3487 20.32 150054 ..... 01.0954 15.80 160003 ..... 01.0272 14.39 160088 ..... 01.1853 16.87 170030 ..... 01.0487 12.94

140252 ..... 01.4849 23.55 150056 ..... 01.8319 23.14 160005 ..... 01.0962 15.72 160089 ..... 01.2264 16.16 170031 ..... 00.8797 12.80

140253 ..... 01.3970 14.08 150057 ..... 02.3139 18.25 160007 ..... 01.0149 13.81 160090 ..... 01.0121 15.53 170032 ..... 01.0645 15.46

140258 ..... 01.5859 22.07 150058 ..... 01.7734 20.30 160008 ..... 01.1611 14.74 160091 ..... 01.0690 12.74 170033 ..... 01.3680 15.54

140271 ..... 01.0367 14.78 150059 ..... 01.3588 21.47 160009 ..... 01.2225 15.87 160092 ..... 01.0710 15.37 170034 ..... 01.0172 13.85

140275 ..... 01.2393 16.99 150060 ..... 01.1408 14.72 160012 ..... 01.0015 15.93 160093 ..... 01.0603 15.71 170035 ..... 00.8913 14.00

140276 ..... 02.0402 21.39 150061 ..... 01.2235 15.33 160013 ..... 01.2088 16.74 160094 ..... 01.1200 15.60 170036 ..... 00.9101 14.08

140280 ..... 01.3633 17.80 150062 ..... 01.1228 17.69 160014 ..... 00.9551 14.41 160095 ..... 01.0625 14.27 170037 ..... 01.0368 16.58

140281 ..... 01.6894 22.14 150063 ..... 01.0545 16.90 160016 ..... 01.2452 17.25 160097 ..... 01.0952 14.59 170038 ..... 00.9220 12.68

140285 ..... 01.2529 26.86 150064 ..... 01.2804 16.17 160018 ..... 00.9374 13.77 160098 ..... 01.0002 15.05 170039 ..... 01.0941 14.19

140286 ..... 01.1496 18.53 150065 ..... 01.2062 18.66 160020 ..... 01.0918 13.84 160099 ..... 00.9166 12.91 170040 ..... 01.6491 19.98

140288 ..... 01.7475 22.93 150066 ..... 01.0055 17.04 160021 ..... 01.0569 15.16 160101 ..... 01.0582 17.55 170041 ..... 01.0778 11.22

140289 ..... 01.3491 16.32 150067 ..... 01.1690 16.20 160023 ..... 01.0267 14.75 160102 ..... 01.4133 16.83 170044 ..... 00.9909 13.97

140290 ..... 01.3868 20.06 150069 ..... 01.2637 17.75 160024 ..... 01.5208 18.26 160103 ..... 01.0464 16.71 170045 ..... 01.0394 15.99

140291 ..... 01.3999 23.45 150070 ..... 01.0571 17.16 160026 ..... 01.0784 17.30 160104 ..... 01.2767 17.17 170049 ..... 01.2914 18.45

140292 ..... 01.1440 20.62 150071 ..... 01.1147 14.38 160027 ..... 01.1359 15.04 160106 ..... 01.0226 15.39 170051 ..... 00.9111 13.41

140294 ..... 01.1807 18.17 150072 ..... 01.2157 16.13 160028 ..... 01.2457 29.74 160107 ..... 01.1907 16.26 170052 ..... 01.1183 14.31

140297 ..... 03.6153 42.09 150073 ..... 01.0490 20.53 160029 ..... 01.5683 20.19 160108 ..... 01.1241 15.98 170053 ..... 00.9906 13.83
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25627

PAGE 6 OF 15

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

170054 ..... 01.0978 13.64 170150 ..... 01.1546 14.00 180067 ..... 01.9594 17.80 190034 ..... 01.1818 15.36 190155 ..... 00.7261 16.10

170055 ..... 01.0862 14.51 170151 ..... 00.9807 12.49 180069 ..... 01.1523 17.35 190035 ..... 01.4071 .......... 190156 ..... 01.0217 12.27

170056 ..... 00.8958 14.93 170152 ..... 01.0368 14.21 180070 ..... 01.1536 13.55 190036 ..... 01.6970 20.46 190158 ..... 01.1942 20.62

170057 ..... 00.9835 12.90 170160 ..... 01.0025 11.81 180072 ..... 01.1750 15.81 190037 ..... 00.9050 11.28 190160 ..... 01.2638 17.06

170058 ..... 01.1567 17.07 170164 ..... 01.0153 15.00 180075 ..... 01.6587 12.66 190039 ..... 01.4112 16.98 190161 ..... 01.0650 14.05

170060 ..... 01.1064 14.95 170166 ..... 01.1487 17.40 180078 ..... 01.0858 18.97 190040 ..... 01.3258 20.34 190162 ..... 01.0985 19.57

170061 ..... 01.1697 14.15 170171 ..... 01.0693 12.88 180079 ..... 01.2462 12.71 190041 ..... 01.5988 19.98 190164 ..... 01.2766 14.89

170063 ..... 00.8588 11.84 170175 ..... 01.3959 17.67 180080 ..... 01.0624 15.09 190043 ..... 01.0674 12.52 190167 ..... 01.1707 18.78

170066 ..... 01.0038 13.66 170176 ..... 01.6751 23.94 180087 ..... 01.3024 14.29 190044 ..... 01.1587 21.11 190170 ..... 00.9093 13.69

170067 ..... 01.0353 14.44 170182 ..... 01.4638 21.54 180088 ..... 01.5749 21.13 190045 ..... 01.4309 21.34 190173 ..... 01.4304 19.33

170068 ..... 01.2562 17.01 170183 ..... 02.0468 15.05 180092 ..... 01.2237 15.98 190046 ..... 01.4383 18.69 190175 ..... 01.6161 20.46

170070 ..... 01.0330 12.73 170184 ..... 01.7569 .......... 180093 ..... 01.3704 16.69 190048 ..... 01.2557 15.02 190176 ..... 01.6907 20.76

170073 ..... 01.1796 15.56 180001 ..... 01.3958 17.78 180094 ..... 01.0627 12.86 190049 ..... 00.9841 15.98 190177 ..... 01.7756 18.85

170074 ..... 01.1210 13.48 180002 ..... 01.1271 17.71 180095 ..... 01.1988 13.96 190050 ..... 01.0974 14.68 190178 ..... 00.9828 10.60

170075 ..... 00.9167 10.71 180004 ..... 01.1260 15.79 180099 ..... 01.2011 12.83 190053 ..... 01.1305 12.51 190182 ..... 01.2638 19.89

170076 ..... 01.0539 12.59 180005 ..... 01.2488 18.80 180101 ..... 01.2773 16.26 190054 ..... 01.3434 16.77 190183 ..... 01.1934 15.22

170077 ..... 00.9613 12.55 180006 ..... 00.9249 12.49 180102 ..... 01.4712 18.17 190059 ..... 00.8927 14.11 190184 ..... 01.0340 15.61

170079 ..... 00.9525 12.75 180007 ..... 01.4823 16.55 180103 ..... 02.2948 18.25 190060 ..... 01.4334 14.94 190185 ..... 01.3460 19.22

170080 ..... 00.9784 12.95 180009 ..... 01.4022 20.11 180104 ..... 01.5599 16.85 190064 ..... 01.5728 22.67 190186 ..... 00.9219 14.11

170081 ..... 00.9351 11.91 180010 ..... 01.9106 18.13 180105 ..... 00.9458 15.32 190065 ..... 01.4938 18.08 190190 ..... 00.8904 12.48

170082 ..... 00.9822 12.06 180011 ..... 01.3471 18.96 180106 ..... 00.8758 13.13 190071 ..... 00.9048 12.68 190191 ..... 01.2236 19.55

170084 ..... 00.9112 29.87 180012 ..... 01.4127 18.41 180108 ..... 00.8320 13.64 190077 ..... 00.9403 13.95 190196 ..... 00.9611 16.22

170085 ..... 00.9055 12.47 180013 ..... 01.4174 17.18 180115 ..... 01.0027 16.43 190078 ..... 01.1522 12.81 190197 ..... 01.1855 17.51

170086 ..... 01.7294 18.97 180014 ..... 01.7276 18.00 180116 ..... 01.3502 16.15 190079 ..... 01.3216 17.02 190199 ..... 01.2599 10.95

170088 ..... 00.9532 10.70 180016 ..... 01.3059 14.83 180117 ..... 01.1374 17.24 190081 ..... 00.9314 13.70 190200 ..... 01.5884 20.17

170089 ..... 00.9736 12.13 180017 ..... 01.3626 14.79 180118 ..... 01.0477 11.54 190083 ..... 01.1019 16.51 190201 ..... 01.0893 18.83

170090 ..... 00.9993 11.36 180018 ..... 01.3348 15.32 180120 ..... 01.0374 16.25 190086 ..... 01.3466 15.04 190202 ..... 01.2511 18.81

170092 ..... 00.8320 12.01 180019 ..... 01.2531 16.76 180121 ..... 01.3111 14.05 190088 ..... 01.3395 19.01 190203 ..... 01.5559 22.35

170093 ..... 00.9126 12.94 180020 ..... 01.1266 16.86 180122 ..... 01.1060 15.93 190089 ..... 01.0953 12.63 190204 ..... 01.4971 20.42

170094 ..... 00.9330 16.97 180021 ..... 01.0695 14.26 180123 ..... 01.4019 18.92 190090 ..... 01.1136 16.03 190205 ..... 01.9390 18.91

170095 ..... 01.1284 13.41 180023 ..... 00.9119 14.80 180124 ..... 01.4305 16.87 190092 ..... 01.4163 21.19 190206 ..... 01.6020 21.26

170097 ..... 00.9893 14.02 180024 ..... 01.4455 15.89 180125 ..... 01.1083 17.87 190095 ..... 01.0410 15.00 190207 ..... 01.2223 17.10

170098 ..... 01.1633 14.54 180025 ..... 01.1748 16.40 180126 ..... 01.2108 11.42 190098 ..... 01.4884 19.10 190208 ..... 00.8302 10.93

170099 ..... 01.2147 12.86 180026 ..... 01.2509 13.57 180127 ..... 01.3576 16.72 190099 ..... 01.2333 17.67 190218 ..... 01.1701 17.36

170100 ..... 01.0623 13.73 180027 ..... 01.3139 15.23 180128 ..... 01.1777 16.18 190102 ..... 01.5818 18.10 190227 ..... 00.8692 30.27

170101 ..... 00.9176 13.46 180028 ..... 01.0814 17.78 180129 ..... 01.0392 15.30 190103 ..... 00.8978 11.00 190231 ..... 01.4412 13.27

170102 ..... 01.0142 12.99 180029 ..... 01.3033 16.86 180130 ..... 01.4202 17.56 190106 ..... 01.1713 17.85 190235 ..... 01.6524 ..........

170103 ..... 01.2839 15.92 180030 ..... 01.1614 16.38 180132 ..... 01.2846 16.14 190109 ..... 01.2506 14.31 190236 ..... 01.4037 ..........

170104 ..... 01.4518 20.25 180031 ..... 01.1179 14.02 180133 ..... 01.3195 22.68 190110 ..... 00.9671 13.76 200001 ..... 01.4021 16.84

170105 ..... 01.0732 15.22 180032 ..... 01.0939 16.97 180134 ..... 01.0985 14.44 190111 ..... 01.5353 19.83 200002 ..... 01.1101 23.41

170106 ..... 00.9680 10.48 180033 ..... 01.1805 16.08 180136 ..... 01.6663 19.72 190112 ..... 01.6582 20.08 200003 ..... 01.1421 16.08

170109 ..... 00.9935 16.20 180034 ..... 01.1401 15.45 180138 ..... 01.2692 17.70 190113 ..... 01.3372 19.82 200006 ..... 01.0161 18.67

170110 ..... 01.0011 15.05 180035 ..... 01.6042 19.58 180139 ..... 01.1175 17.89 190114 ..... 01.0360 13.12 200007 ..... 01.0238 16.64

170112 ..... 01.0327 13.55 180036 ..... 01.2081 18.69 180140 ..... 01.0543 22.60 190115 ..... 01.2011 19.30 200008 ..... 01.2487 20.05

170113 ..... 01.0910 15.23 180037 ..... 01.3315 19.96 180141 ..... 01.7850 .......... 190116 ..... 01.1612 15.43 200009 ..... 01.8248 20.28

170114 ..... 01.0309 14.05 180038 ..... 01.4356 15.84 190001 ..... 00.9574 22.06 190118 ..... 01.0653 13.08 200012 ..... 01.1253 16.83

170115 ..... 00.9963 12.43 180040 ..... 01.9798 18.75 190002 ..... 01.7233 18.29 190120 ..... 01.0389 13.99 200013 ..... 01.1175 15.39

170116 ..... 01.0782 15.42 180041 ..... 01.1067 14.94 190003 ..... 01.4208 18.68 190122 ..... 01.3127 13.83 200015 ..... 01.2672 17.80

170117 ..... 00.9897 13.41 180042 ..... 01.1356 15.00 190004 ..... 01.4619 16.87 190124 ..... 01.6393 19.92 200016 ..... 01.0377 16.48

170119 ..... 00.9907 13.57 180043 ..... 01.1907 19.10 190005 ..... 01.5814 16.64 190125 ..... 01.5379 18.47 200018 ..... 01.2179 16.45

170120 ..... 01.3100 12.93 180044 ..... 01.2212 17.26 190006 ..... 01.3309 15.31 190128 ..... 01.1054 18.95 200019 ..... 01.2635 18.12

170122 ..... 01.7443 18.82 180045 ..... 01.3799 17.34 190007 ..... 01.0296 14.17 190130 ..... 00.9720 12.14 200020 ..... 01.1295 19.42

170123 ..... 01.7876 18.98 180046 ..... 01.1868 16.65 190008 ..... 01.6750 19.37 190131 ..... 01.2328 17.54 200021 ..... 01.1599 18.52

170124 ..... 00.9925 13.55 180047 ..... 01.0316 14.66 190009 ..... 01.3215 14.70 190133 ..... 00.9626 12.86 200023 ..... 00.9037 14.08

170126 ..... 00.9618 12.53 180048 ..... 01.2731 16.28 190010 ..... 01.1133 16.24 190134 ..... 01.0045 16.50 200024 ..... 01.4120 19.55

170128 ..... 00.9122 14.70 180049 ..... 01.3932 16.09 190011 ..... 01.1696 15.32 190135 ..... 01.4522 20.69 200025 ..... 01.1595 19.60

170131 ..... 01.1686 12.10 180050 ..... 01.2650 17.25 190013 ..... 01.3473 16.26 190136 ..... 01.2074 11.11 200026 ..... 01.0448 15.97

170133 ..... 01.1015 16.69 180051 ..... 01.3715 15.43 190014 ..... 01.1457 16.03 190138 ..... 00.8637 20.29 200027 ..... 01.2326 16.90

170134 ..... 00.9044 13.04 180053 ..... 01.1052 14.96 190015 ..... 01.2583 18.74 190140 ..... 00.9874 11.98 200028 ..... 00.9883 16.14

170137 ..... 01.1656 17.98 180054 ..... 01.1345 15.82 190017 ..... 01.3983 14.84 190142 ..... 00.9321 14.53 200031 ..... 01.2524 15.04

170139 ..... 01.0729 12.91 180055 ..... 01.2319 14.70 190018 ..... 01.1580 17.48 190144 ..... 01.2665 16.26 200032 ..... 01.2974 17.40

170142 ..... 01.2852 17.02 180056 ..... 01.1288 16.33 190019 ..... 01.7296 19.64 190145 ..... 01.0068 14.74 200033 ..... 01.7963 ..........

170143 ..... 01.1875 15.24 180058 ..... 01.0463 13.04 190020 ..... 01.1693 17.77 190146 ..... 01.6123 21.10 200034 ..... 01.2207 18.06

170144 ..... 01.6583 13.79 180059 ..... 00.8671 15.28 190025 ..... 01.3335 13.33 190147 ..... 00.9695 14.36 200037 ..... 01.2183 16.94

170145 ..... 01.1081 14.18 180063 ..... 01.1789 11.94 190026 ..... 01.5020 18.00 190148 ..... 00.9710 13.91 200038 ..... 01.1302 19.07

170146 ..... 01.5294 18.68 180064 ..... 01.3252 14.68 190027 ..... 01.5422 17.46 190149 ..... 01.0118 14.40 200039 ..... 01.2896 19.74

170147 ..... 01.2024 18.98 180065 ..... 01.0035 12.89 190029 ..... 01.1748 17.67 190151 ..... 01.2151 12.80 200040 ..... 01.1290 19.05

170148 ..... 01.4951 17.89 180066 ..... 01.1563 18.08 190033 ..... 00.9756 10.02 190152 ..... 01.4896 20.71 200041 ..... 01.1543 18.64
25628 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

PAGE 7 OF 15

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

200043 ..... 00.7365 18.37 220017 ..... 01.3977 14.12 220153 ..... 01.0232 22.56 230100 ..... 01.1670 15.57 230213 ..... 00.9993 15.25

200050 ..... 01.1575 17.35 220019 ..... 01.1645 19.12 220154 ..... 00.9445 22.42 230101 ..... 01.1095 18.36 230216 ..... 01.5651 17.80

200051 ..... 01.0114 19.57 220020 ..... 01.2268 19.47 220162 ..... 01.2697 .......... 230103 ..... 01.0400 20.72 230217 ..... 01.2521 22.94

200052 ..... 01.0406 15.56 220023 ..... 00.6107 19.30 220163 ..... 02.1199 24.87 230104 ..... 01.5911 22.43 230219 ..... 00.8768 19.28

200055 ..... 01.1614 17.37 220024 ..... 01.2158 21.22 220171 ..... 01.6207 22.92 230105 ..... 01.7568 20.27 230221 ..... 00.8720 24.54

200062 ..... 00.9472 15.91 220025 ..... 01.1292 18.70 230001 ..... 01.1902 18.07 230106 ..... 01.3003 20.51 230222 ..... 01.4495 19.43

200063 ..... 01.3059 18.34 220028 ..... 01.4722 21.01 230002 ..... 01.2759 20.69 230107 ..... 00.9076 14.72 230223 ..... 01.3326 21.85

200066 ..... 01.1622 16.74 220029 ..... 01.1851 24.16 230003 ..... 01.1581 18.62 230108 ..... 01.2121 18.37 230227 ..... 01.4724 21.56

210001 ..... 01.4925 21.16 220030 ..... 01.1533 15.00 230004 ..... 01.7098 22.86 230110 ..... 01.3576 17.83 230230 ..... 01.6794 22.01

210002 ..... 01.9930 18.07 220031 ..... 01.9215 .......... 230005 ..... 01.2844 18.86 230113 ..... 00.9199 20.15 230232 ..... 00.9510 17.15

210003 ..... 01.6014 21.93 220033 ..... 01.2840 20.97 230006 ..... 01.1008 18.53 230115 ..... 01.0388 17.19 230235 ..... 01.0957 16.27

210004 ..... 01.3657 23.18 220035 ..... 01.2837 24.51 230007 ..... 00.9571 18.95 230116 ..... 00.9248 16.31 230236 ..... 01.3249 21.58

210005 ..... 01.2762 19.38 220036 ..... 01.5965 21.66 230012 ..... 00.8563 12.18 230117 ..... 01.8993 26.08 230239 ..... 01.1389 13.72

210006 ..... 01.1400 17.16 220038 ..... 01.2959 26.32 230013 ..... 01.4022 21.05 230118 ..... 01.2189 17.43 230241 ..... 01.1643 17.52

210007 ..... 01.7371 25.17 220041 ..... 01.2273 23.41 230015 ..... 01.2010 20.91 230119 ..... 01.2966 21.44 230244 ..... 01.3959 21.17

210008 ..... 01.3938 19.26 220042 ..... 01.2464 24.13 230017 ..... 01.5028 28.89 230120 ..... 01.1514 18.40 230253 ..... 00.9911 18.85

210009 ..... 01.8131 21.72 220046 ..... 01.3702 23.14 230019 ..... 01.4696 22.20 230121 ..... 01.2299 20.61 230254 ..... 01.2624 21.20

210010 ..... 01.1495 15.64 220049 ..... 01.3541 18.47 230020 ..... 01.7404 21.30 230122 ..... 01.3428 19.37 230257 ..... 00.7824 18.51

210011 ..... 01.3419 19.67 220050 ..... 01.1242 19.98 230021 ..... 01.5653 18.27 230124 ..... 01.1625 18.52 230259 ..... 01.1882 21.59

210012 ..... 01.6374 22.07 220051 ..... 01.2183 21.10 230022 ..... 01.2543 18.76 230128 ..... 01.3957 22.70 230264 ..... 01.6939 14.86

210013 ..... 01.3219 19.82 220052 ..... 01.3247 24.59 230024 ..... 01.4460 22.98 230130 ..... 01.6687 22.34 230269 ..... 01.3782 22.69

210015 ..... 01.2992 19.60 220053 ..... 01.2325 20.02 230027 ..... 01.1127 17.48 230132 ..... 01.3690 24.82 230270 ..... 01.1731 20.20

210016 ..... 01.8243 22.33 220055 ..... 01.2994 13.69 230029 ..... 01.5562 19.51 230133 ..... 01.2687 17.99 230273 ..... 01.4465 22.29

210017 ..... 01.2218 15.90 220057 ..... 01.4056 22.67 230030 ..... 01.3295 16.78 230135 ..... 01.3180 23.03 230275 ..... 00.5262 19.58

210018 ..... 01.3056 21.29 220058 ..... 01.1529 18.51 230031 ..... 01.4311 19.42 230137 ..... 01.1560 18.31 230276 ..... 00.6644 21.40

210019 ..... 01.5805 18.39 220060 ..... 01.2952 25.42 230032 ..... 01.7502 19.80 230141 ..... 01.6323 22.96 230277 ..... 01.2430 23.05

210022 ..... 01.5039 21.14 220062 ..... 00.5762 19.65 230034 ..... 01.2739 18.80 230142 ..... 01.3057 19.01 230278 ..... 01.4214 17.82

210023 ..... 01.3373 21.51 220063 ..... 01.2663 19.84 230035 ..... 01.0906 20.47 230143 ..... 01.3112 18.35 230279 ..... 00.6584 15.95

210024 ..... 01.5453 20.11 220064 ..... 01.2830 21.51 230036 ..... 01.2229 20.75 230144 ..... 01.1462 20.61 230280 ..... 00.9997 12.33

210025 ..... 01.3740 18.95 220065 ..... 01.2956 19.95 230037 ..... 01.1368 17.66 230145 ..... 01.1934 18.05 240001 ..... 01.5448 22.78

210026 ..... 01.3830 17.97 220066 ..... 01.3789 21.73 230038 ..... 01.6671 21.58 230146 ..... 01.2748 19.36 240002 ..... 01.7516 20.94

210027 ..... 01.2945 17.66 220067 ..... 01.3230 22.81 230040 ..... 01.1819 20.58 230147 ..... 01.3954 17.47 240004 ..... 01.5826 21.10

210028 ..... 01.2229 18.31 220070 ..... 01.2219 19.89 230041 ..... 01.2518 19.27 230149 ..... 01.1505 16.14 240005 ..... 00.9321 17.38

210029 ..... 01.2710 14.51 220071 ..... 01.9036 24.06 230042 ..... 01.2328 20.08 230151 ..... 01.4024 21.20 240006 ..... 01.1358 20.97

210030 ..... 01.1576 19.24 220073 ..... 01.3068 25.94 230046 ..... 01.9346 23.28 230153 ..... 01.1458 16.66 240007 ..... 01.0656 15.50

210031 ..... 01.2844 16.76 220074 ..... 01.4397 28.44 230047 ..... 01.3796 19.17 230154 ..... 00.9500 14.32 240008 ..... 01.1157 19.71

210032 ..... 01.1792 18.71 220075 ..... 01.4818 20.18 230053 ..... 01.6002 24.58 230155 ..... 01.0478 17.35 240009 ..... 00.9226 14.31

210033 ..... 01.2737 18.96 220076 ..... 01.1822 .......... 230054 ..... 01.8075 19.80 230156 ..... 01.7144 23.80 240010 ..... 01.9880 24.41

210034 ..... 01.3510 20.17 220077 ..... 01.7973 24.84 230055 ..... 01.1704 19.01 230157 ..... 01.2003 22.20 240011 ..... 01.1532 17.81

210035 ..... 01.2976 19.08 220079 ..... 01.1889 21.38 230056 ..... 00.9664 15.57 230159 ..... 01.3458 17.84 240013 ..... 01.3350 18.17

210037 ..... 01.2736 18.27 220080 ..... 01.3076 19.50 230058 ..... 01.0994 18.45 230162 ..... 01.0605 19.93 240014 ..... 01.0774 20.29

210038 ..... 01.4108 21.78 220081 ..... 01.0949 26.78 230059 ..... 01.5035 19.06 230165 ..... 01.8769 22.77 240016 ..... 01.3927 18.22

210039 ..... 01.1817 19.69 220082 ..... 01.2893 19.76 230060 ..... 01.2247 18.53 230167 ..... 01.7979 19.39 240017 ..... 01.0659 17.25

210040 ..... 01.2977 23.05 220083 ..... 01.1675 21.76 230062 ..... 00.9643 15.71 230169 ..... 01.3453 23.25 240018 ..... 01.2884 17.23

210043 ..... 01.3140 21.29 220084 ..... 01.3389 26.31 230063 ..... 01.3202 19.89 230171 ..... 01.0161 14.41 240019 ..... 01.2645 21.39

210044 ..... 01.3429 21.63 220086 ..... 01.7743 .......... 230065 ..... 01.3020 20.37 230172 ..... 01.1855 19.10 240020 ..... 01.1651 20.04

210045 ..... 01.0234 11.01 220088 ..... 01.6385 23.68 230066 ..... 01.3702 21.26 230174 ..... 01.3641 20.84 240021 ..... 01.0408 16.96

210048 ..... 01.2485 22.46 220089 ..... 01.2541 21.52 230069 ..... 01.1366 22.24 230175 ..... 03.7062 .......... 240022 ..... 01.1137 19.13

210049 ..... 01.1655 17.20 220090 ..... 01.2774 21.06 230070 ..... 01.6318 20.99 230176 ..... 01.2172 22.12 240023 ..... 00.9935 19.88

210051 ..... 01.4205 22.78 220092 ..... 01.2563 29.72 230071 ..... 01.1883 22.62 230178 ..... 01.0025 17.48 240025 ..... 01.1418 16.29

210054 ..... 01.3626 21.94 220094 ..... 01.4476 18.10 230072 ..... 01.2717 19.89 230180 ..... 01.1699 14.55 240027 ..... 01.0297 16.33

210055 ..... 01.2721 22.10 220095 ..... 01.2243 18.87 230075 ..... 01.4810 20.07 230184 ..... 01.1598 18.23 240028 ..... 01.1529 18.52

210056 ..... 01.3993 17.67 220098 ..... 01.3462 17.39 230076 ..... 01.3291 22.97 230186 ..... 01.2450 15.20 240029 ..... 01.1603 18.10

210057 ..... 01.4721 24.67 220100 ..... 01.2697 25.09 230077 ..... 01.9370 19.36 230188 ..... 01.1176 15.81 240030 ..... 01.2834 17.99

210058 ..... 01.4828 18.67 220101 ..... 01.4781 24.24 230078 ..... 01.2553 16.56 230189 ..... 00.9585 15.39 240031 ..... 00.9756 16.71

210059 ..... 01.2611 21.98 220104 ..... 01.4373 23.69 230080 ..... 01.2411 19.94 230190 ..... 01.0724 24.98 240036 ..... 01.5650 20.26

210060 ..... 01.2540 .......... 220105 ..... 01.3499 20.60 230081 ..... 01.2578 16.66 230191 ..... 00.9623 17.58 240037 ..... 01.0233 18.19

210061 ..... 01.1774 18.56 220106 ..... 01.2300 23.09 230082 ..... 01.1162 17.08 230193 ..... 01.2584 17.77 240038 ..... 01.4973 24.56

220001 ..... 01.2775 27.10 220108 ..... 01.1989 22.28 230085 ..... 01.0922 18.91 230195 ..... 01.3347 21.46 240040 ..... 01.2454 20.15

220002 ..... 01.5400 18.62 220110 ..... 02.0189 29.18 230086 ..... 00.9486 17.36 230197 ..... 01.4218 21.17 240041 ..... 01.1644 17.48

220003 ..... 01.1363 17.49 220111 ..... 01.2643 21.79 230087 ..... 01.0889 16.19 230199 ..... 01.1115 19.29 240043 ..... 01.1966 17.00

220006 ..... 01.4328 20.39 220116 ..... 01.9394 .......... 230089 ..... 01.2754 23.86 230201 ..... 01.1456 15.09 240044 ..... 01.1842 18.04

220008 ..... 01.2873 21.58 220119 ..... 01.3311 23.69 230092 ..... 01.3562 19.28 230204 ..... 01.4307 21.66 240045 ..... 01.0477 21.34

220010 ..... 01.3417 21.70 220123 ..... 01.0577 23.94 230093 ..... 01.2768 19.05 230205 ..... 01.0377 16.37 240047 ..... 01.5436 21.26

220011 ..... 01.1581 28.81 220126 ..... 01.3572 19.87 230095 ..... 01.1791 17.06 230207 ..... 01.2683 19.90 240048 ..... 01.2443 22.64

220012 ..... 01.3404 35.18 220128 ..... 00.8929 21.18 230096 ..... 01.0974 24.02 230208 ..... 01.3205 17.76 240049 ..... 01.7730 22.43

220015 ..... 01.1918 22.77 220133 ..... 00.9081 27.36 230097 ..... 01.6121 19.12 230211 ..... 00.9047 21.59 240050 ..... 01.1639 24.71

220016 ..... 01.3686 21.58 220135 ..... 01.3076 26.10 230099 ..... 01.1463 19.68 230212 ..... 01.0827 23.46 240051 ..... 01.0123 18.49
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25629

PAGE 8 OF 15

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

240052 ..... 01.3097 18.64 240139 ..... 00.9667 16.59 250042 ..... 01.2795 15.45 260003 ..... 01.1304 13.48 260105 ..... 01.8950 20.26

240053 ..... 01.5210 20.25 240141 ..... 01.1702 21.09 250043 ..... 00.9854 12.25 260004 ..... 01.0516 13.31 260107 ..... 01.4575 19.81

240056 ..... 01.2479 21.74 240142 ..... 01.1458 19.27 250044 ..... 01.0267 15.41 260005 ..... 01.6188 20.26 260108 ..... 01.8607 21.29

240057 ..... 01.8120 22.68 240143 ..... 00.9530 13.94 250045 ..... 01.2004 18.75 260006 ..... 01.5009 20.55 260109 ..... 00.9884 12.92

240058 ..... 00.9732 14.79 240144 ..... 01.0302 16.74 250047 ..... 00.9728 15.45 260008 ..... 01.3629 16.53 260110 ..... 01.6869 15.15

240059 ..... 01.0983 21.81 240145 ..... 01.0332 15.57 250048 ..... 01.5487 15.26 260009 ..... 01.2581 16.29 260113 ..... 01.1477 14.76

240061 ..... 01.8085 24.36 240146 ..... 00.9306 19.10 250049 ..... 00.8905 11.34 260011 ..... 01.6980 18.75 260115 ..... 01.2593 17.02

240063 ..... 01.4355 22.81 240148 ..... 01.0485 14.55 250050 ..... 01.2741 13.43 260012 ..... 01.1050 12.84 260116 ..... 01.0817 15.06

240064 ..... 01.2914 21.93 240150 ..... 00.9199 12.84 250051 ..... 00.8862 10.57 260013 ..... 01.1935 15.32 260119 ..... 01.2307 15.30

240065 ..... 01.0337 12.44 240152 ..... 01.0164 19.91 250057 ..... 01.2316 15.59 260015 ..... 01.2710 16.27 260120 ..... 01.1985 16.64

240066 ..... 01.3815 21.19 240153 ..... 01.0056 15.23 250058 ..... 01.1873 14.40 260017 ..... 01.2333 15.54 260122 ..... 01.1738 12.73

240069 ..... 01.1890 19.07 240154 ..... 01.0449 17.00 250059 ..... 01.0410 14.21 260018 ..... 00.9010 10.09 260123 ..... 01.0789 14.05

240071 ..... 01.1104 19.55 240155 ..... 00.8945 19.40 250060 ..... 00.7799 08.90 260019 ..... 01.0877 14.52 260127 ..... 01.0109 15.92

240072 ..... 01.0197 16.80 240157 ..... 01.0929 14.13 250061 ..... 00.8857 17.69 260020 ..... 01.7249 20.07 260128 ..... 01.0125 10.96

240073 ..... 00.9372 16.40 240160 ..... 01.0026 16.30 250063 ..... 00.8515 12.44 260021 ..... 01.4657 17.59 260129 ..... 01.2317 15.69

240075 ..... 01.1813 19.91 240161 ..... 00.9970 14.99 250065 ..... 00.9231 12.61 260022 ..... 01.2879 19.05 260131 ..... 01.2494 18.04

240076 ..... 01.0703 21.04 240162 ..... 01.0628 16.59 250066 ..... 00.9111 13.53 260023 ..... 01.4980 34.66 260134 ..... 01.1693 15.67

240077 ..... 00.9446 14.31 240163 ..... 00.9935 17.79 250067 ..... 01.1344 14.67 260024 ..... 00.9639 12.96 260137 ..... 01.7177 15.26

240078 ..... 01.4829 23.66 240166 ..... 01.1120 15.60 250068 ..... 00.8476 11.36 260025 ..... 01.3101 14.68 260138 ..... 01.8700 21.26

240079 ..... 01.0280 15.37 240169 ..... 00.9128 15.98 250069 ..... 01.3525 17.35 260027 ..... 01.6202 21.58 260141 ..... 01.9087 19.54

240080 ..... 01.5649 22.34 240170 ..... 01.1056 17.38 250071 ..... 00.9308 11.63 260029 ..... 01.2388 19.02 260142 ..... 01.1144 15.65

240082 ..... 01.1936 17.03 240171 ..... 01.0726 15.79 250072 ..... 01.4199 18.43 260030 ..... 01.1850 10.36 260143 ..... 00.9985 12.75

240083 ..... 01.3140 17.90 240172 ..... 00.9529 15.82 250077 ..... 00.9293 11.97 260031 ..... 01.6090 18.38 260147 ..... 00.9753 13.55

240084 ..... 01.2434 20.04 240173 ..... 00.8928 16.66 250078 ..... 01.4771 14.93 260032 ..... 01.6629 18.43 260148 ..... 00.9263 10.32

240085 ..... 00.9719 17.41 240179 ..... 01.0132 16.66 250079 ..... 00.8824 17.44 260034 ..... 01.0573 15.99 260158 ..... 01.0224 12.65

240086 ..... 01.0849 17.64 240184 ..... 00.9886 13.04 250081 ..... 01.3211 16.03 260035 ..... 01.0046 11.74 260159 ..... 00.9863 19.26

240087 ..... 01.2026 14.87 240187 ..... 01.1930 18.48 250082 ..... 01.4033 13.51 260036 ..... 01.0154 15.34 260160 ..... 01.0544 15.82

240088 ..... 01.3869 19.81 240193 ..... 01.0223 17.61 250083 ..... 00.9515 12.27 260039 ..... 01.1258 13.86 260162 ..... 01.5557 20.64

240089 ..... 00.9840 17.72 240196 ..... 00.6319 22.78 250084 ..... 01.1844 17.73 260040 ..... 01.6625 15.28 260163 ..... 01.2241 14.59

240090 ..... 01.0465 14.69 240200 ..... 00.8680 14.48 250085 ..... 00.9749 12.58 260042 ..... 01.2599 17.82 260164 ..... 00.9519 13.24

240093 ..... 01.3293 17.64 240205 ..... 00.9138 .......... 250088 ..... 01.0022 16.53 260044 ..... 01.0487 15.91 260166 ..... 01.2346 19.78

240094 ..... 00.9622 20.49 240206 ..... 00.8411 .......... 250089 ..... 01.2121 13.89 260047 ..... 01.4767 17.20 260172 ..... 00.9986 12.55

240096 ..... 00.9800 17.63 240207 ..... 01.2109 21.80 250093 ..... 01.1337 14.36 260048 ..... 01.2953 20.70 260173 ..... 01.0314 12.21

240097 ..... 01.0196 21.79 240210 ..... 01.2788 22.90 250094 ..... 01.3184 15.45 260050 ..... 01.0431 16.40 260175 ..... 01.1175 16.34

240098 ..... 00.9533 20.33 240211 ..... 00.9038 14.75 250095 ..... 01.0053 15.92 260052 ..... 01.3352 19.75 260176 ..... 01.6500 17.62

240099 ..... 01.0631 13.30 250001 ..... 01.5514 17.39 250096 ..... 01.1988 17.01 260053 ..... 01.1737 11.73 260177 ..... 01.2846 20.19

240100 ..... 01.2892 18.97 250002 ..... 00.9820 17.13 250097 ..... 01.3216 15.83 260054 ..... 01.3147 16.07 260178 ..... 01.4976 20.94

240101 ..... 01.1825 20.41 250003 ..... 01.0084 18.40 250098 ..... 00.8380 16.66 260055 ..... 00.9908 10.97 260179 ..... 01.6431 20.52

240102 ..... 00.9603 12.87 250004 ..... 01.4873 17.91 250099 ..... 01.2609 14.01 260057 ..... 01.1503 16.96 260180 ..... 01.7064 18.96

240103 ..... 01.0505 16.28 250005 ..... 00.9412 09.95 250100 ..... 01.2905 15.26 260059 ..... 01.2691 14.66 260183 ..... 01.5177 16.58

240104 ..... 01.2301 21.81 250006 ..... 00.9862 14.60 250101 ..... 00.8850 16.65 260061 ..... 01.1020 14.06 260186 ..... 01.4347 17.27

240105 ..... 00.9597 13.46 250007 ..... 01.2808 19.42 250102 ..... 01.6048 17.06 260062 ..... 01.2033 18.91 260188 ..... 01.2198 18.37

240106 ..... 01.4052 26.55 250008 ..... 00.9814 13.33 250104 ..... 01.4486 17.62 260063 ..... 01.0697 15.44 260189 ..... 00.8526 10.87

240107 ..... 00.9916 17.31 250009 ..... 01.2300 17.50 250105 ..... 00.9434 13.40 260064 ..... 01.3240 16.92 260190 ..... 01.2045 18.00

240108 ..... 01.0081 17.24 250010 ..... 01.0398 12.77 250107 ..... 00.8815 14.53 260065 ..... 01.8217 18.25 260191 ..... 01.2516 18.58

240109 ..... 00.9484 12.99 250012 ..... 00.9311 19.88 250109 ..... 00.8949 15.37 260066 ..... 01.0266 15.01 260193 ..... 01.2915 26.66

240110 ..... 00.9668 16.33 250015 ..... 01.0847 10.44 250112 ..... 00.9717 13.07 260067 ..... 00.8671 13.74 260195 ..... 01.2198 16.53

240111 ..... 01.0666 19.00 250017 ..... 00.9989 16.64 250117 ..... 01.0769 14.70 260068 ..... 01.6718 20.21 260197 ..... 01.1405 25.99

240112 ..... 00.9994 14.73 250018 ..... 00.9513 13.02 250119 ..... 01.1164 12.45 260070 ..... 01.0429 14.48 260198 ..... 01.3077 16.46

240114 ..... 00.9257 14.74 250019 ..... 01.4335 17.00 250120 ..... 01.1106 13.09 260073 ..... 01.1387 12.89 260200 ..... 01.2666 19.43

240115 ..... 01.6191 21.63 250020 ..... 00.9455 13.52 250122 ..... 01.2481 16.91 260074 ..... 01.3021 13.93 260205 ..... 01.3757 ..........

240116 ..... 00.9343 13.96 250021 ..... 00.8815 08.57 250123 ..... 01.2786 18.73 260077 ..... 01.7307 17.13 270002 ..... 01.3026 14.15

240117 ..... 01.1588 18.18 250023 ..... 00.9552 12.77 250124 ..... 00.9126 11.59 260078 ..... 01.1782 14.62 270003 ..... 01.2653 21.02

240119 ..... 00.8258 20.58 250024 ..... 00.9084 13.60 250125 ..... 01.3155 16.38 260079 ..... 01.0765 14.32 270004 ..... 01.6961 18.01

240121 ..... 00.9397 21.27 250025 ..... 01.2071 18.06 250126 ..... 00.9754 14.17 260080 ..... 01.0516 11.77 270006 ..... 00.9221 16.35

240122 ..... 01.0517 18.93 250027 ..... 00.9570 11.90 250127 ..... 00.8201 .......... 260081 ..... 01.6079 18.83 270007 ..... 00.8770 12.23

240123 ..... 01.0109 15.03 250029 ..... 00.8773 12.96 250128 ..... 01.0941 12.06 260082 ..... 01.1768 13.93 270009 ..... 01.1201 19.32

240124 ..... 00.9676 18.39 250030 ..... 00.9739 14.45 250131 ..... 01.0232 11.03 260085 ..... 01.5720 19.71 270011 ..... 01.0312 18.28

240125 ..... 00.9278 11.73 250031 ..... 01.3079 18.54 250134 ..... 00.9919 16.70 260086 ..... 01.0978 15.09 270012 ..... 01.5921 18.33

240127 ..... 01.1171 14.25 250032 ..... 01.2608 16.21 250136 ..... 00.8821 17.66 260091 ..... 01.7219 19.76 270014 ..... 01.8294 17.81

240128 ..... 01.1221 15.77 250033 ..... 01.0514 15.66 250138 ..... 01.2904 17.90 260094 ..... 01.1985 16.48 270016 ..... 00.8992 15.97

240129 ..... 01.0143 17.56 250034 ..... 01.6577 14.46 250141 ..... 01.2616 15.71 260095 ..... 01.4477 16.89 270017 ..... 01.2378 19.09

240130 ..... 00.9625 15.66 250035 ..... 00.8681 13.84 250145 ..... 00.8232 10.04 260096 ..... 01.5927 22.03 270019 ..... 01.0001 15.86

240132 ..... 01.2209 22.40 250036 ..... 00.9700 14.48 250146 ..... 00.9630 13.97 260097 ..... 01.2007 14.79 270021 ..... 01.1771 16.67

240133 ..... 01.1986 17.72 250037 ..... 00.9132 10.05 250148 ..... 01.0955 19.08 260100 ..... 01.0435 15.72 270023 ..... 01.3055 21.22

240135 ..... 00.8725 14.11 250038 ..... 00.9700 14.37 250149 ..... 00.8930 12.04 260102 ..... 01.0442 18.57 270026 ..... 00.8850 14.97

240137 ..... 01.2258 18.97 250039 ..... 00.9941 13.36 260001 ..... 01.7040 18.05 260103 ..... 01.2885 17.51 270027 ..... 01.1158 12.40

240138 ..... 00.9522 12.97 250040 ..... 01.3026 16.20 260002 ..... 01.4644 21.10 260104 ..... 01.7564 18.42 270028 ..... 01.1217 15.50
25630 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

PAGE 9 OF 15

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

270029 ..... 00.9579 18.18 280051 ..... 01.0812 15.15 290021 ..... 01.6244 21.94 310041 ..... 01.4067 23.71 320023 ..... 01.0840 16.73

270032 ..... 01.1262 16.20 280052 ..... 01.0846 13.32 290022 ..... 01.7010 17.94 310042 ..... 01.2416 23.53 320030 ..... 01.1495 16.84

270033 ..... 00.8614 15.58 280054 ..... 01.2607 17.98 290027 ..... 00.9528 17.23 310043 ..... 01.1431 20.86 320031 ..... 00.8258 17.05

270035 ..... 01.0099 18.28 280055 ..... 00.9182 14.40 290029 ..... 00.9833 .......... 310044 ..... 01.2847 20.70 320032 ..... 00.9003 17.10

270036 ..... 00.8802 12.78 280056 ..... 00.9752 14.45 290032 ..... 01.4115 22.30 310045 ..... 01.4639 27.19 320033 ..... 01.1552 22.76

270039 ..... 01.0024 15.36 280057 ..... 00.9835 15.40 290036 ..... 00.9391 51.78 310047 ..... 01.3682 24.34 320035 ..... 01.0299 22.89

270040 ..... 01.1080 18.24 280058 ..... 01.3029 18.34 290038 ..... 00.9923 19.95 310048 ..... 01.2820 22.81 320037 ..... 01.2216 23.31

270041 ..... 01.1062 15.74 280060 ..... 01.5871 18.65 290039 ..... 01.3219 .......... 310049 ..... 01.2927 25.66 320038 ..... 01.2326 16.83

270044 ..... 01.1453 13.98 280061 ..... 01.4293 17.06 300001 ..... 01.3935 21.15 310050 ..... 01.2323 23.05 320046 ..... 01.2948 20.88

270046 ..... 00.9619 14.85 280062 ..... 01.0987 13.35 300003 ..... 01.9474 23.98 310051 ..... 01.3560 24.27 320048 ..... 01.2823 14.43

270048 ..... 01.1003 16.41 280064 ..... 01.0290 15.52 300005 ..... 01.2963 20.28 310052 ..... 01.2951 22.60 320057 ..... 00.9566 ..........

270049 ..... 01.7959 20.21 280065 ..... 01.2779 18.54 300006 ..... 01.1897 19.05 310054 ..... 01.3459 24.60 320058 ..... 00.7512 ..........

270050 ..... 01.0985 17.98 280066 ..... 01.0654 12.50 300007 ..... 01.1006 18.33 310057 ..... 01.3357 21.17 320059 ..... 01.0062 ..........

270051 ..... 01.3389 21.08 280068 ..... 00.9650 09.45 300008 ..... 01.2856 19.44 310058 ..... 01.1060 24.61 320060 ..... 00.8691 ..........

270052 ..... 01.0417 17.86 280070 ..... 01.0106 11.19 300009 ..... 01.1291 19.41 310060 ..... 01.2001 18.63 320061 ..... 01.1829 ..........

270057 ..... 01.2418 18.93 280073 ..... 01.0056 13.68 300010 ..... 01.1911 19.48 310061 ..... 01.2520 21.39 320062 ..... 00.8839 ..........

270058 ..... 00.9052 13.38 280074 ..... 01.1152 14.02 300011 ..... 01.3744 22.78 310062 ..... 01.3076 20.98 320063 ..... 01.3049 16.68

270059 ..... 00.7748 15.90 280075 ..... 01.1776 13.70 300012 ..... 01.3351 21.77 310063 ..... 01.3696 21.02 320065 ..... 01.2881 16.05

270060 ..... 00.9593 15.08 280076 ..... 01.0520 13.95 300013 ..... 01.1894 17.57 310064 ..... 01.3195 24.32 320067 ..... 00.8533 15.74

270063 ..... 00.9957 14.82 280077 ..... 01.3183 17.95 300014 ..... 01.2855 19.49 310067 ..... 01.3185 22.76 320068 ..... 00.9287 16.40

270072 ..... 00.8066 13.85 280079 ..... 01.0646 10.61 300015 ..... 01.2367 18.54 310069 ..... 01.2924 22.42 320069 ..... 00.9720 10.83

270073 ..... 01.1764 11.83 280080 ..... 01.1041 13.61 300016 ..... 01.2347 18.83 310070 ..... 01.4173 23.33 320070 ..... 00.9663 ..........

270074 ..... 00.8989 .......... 280081 ..... 01.7829 18.66 300017 ..... 01.3038 21.18 310072 ..... 01.3090 21.25 320074 ..... 01.0956 18.00

270075 ..... 00.9172 .......... 280082 ..... 01.0111 13.50 300018 ..... 01.3126 20.22 310073 ..... 01.6320 25.21 320079 ..... 01.1739 17.24

270076 ..... 00.7682 .......... 280083 ..... 01.0442 14.26 300019 ..... 01.2127 19.97 310074 ..... 01.4198 22.66 330001 ..... 01.1965 25.94

270079 ..... 00.8978 13.71 280084 ..... 01.0067 11.42 300020 ..... 01.3060 20.45 310075 ..... 01.4342 24.11 330002 ..... 01.4751 25.86

270080 ..... 01.1930 16.88 280088 ..... 01.7594 .......... 300021 ..... 01.0885 17.07 310076 ..... 01.4454 29.78 330003 ..... 01.3224 15.68

270081 ..... 01.0272 12.52 280089 ..... 01.0559 17.29 300022 ..... 01.0547 17.35 310077 ..... 01.6821 25.08 330004 ..... 01.2944 19.87

270082 ..... 01.0743 16.17 280090 ..... 00.9608 14.34 300023 ..... 01.3847 20.45 310078 ..... 01.3970 23.81 330005 ..... 01.8198 23.51

270083 ..... 01.0915 15.30 280091 ..... 01.1064 14.54 300024 ..... 01.2611 19.20 310081 ..... 01.3268 21.63 330006 ..... 01.2708 26.60

270084 ..... 00.8820 14.83 280092 ..... 00.9797 13.94 300028 ..... 01.2139 17.28 310083 ..... 01.3087 22.57 330007 ..... 01.3120 18.50

280001 ..... 01.1071 14.99 280094 ..... 01.1321 15.40 300029 ..... 01.3666 22.33 310084 ..... 01.3916 21.85 330008 ..... 01.1599 16.96

280003 ..... 02.1164 18.85 280097 ..... 00.9649 11.94 300033 ..... 01.1353 16.28 310086 ..... 01.2187 21.24 330009 ..... 01.2889 30.94

280005 ..... 01.4013 17.73 280098 ..... 00.9699 10.71 300034 ..... 02.0334 22.41 310087 ..... 01.3224 20.28 330010 ..... 01.3763 12.50

280009 ..... 01.7524 18.19 280101 ..... 01.1002 13.51 310001 ..... 01.8034 25.91 310088 ..... 01.2207 20.56 330011 ..... 01.3000 19.95

280011 ..... 00.8691 12.42 280102 ..... 00.9272 12.45 310002 ..... 01.8222 25.58 310090 ..... 01.3629 24.24 330012 ..... 01.6985 29.74

280013 ..... 01.9321 21.09 280104 ..... 00.9947 13.11 310003 ..... 01.2776 23.65 310091 ..... 01.2907 20.77 330013 ..... 02.0896 17.73

280014 ..... 00.9234 13.35 280105 ..... 01.2732 18.10 310005 ..... 01.2322 21.08 310092 ..... 01.3142 21.20 330014 ..... 01.3552 29.38

280015 ..... 01.0353 15.29 280106 ..... 00.9818 14.48 310006 ..... 01.2754 22.66 310093 ..... 01.1662 20.42 330016 ..... 01.0658 16.94

280017 ..... 01.1197 14.01 280107 ..... 01.0910 11.45 310008 ..... 01.3528 23.42 310096 ..... 01.8816 23.74 330019 ..... 01.3051 27.77

280018 ..... 01.0384 13.73 280108 ..... 01.1303 15.09 310009 ..... 01.3133 23.49 310105 ..... 01.3010 24.12 330020 ..... 01.0469 14.30

280020 ..... 01.6464 19.60 280109 ..... 00.9214 10.58 310010 ..... 01.2849 20.79 310108 ..... 01.4365 24.39 330023 ..... 01.2634 23.47

280021 ..... 01.2618 16.90 280110 ..... 01.0019 11.44 310011 ..... 01.2108 21.51 310110 ..... 01.2714 20.54 330024 ..... 01.8333 31.66

280022 ..... 01.0382 14.17 280111 ..... 01.2495 18.27 310012 ..... 01.6569 26.14 310111 ..... 01.3831 23.33 330025 ..... 01.1052 13.57

280023 ..... 01.3988 16.83 280114 ..... 00.9200 13.00 310013 ..... 01.4193 21.54 310112 ..... 01.3408 21.93 330027 ..... 01.3596 31.94

280024 ..... 00.9571 11.90 280115 ..... 00.9323 16.12 310014 ..... 01.6973 25.20 310113 ..... 01.2698 21.81 330028 ..... 01.4711 25.53

280025 ..... 00.9430 12.87 280117 ..... 01.0899 15.93 310015 ..... 01.9538 25.55 310115 ..... 01.3332 21.37 330029 ..... 01.0082 19.40

280026 ..... 01.2113 14.79 280118 ..... 00.9335 16.45 310016 ..... 01.2558 24.30 310116 ..... 01.2758 22.74 330030 ..... 01.2557 16.43

280028 ..... 01.1079 15.15 280119 ..... 00.8703 .......... 310017 ..... 01.3828 23.95 310118 ..... 01.2657 22.78 330033 ..... 01.2798 16.66

280029 ..... 01.1344 15.52 280123 ..... 00.8938 .......... 310018 ..... 01.1258 21.68 310119 ..... 01.7103 30.34 330034 ..... 00.6391 30.46

280030 ..... 01.7044 27.82 280125 ..... 01.2392 .......... 310019 ..... 01.6672 24.86 310120 ..... 01.0971 20.79 330036 ..... 01.3056 19.62

280031 ..... 01.0150 13.61 290001 ..... 01.6935 23.03 310020 ..... 01.3887 22.65 320001 ..... 01.3857 17.43 330037 ..... 01.1546 15.46

280032 ..... 01.3002 16.45 290002 ..... 00.9128 16.13 310021 ..... 01.3817 23.63 320002 ..... 01.3670 19.13 330038 ..... 01.2340 15.52

280033 ..... 01.0406 15.69 290003 ..... 01.6810 25.76 310022 ..... 01.3156 21.10 320003 ..... 01.1238 13.29 330041 ..... 01.3043 36.69

280035 ..... 01.0337 13.65 290005 ..... 01.4874 20.79 310024 ..... 01.3022 23.65 320004 ..... 01.2792 14.96 330043 ..... 01.3194 33.46

280037 ..... 01.0415 15.48 290006 ..... 01.2561 19.14 310025 ..... 01.2009 21.93 320005 ..... 01.3531 20.75 330044 ..... 01.3085 18.10

280038 ..... 01.0023 15.49 290007 ..... 01.8502 27.93 310026 ..... 01.2043 23.19 320006 ..... 01.4170 14.55 330045 ..... 01.4176 27.45

280039 ..... 01.0469 15.70 290008 ..... 01.2147 19.60 310027 ..... 01.3265 21.41 320009 ..... 01.6244 17.17 330046 ..... 01.4603 30.06

280040 ..... 01.6269 19.18 290009 ..... 01.6221 17.91 310028 ..... 01.2526 21.94 320011 ..... 01.0077 17.05 330047 ..... 01.1772 16.85

280041 ..... 00.9134 12.05 290010 ..... 01.2399 14.00 310029 ..... 01.9458 23.14 320012 ..... 00.9924 16.53 330048 ..... 01.2917 17.45

280042 ..... 01.0344 15.14 290011 ..... 00.9015 15.52 310031 ..... 02.8675 22.58 320013 ..... 01.1521 17.67 330049 ..... 01.2386 17.85

280043 ..... 01.0147 15.47 290012 ..... 01.3753 21.50 310032 ..... 01.3467 22.51 320014 ..... 01.1514 14.63 330053 ..... 01.1874 14.83

280045 ..... 01.0969 16.10 290013 ..... 01.0527 18.62 310034 ..... 01.2580 21.58 320016 ..... 01.1211 15.17 330055 ..... 01.6244 29.81

280046 ..... 01.1072 12.37 290014 ..... 00.9699 17.46 310036 ..... 01.1893 19.11 320017 ..... 01.2111 16.75 330056 ..... 01.4395 30.22

280047 ..... 01.0907 18.01 290015 ..... 00.9197 15.18 310037 ..... 01.3653 27.57 320018 ..... 01.5827 18.43 330057 ..... 01.6763 18.74

280048 ..... 01.2131 13.82 290016 ..... 01.1837 22.67 310038 ..... 01.9545 26.13 320019 ..... 01.4848 19.57 330058 ..... 01.3057 16.66

280049 ..... 01.0412 15.08 290019 ..... 01.3426 19.74 310039 ..... 01.2827 21.22 320021 ..... 01.7502 17.99 330059 ..... 01.5787 33.67

280050 ..... 00.9263 13.71 290020 ..... 01.0445 17.29 310040 ..... 01.2393 23.99 320022 ..... 01.2213 16.24 330061 ..... 01.3166 24.36
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25631

PAGE 10 OF 15

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

330062 ..... 01.0733 17.10 330179 ..... 00.9045 14.60 330275 ..... 01.2903 22.06 340031 ..... 01.0066 12.83 340129 ..... 01.2985 18.11

330064 ..... 01.4892 32.11 330180 ..... 01.1983 16.27 330276 ..... 01.1685 17.92 340032 ..... 01.3624 18.77 340130 ..... 01.3225 19.83

330065 ..... 01.2030 18.54 330181 ..... 01.3528 31.07 330277 ..... 01.1085 16.57 340035 ..... 01.1531 17.23 340131 ..... 01.5209 18.16

330066 ..... 01.2766 17.98 330182 ..... 02.5453 30.48 330279 ..... 01.3577 19.05 340036 ..... 01.2139 18.25 340132 ..... 01.3256 16.27

330067 ..... 01.3948 20.64 330183 ..... 01.4677 19.94 330285 ..... 01.8458 22.66 340037 ..... 01.0873 14.46 340133 ..... 01.1268 14.74

330072 ..... 01.4097 29.92 330184 ..... 01.3264 27.58 330286 ..... 01.3379 24.38 340038 ..... 01.1012 16.68 340137 ..... 01.1310 15.62

330073 ..... 01.2255 15.82 330185 ..... 01.2827 24.72 330290 ..... 01.6841 32.27 340039 ..... 01.2681 19.88 340138 ..... 01.0625 16.94

330074 ..... 01.3127 17.25 330186 ..... 00.5618 20.30 330293 ..... 01.1953 15.09 340040 ..... 01.8191 18.61 340141 ..... 01.7229 20.28

330075 ..... 01.0589 17.73 330188 ..... 01.1830 18.71 330304 ..... 01.2338 27.04 340041 ..... 01.2094 17.69 340142 ..... 01.2350 15.79

330078 ..... 01.4268 17.96 330189 ..... 01.3232 16.54 330306 ..... 01.4286 28.10 340042 ..... 01.2260 15.70 340143 ..... 01.4228 19.62

330079 ..... 01.2427 17.22 330191 ..... 01.3283 18.17 330307 ..... 01.2663 19.23 340044 ..... 01.1020 18.87 340144 ..... 01.3656 18.96

330080 ..... 01.3325 27.06 330193 ..... 01.3516 28.64 330314 ..... 01.3785 21.50 340045 ..... 00.9956 14.02 340145 ..... 01.4314 18.88

330084 ..... 01.0696 17.68 330194 ..... 01.7808 31.20 330315 ..... 16.0413 30.36 340047 ..... 01.8288 19.42 340146 ..... 01.1145 14.28

330085 ..... 01.2974 18.59 330195 ..... 01.6416 31.94 330316 ..... 01.3084 22.23 340048 ..... 01.0275 05.23 340147 ..... 01.2535 19.21

330086 ..... 01.2666 26.87 330196 ..... 01.2608 27.80 330327 ..... 00.9713 16.98 340049 ..... 01.0355 17.75 340148 ..... 01.4937 18.55

330088 ..... 01.0531 22.43 330197 ..... 01.1287 16.79 330331 ..... 01.3121 29.10 340050 ..... 01.2003 17.95 340151 ..... 01.2078 15.67

330090 ..... 01.5991 17.92 330198 ..... 01.3837 23.21 330332 ..... 01.2892 26.99 340051 ..... 01.3356 16.79 340153 ..... 01.8814 19.87

330091 ..... 01.3584 18.01 330199 ..... 01.3382 25.90 330333 ..... 01.2444 51.91 340052 ..... 01.0223 21.14 340155 ..... 01.3840 21.24

330092 ..... 01.0542 14.25 330201 ..... 01.6866 40.72 330336 ..... 01.3094 30.29 340053 ..... 01.6440 19.44 340156 ..... 00.7966 ..........

330094 ..... 01.2399 17.06 330202 ..... 01.3886 27.41 330338 ..... 01.2333 20.97 340054 ..... 01.2239 14.35 340158 ..... 01.1278 16.49

330095 ..... 01.2452 18.40 330203 ..... 01.3959 19.61 330339 ..... 00.9320 18.87 340055 ..... 01.2769 17.40 340159 ..... 01.1375 16.21

330096 ..... 01.1887 15.81 330204 ..... 01.3552 28.88 330340 ..... 01.2344 22.43 340060 ..... 01.1293 17.75 340160 ..... 01.1672 14.11

330097 ..... 01.2171 15.32 330205 ..... 01.1763 19.85 330350 ..... 01.6747 28.46 340061 ..... 01.7280 20.31 340162 ..... 01.1787 16.56

330100 ..... 00.7936 28.03 330208 ..... 01.2263 26.41 330353 ..... 01.2772 31.43 340063 ..... 01.0171 22.75 340164 ..... 01.4579 20.69

330101 ..... 01.8106 30.39 330209 ..... 01.1811 24.53 330354 ..... 01.5676 .......... 340064 ..... 01.2364 17.05 340166 ..... 01.2776 19.58

330102 ..... 01.3312 17.00 330211 ..... 01.2029 18.46 330357 ..... 01.3809 34.81 340065 ..... 01.2854 15.89 340168 ..... 00.4875 15.15

330103 ..... 01.2449 16.63 330212 ..... 01.1468 24.26 330359 ..... 00.9373 29.31 340067 ..... 01.1587 18.20 340171 ..... 01.2031 ..........

330104 ..... 01.4313 27.69 330213 ..... 01.1701 18.39 330372 ..... 01.1964 22.25 340068 ..... 01.2139 16.56 340173 ..... 01.2130 ..........

330106 ..... 01.6949 34.04 330214 ..... 01.8173 31.94 330381 ..... 01.2852 29.21 340069 ..... 01.8495 20.34 350001 ..... 00.9857 14.51

330107 ..... 01.3314 26.04 330215 ..... 01.2026 17.11 330385 ..... 01.1940 29.15 340070 ..... 01.3026 18.49 350002 ..... 01.8548 16.86

330108 ..... 01.2467 16.97 330218 ..... 01.0527 20.44 330386 ..... 01.2158 23.26 340071 ..... 01.0889 15.86 350003 ..... 01.1701 16.63

330111 ..... 01.0751 15.08 330219 ..... 01.6629 20.87 330387 ..... 00.7923 30.68 340072 ..... 01.1279 15.86 350004 ..... 01.9174 18.34

330114 ..... 00.9490 15.82 330221 ..... 01.2904 29.07 330389 ..... 01.7245 31.92 340073 ..... 01.5386 19.84 350005 ..... 01.0598 14.07

330115 ..... 01.2405 16.12 330222 ..... 01.2606 18.36 330390 ..... 01.3751 31.67 340075 ..... 01.1939 16.88 350006 ..... 01.5142 16.25

330116 ..... 00.9611 15.34 330223 ..... 01.0770 16.39 330393 ..... 01.7444 25.45 340080 ..... 01.0339 15.49 350007 ..... 00.8879 13.24

330118 ..... 01.6591 20.00 330224 ..... 01.2569 21.50 330394 ..... 01.5407 18.21 340084 ..... 01.0889 16.12 350008 ..... 00.9420 16.74

330119 ..... 01.7636 32.85 330225 ..... 01.1739 24.76 330395 ..... 01.3488 33.16 340085 ..... 01.1663 16.33 350009 ..... 01.1468 17.04

330121 ..... 01.0383 15.12 330226 ..... 01.2590 17.82 330396 ..... 01.1754 31.55 340087 ..... 01.1169 16.53 350010 ..... 01.1050 13.74

330122 ..... 01.0650 22.97 330229 ..... 01.3257 16.25 330397 ..... 01.3150 30.46 340088 ..... 01.1258 18.13 350011 ..... 01.8836 20.64

330125 ..... 01.9179 20.66 330230 ..... 01.3791 29.27 330398 ..... 01.3550 29.49 340089 ..... 01.0120 13.83 350012 ..... 01.1086 13.55

330126 ..... 01.1519 22.70 330231 ..... 01.0674 29.53 330399 ..... 01.2625 29.60 340090 ..... 01.1444 17.83 350013 ..... 01.1051 16.53

330127 ..... 01.3403 29.65 330232 ..... 01.2445 17.76 340001 ..... 01.4796 17.91 340091 ..... 01.7002 19.89 350014 ..... 00.9841 13.14

330128 ..... 01.2625 29.68 330233 ..... 01.4948 30.49 340002 ..... 01.8416 18.45 340093 ..... 01.0697 13.96 350015 ..... 01.7381 16.56

330132 ..... 01.2001 13.55 330234 ..... 02.3119 31.88 340003 ..... 01.1252 17.14 340094 ..... 01.4789 18.27 350016 ..... 01.0963 11.47

330133 ..... 01.3701 34.67 330235 ..... 01.1204 19.21 340004 ..... 01.4483 18.79 340096 ..... 01.1483 17.40 350017 ..... 01.3990 16.68

330135 ..... 01.1994 19.14 330236 ..... 01.4074 28.47 340005 ..... 01.1650 14.89 340097 ..... 01.1445 17.69 350018 ..... 01.0846 17.93

330136 ..... 01.2894 19.26 330238 ..... 01.1749 15.02 340006 ..... 01.0428 14.76 340098 ..... 01.6889 19.32 350019 ..... 01.6863 18.72

330140 ..... 01.7769 18.58 330239 ..... 01.1666 16.21 340007 ..... 01.1704 16.96 340099 ..... 01.2134 13.03 350021 ..... 01.0260 12.00

330141 ..... 01.3850 24.49 330240 ..... 01.3279 27.67 340008 ..... 01.1373 17.84 340101 ..... 01.0627 11.87 350023 ..... 00.9286 15.16

330144 ..... 00.9394 15.19 330241 ..... 01.9705 21.51 340010 ..... 01.2998 17.56 340104 ..... 00.9970 11.37 350024 ..... 01.0368 16.47

330148 ..... 01.0767 15.47 330242 ..... 01.3423 25.14 340011 ..... 01.1622 15.71 340105 ..... 01.3725 18.85 350025 ..... 01.0095 14.00

330151 ..... 01.1172 14.68 330245 ..... 01.3076 17.00 340012 ..... 01.3162 17.04 340106 ..... 01.2505 20.04 350027 ..... 00.9540 14.46

330152 ..... 01.4137 30.10 330246 ..... 01.3839 25.91 340013 ..... 01.2800 17.33 340107 ..... 01.3591 17.08 350029 ..... 00.8728 12.98

330153 ..... 01.7338 16.97 330247 ..... 00.9015 27.38 340014 ..... 01.5587 22.23 340109 ..... 01.3186 17.38 350030 ..... 01.0496 16.65

330154 ..... 01.7268 .......... 330249 ..... 01.1933 16.18 340015 ..... 01.3007 20.37 340111 ..... 01.1989 14.63 350033 ..... 00.9198 14.40

330157 ..... 01.3501 19.72 330250 ..... 01.2870 17.98 340016 ..... 01.1912 16.24 340112 ..... 00.9917 15.24 350034 ..... 00.9924 17.45

330158 ..... 01.4999 20.48 330252 ..... 00.9461 16.84 340017 ..... 01.2474 14.31 340113 ..... 01.8577 20.59 350035 ..... 00.9005 10.21

330159 ..... 01.2907 17.88 330254 ..... 01.1696 17.12 340018 ..... 01.2456 16.25 340114 ..... 01.5500 20.34 350038 ..... 01.0922 15.28

330160 ..... 01.4736 29.42 330258 ..... 01.3355 30.01 340019 ..... 01.0224 20.26 340115 ..... 01.5723 19.35 350039 ..... 01.0288 14.75

330162 ..... 01.2185 27.06 330259 ..... 01.5025 23.47 340020 ..... 01.1977 19.04 340116 ..... 01.8178 19.81 350041 ..... 01.0442 17.60

330163 ..... 01.1905 19.14 330261 ..... 01.2944 26.17 340021 ..... 01.2336 17.51 340119 ..... 01.2970 16.41 350042 ..... 01.1142 15.19

330164 ..... 01.4954 19.87 330263 ..... 01.0305 17.91 340022 ..... 01.0586 16.91 340120 ..... 01.0817 13.56 350043 ..... 01.5670 14.65

330166 ..... 01.0125 13.56 330264 ..... 01.2135 21.71 340023 ..... 01.3771 17.77 340121 ..... 01.0648 15.43 350044 ..... 00.8768 11.49

330167 ..... 01.6539 29.65 330265 ..... 01.3931 16.33 340024 ..... 01.1393 16.33 340123 ..... 01.0906 15.57 350047 ..... 01.1941 16.54

330169 ..... 01.4639 32.41 330267 ..... 01.3643 23.95 340025 ..... 01.2234 15.47 340124 ..... 01.0127 13.98 350049 ..... 01.3354 13.86

330171 ..... 01.4007 23.94 330268 ..... 00.9663 15.02 340027 ..... 01.2058 16.89 340125 ..... 01.4796 16.50 350050 ..... 00.9591 11.89

330175 ..... 01.1894 15.10 330270 ..... 01.9872 31.03 340028 ..... 01.5976 16.85 340126 ..... 01.3940 16.50 350051 ..... 00.9832 15.74

330177 ..... 00.9633 14.78 330273 ..... 01.3059 25.72 340030 ..... 02.0173 21.06 340127 ..... 01.3339 17.51 350053 ..... 01.0118 11.88
25632 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

PAGE 11 OF 15

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

350055 ..... 00.9999 13.76 360074 ..... 01.3337 18.00 360159 ..... 01.2116 19.84 370029 ..... 01.2602 13.51 370149 ..... 01.2900 15.69

350056 ..... 00.9564 13.88 360075 ..... 01.4441 21.40 360161 ..... 01.2549 13.69 370030 ..... 01.1832 16.49 370153 ..... 01.0658 14.06

350058 ..... 00.9230 12.18 360076 ..... 01.3645 18.64 360163 ..... 01.8032 20.26 370032 ..... 01.5887 16.17 370154 ..... 01.0434 14.12

350060 ..... 00.8587 08.80 360077 ..... 01.5831 19.38 360164 ..... 00.9634 15.60 370033 ..... 01.0599 12.34 370156 ..... 01.0577 17.29

350061 ..... 01.0645 15.31 360078 ..... 01.2491 19.90 360165 ..... 01.1732 17.81 370034 ..... 01.2337 14.36 370158 ..... 01.0253 12.09

350063 ..... 00.8843 .......... 360079 ..... 01.8666 21.04 360166 ..... 01.1873 16.01 370035 ..... 01.6429 16.77 370159 ..... 01.3951 15.05

350064 ..... 00.8364 .......... 360080 ..... 01.1462 15.68 360170 ..... 01.3808 16.53 370036 ..... 01.0721 10.54 370163 ..... 01.0022 14.57

360001 ..... 01.3790 17.65 360081 ..... 01.3761 19.70 360172 ..... 01.3455 17.89 370037 ..... 01.7160 18.63 370165 ..... 01.1291 11.97

360002 ..... 01.1925 17.82 360082 ..... 01.3254 23.27 360174 ..... 01.3284 18.44 370038 ..... 01.0052 11.68 370166 ..... 01.1323 15.55

360003 ..... 01.7561 22.14 360084 ..... 01.6045 20.53 360175 ..... 01.1937 20.19 370039 ..... 01.2616 13.93 370169 ..... 01.0593 11.91

360006 ..... 01.8372 20.93 360085 ..... 01.8333 21.47 360176 ..... 01.1290 15.34 370040 ..... 01.0977 15.04 370170 ..... 01.0046 ..........

360007 ..... 01.0627 15.95 360086 ..... 01.4331 17.81 360177 ..... 01.2931 18.27 370041 ..... 00.9733 16.47 370171 ..... 01.0182 ..........

360008 ..... 01.2396 17.78 360087 ..... 01.4291 18.51 360178 ..... 01.2433 17.16 370042 ..... 00.8835 13.98 370172 ..... 00.9229 ..........

360009 ..... 01.4867 17.38 360088 ..... 01.3676 19.09 360179 ..... 01.3391 19.50 370043 ..... 00.9443 15.18 370173 ..... 01.1000 ..........

360010 ..... 01.2461 17.09 360089 ..... 01.1769 17.84 360180 ..... 02.1577 23.00 370045 ..... 00.9900 09.83 370174 ..... 00.7547 ..........

360011 ..... 01.3403 18.91 360090 ..... 01.2425 19.75 360184 ..... 00.4293 18.76 370046 ..... 00.9817 10.89 370176 ..... 01.2219 16.29

360012 ..... 01.3150 19.72 360091 ..... 01.2836 20.40 360185 ..... 01.2259 18.13 370047 ..... 01.3904 15.04 370177 ..... 00.9737 10.48

360013 ..... 01.1386 18.36 360092 ..... 01.1263 19.47 360186 ..... 01.1539 10.45 370048 ..... 01.2228 15.40 370178 ..... 01.0021 11.20

360014 ..... 01.2083 18.87 360093 ..... 01.1654 17.64 360187 ..... 01.4085 17.67 370049 ..... 01.3327 15.44 370179 ..... 00.7441 15.19

360016 ..... 01.6147 18.36 360094 ..... 01.3940 18.15 360188 ..... 00.9725 17.11 370051 ..... 00.9867 11.30 370180 ..... 00.9135 ..........

360017 ..... 01.8633 21.51 360095 ..... 01.2581 19.83 360189 ..... 01.1592 16.98 370054 ..... 01.4696 16.32 370183 ..... 01.0309 10.35

360018 ..... 01.6285 19.87 360096 ..... 01.1266 17.46 360192 ..... 01.3663 21.31 370056 ..... 01.5245 18.44 370186 ..... 00.9921 13.32

360019 ..... 01.2657 21.76 360098 ..... 01.4265 18.26 360193 ..... 01.2971 16.98 370057 ..... 01.1165 15.27 370190 ..... 01.5486 26.42

360020 ..... 01.4424 20.72 360099 ..... 01.0479 19.53 360194 ..... 01.2855 17.89 370059 ..... 01.0974 17.49 370192 ..... 01.2229 16.30

360024 ..... 01.3762 17.75 360100 ..... 01.2888 18.00 360195 ..... 01.1587 19.33 370060 ..... 01.1260 13.90 370196 ..... 00.8240 ..........

360025 ..... 01.3562 19.40 360101 ..... 01.3901 21.04 360197 ..... 01.1688 19.16 370063 ..... 01.1782 16.95 370197 ..... 00.9846 ..........

360026 ..... 01.3485 16.21 360102 ..... 01.2869 19.19 360200 ..... 01.0276 15.62 370064 ..... 00.9593 10.71 370198 ..... 01.7997 ..........

360027 ..... 01.4597 20.14 360103 ..... 01.3578 19.87 360203 ..... 01.2094 14.41 370065 ..... 00.9924 15.36 380001 ..... 01.2902 18.13

360028 ..... 01.4846 17.21 360106 ..... 01.1021 16.08 360204 ..... 01.2422 19.09 370071 ..... 01.0530 10.05 380002 ..... 01.2715 18.07

360029 ..... 01.1846 17.74 360107 ..... 01.2417 17.37 360210 ..... 01.2012 20.61 370072 ..... 00.8635 14.04 380003 ..... 01.2260 28.86

360030 ..... 01.2891 16.67 360108 ..... 01.0913 16.45 360211 ..... 01.2671 19.64 370076 ..... 01.2612 12.45 380004 ..... 01.7003 23.04

360031 ..... 01.2807 19.33 360109 ..... 01.1094 18.64 360212 ..... 01.3941 20.16 370078 ..... 01.7411 16.06 380005 ..... 01.2187 22.81

360032 ..... 01.0729 17.87 360112 ..... 01.8012 23.33 360213 ..... 01.2686 18.05 370079 ..... 00.9534 15.91 380006 ..... 01.2870 19.61

360034 ..... 01.3225 14.77 360113 ..... 01.3630 15.36 360218 ..... 01.3047 18.29 370080 ..... 00.9738 14.18 380007 ..... 01.6852 24.92

360035 ..... 01.6186 20.73 360114 ..... 01.1017 17.48 360230 ..... 01.5624 21.16 370082 ..... 00.9220 13.85 380008 ..... 01.0543 19.56

360036 ..... 01.3579 19.04 360115 ..... 01.2554 17.92 360231 ..... 01.1494 12.39 370083 ..... 00.9508 12.81 380009 ..... 01.8821 22.90

360037 ..... 02.0580 21.38 360116 ..... 01.0983 17.49 360234 ..... 01.3469 16.44 370084 ..... 01.0827 13.65 380010 ..... 01.0520 22.58

360038 ..... 01.5828 20.60 360118 ..... 01.3521 18.34 360236 ..... 01.2893 25.36 370085 ..... 00.8717 13.21 380011 ..... 01.0490 19.05

360039 ..... 01.3135 17.40 360121 ..... 01.2409 19.22 360239 ..... 01.3034 19.65 370086 ..... 01.1713 11.51 380013 ..... 01.3177 20.62

360040 ..... 01.3495 17.81 360123 ..... 01.2744 19.33 360241 ..... 00.4699 21.14 370089 ..... 01.2580 15.23 380014 ..... 01.6295 22.02

360041 ..... 01.3392 18.83 360125 ..... 01.0992 17.41 360242 ..... 01.8068 .......... 370091 ..... 01.7259 19.16 380017 ..... 01.9390 25.87

360042 ..... 01.1862 18.02 360126 ..... 01.2179 20.75 360243 ..... 00.7287 14.26 370092 ..... 01.0247 14.09 380018 ..... 01.8034 20.94

360044 ..... 01.1205 15.83 360127 ..... 01.1844 17.85 360245 ..... 00.7295 15.21 370093 ..... 01.8539 17.71 380019 ..... 01.2880 21.45

360045 ..... 01.4762 20.73 360128 ..... 01.1314 15.05 360247 ..... 00.4164 .......... 370094 ..... 01.5130 19.25 380020 ..... 01.5022 21.41

360046 ..... 01.1449 17.71 360129 ..... 00.9665 15.12 360248 ..... 01.7504 .......... 370095 ..... 00.9994 11.75 380021 ..... 01.2890 21.57

360047 ..... 01.1368 14.51 360130 ..... 01.1237 15.93 370001 ..... 01.7845 20.06 370097 ..... 01.3708 17.38 380022 ..... 01.1715 22.57

360048 ..... 01.8279 21.60 360131 ..... 01.3442 18.99 370002 ..... 01.1524 13.71 370099 ..... 01.1771 14.07 380023 ..... 01.2243 18.43

360049 ..... 01.1856 19.60 360132 ..... 01.4255 18.28 370004 ..... 01.2310 16.67 370100 ..... 01.0076 14.49 380025 ..... 01.3449 25.35

360050 ..... 01.0987 12.40 360133 ..... 01.5948 18.70 370005 ..... 01.0032 14.07 370103 ..... 00.9320 16.27 380026 ..... 01.1604 19.09

360051 ..... 01.6396 23.55 360134 ..... 01.7247 20.07 370006 ..... 01.2654 15.48 370105 ..... 01.9777 18.43 380027 ..... 01.2943 22.82

360052 ..... 01.7665 18.65 360136 ..... 01.0811 16.90 370007 ..... 01.2216 14.36 370106 ..... 01.5469 18.37 380029 ..... 01.1592 18.33

360054 ..... 01.2934 16.53 360137 ..... 01.6532 19.95 370008 ..... 01.3784 17.77 370108 ..... 01.1298 11.81 380031 ..... 00.9808 22.48

360055 ..... 01.2577 19.64 360140 ..... 00.9788 16.21 370011 ..... 01.0524 12.91 370112 ..... 01.0696 14.65 380033 ..... 01.7744 24.22

360056 ..... 01.4280 20.89 360141 ..... 01.5661 23.32 370012 ..... 00.8733 09.87 370113 ..... 01.1887 15.11 380035 ..... 01.2910 21.53

360057 ..... 01.1603 15.46 360142 ..... 01.0197 16.62 370013 ..... 01.8435 19.24 370114 ..... 01.6464 15.79 380036 ..... 01.0585 20.79

360058 ..... 01.2702 17.56 360143 ..... 01.4294 19.90 370014 ..... 01.2842 19.35 370121 ..... 01.1723 16.84 380037 ..... 01.2761 20.52

360059 ..... 01.6935 21.65 360144 ..... 01.3319 19.89 370015 ..... 01.2181 17.16 370122 ..... 01.1283 12.45 380038 ..... 01.3383 25.28

360062 ..... 01.5157 20.52 360145 ..... 01.6848 18.18 370016 ..... 01.3747 16.52 370123 ..... 01.3288 17.25 380039 ..... 01.3184 21.50

360063 ..... 01.1355 18.29 360147 ..... 01.2300 16.40 370017 ..... 01.1872 11.23 370125 ..... 00.9809 12.01 380040 ..... 01.2643 21.08

360064 ..... 01.6110 21.73 360148 ..... 01.1746 17.80 370018 ..... 01.3459 18.25 370126 ..... 00.9821 12.07 380042 ..... 01.0847 17.33

360065 ..... 01.2978 18.23 360149 ..... 01.2144 18.68 370019 ..... 01.3577 14.79 370131 ..... 00.9568 15.71 380047 ..... 01.7005 21.15

360066 ..... 01.5064 18.92 360150 ..... 01.2765 20.02 370020 ..... 01.3041 11.86 370133 ..... 01.1458 11.04 380048 ..... 01.0727 15.35

360067 ..... 01.1473 13.46 360151 ..... 01.3441 17.15 370021 ..... 00.9234 10.38 370138 ..... 01.0828 15.12 380050 ..... 01.4632 18.30

360068 ..... 01.7403 21.49 360152 ..... 01.5138 19.73 370022 ..... 01.3220 17.34 370139 ..... 01.1101 11.70 380051 ..... 01.6000 20.79

360069 ..... 01.1413 17.25 360153 ..... 01.1322 13.86 370023 ..... 01.3350 16.03 370140 ..... 01.0074 11.92 380052 ..... 01.2194 17.97

360070 ..... 01.6991 16.22 360154 ..... 01.0127 13.29 370025 ..... 01.3416 16.09 370141 ..... 01.3413 15.22 380055 ..... 01.0479 25.16

360071 ..... 01.3655 14.35 360155 ..... 01.3655 20.38 370026 ..... 01.4980 16.66 370146 ..... 01.1663 11.23 380056 ..... 01.1095 16.82

360072 ..... 01.2294 17.52 360156 ..... 01.2889 18.45 370028 ..... 01.9096 20.31 370148 ..... 01.4901 27.04 380060 ..... 01.4546 22.68
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25633

PAGE 12 OF 15

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

380061 ..... 01.5010 21.24 390054 ..... 01.1925 16.20 390138 ..... 01.3274 17.99 390242 ..... 01.3211 18.77 400120 ..... 01.3210 09.45

380062 ..... 01.2271 18.32 390055 ..... 01.8803 26.53 390139 ..... 01.5292 23.00 390244 ..... 00.9008 12.10 400121 ..... 00.9061 06.57

380063 ..... 01.2398 18.55 390056 ..... 01.1583 16.53 390142 ..... 01.6012 28.56 390245 ..... 01.4283 21.37 400122 ..... 01.0071 07.20

380064 ..... 01.3645 18.24 390057 ..... 01.3181 19.58 390145 ..... 01.3627 20.30 390246 ..... 01.2381 17.91 400123 ..... 01.1923 08.39

380065 ..... 01.2612 22.48 390058 ..... 01.2736 18.64 390146 ..... 01.2696 16.85 390247 ..... 01.0888 20.42 400124 ..... 02.6899 11.00

380066 ..... 01.3314 20.01 390060 ..... 01.2044 16.88 390147 ..... 01.2520 20.55 390249 ..... 01.0117 12.79 410001 ..... 01.3885 21.15

380068 ..... 00.9929 21.71 390061 ..... 01.5126 20.08 390150 ..... 01.1850 20.98 390256 ..... 01.8065 24.05 410004 ..... 01.3542 21.95

380069 ..... 01.1237 19.35 390062 ..... 01.1873 16.43 390151 ..... 01.2236 19.88 390258 ..... 01.3894 20.71 410005 ..... 01.3893 22.97

380070 ..... 01.3856 25.32 390063 ..... 01.7711 20.19 390152 ..... 01.0833 17.35 390260 ..... 01.2324 23.05 410006 ..... 01.3047 21.58

380071 ..... 01.2895 20.13 390065 ..... 01.2445 19.95 390153 ..... 01.2347 22.04 390262 ..... 01.8663 18.17 410007 ..... 01.6895 21.22

380072 ..... 00.9525 16.03 390066 ..... 01.2979 19.58 390154 ..... 01.2149 17.37 390263 ..... 01.4746 19.75 410008 ..... 01.2641 20.03

380075 ..... 01.3760 19.99 390067 ..... 01.7841 19.97 390156 ..... 01.4353 20.56 390265 ..... 01.3029 19.06 410009 ..... 01.3206 23.53

380078 ..... 00.9840 18.28 390068 ..... 01.3034 19.04 390157 ..... 01.3790 18.98 390266 ..... 01.2200 16.95 410010 ..... 01.0628 26.80

380081 ..... 01.1300 18.28 390069 ..... 01.3386 20.08 390158 ..... 01.5582 19.47 390267 ..... 01.3089 19.01 410011 ..... 01.2360 23.92

380082 ..... 01.3109 21.55 390070 ..... 01.3343 19.37 390160 ..... 01.2930 19.68 390268 ..... 01.3484 21.17 410012 ..... 01.8346 21.15

380083 ..... 01.2950 21.90 390071 ..... 01.0930 15.04 390161 ..... 01.1318 13.75 390270 ..... 01.3595 17.08 410013 ..... 01.2926 24.44

380084 ..... 01.2579 21.98 390072 ..... 01.0866 15.49 390162 ..... 01.5617 21.02 390272 ..... 00.4562 .......... 420002 ..... 01.3852 21.83

380087 ..... 01.0848 12.91 390073 ..... 01.6243 19.82 390163 ..... 01.2249 16.11 390277 ..... 00.5292 23.14 420004 ..... 01.8530 18.30

380088 ..... 01.0227 18.65 390074 ..... 01.2608 16.62 390164 ..... 02.1585 22.59 390278 ..... 00.6728 16.94 420005 ..... 01.1718 15.14

380089 ..... 01.3275 23.92 390075 ..... 01.3632 17.48 390166 ..... 01.1125 18.97 390279 ..... 01.0386 14.40 420006 ..... 01.1714 17.68

380090 ..... 01.2856 25.49 390076 ..... 01.4253 21.97 390167 ..... 01.3655 21.84 400001 ..... 01.2646 09.39 420007 ..... 01.5056 17.78

380091 ..... 01.3021 24.95 390078 ..... 01.0805 18.92 390168 ..... 01.2845 18.12 400002 ..... 01.6156 10.99 420009 ..... 01.2431 17.01

390001 ..... 01.4101 21.89 390079 ..... 01.7802 17.91 390169 ..... 01.2814 18.85 400003 ..... 01.3181 08.34 420010 ..... 01.2029 15.22

390002 ..... 01.2997 19.71 390080 ..... 01.3128 18.40 390170 ..... 01.8882 21.93 400004 ..... 01.1998 08.16 420011 ..... 01.1862 15.88

390003 ..... 01.2251 17.48 390081 ..... 01.3443 21.33 390173 ..... 01.2026 17.81 400005 ..... 01.0804 06.50 420014 ..... 01.0521 15.49

390004 ..... 01.3957 17.68 390083 ..... 01.2260 17.49 390174 ..... 01.6821 28.75 400006 ..... 01.2047 07.62 420015 ..... 01.3602 17.27

390005 ..... 01.0449 16.56 390084 ..... 01.1848 15.92 390176 ..... 01.1634 18.54 400007 ..... 01.1616 07.13 420016 ..... 00.9967 14.27

390006 ..... 01.7963 18.43 390086 ..... 01.1623 17.91 390178 ..... 01.3125 19.14 400009 ..... 01.0382 07.64 420018 ..... 01.8076 19.64

390007 ..... 01.2165 20.24 390088 ..... 01.3418 21.04 390179 ..... 01.3565 21.31 400010 ..... 00.9135 10.07 420019 ..... 01.1909 14.81

390008 ..... 01.1475 16.70 390090 ..... 01.7964 20.56 390180 ..... 01.4771 23.13 400011 ..... 01.0608 07.81 420020 ..... 01.2623 17.58

390009 ..... 01.6945 19.72 390091 ..... 01.1404 18.52 390181 ..... 01.0478 19.10 400012 ..... 01.1906 07.69 420023 ..... 01.4452 19.27

390010 ..... 01.2666 16.99 390093 ..... 01.1546 15.95 390183 ..... 01.1759 18.03 400013 ..... 01.2834 08.06 420026 ..... 01.8876 18.73

390011 ..... 01.2805 18.32 390095 ..... 01.2041 15.21 390184 ..... 01.1047 18.24 400014 ..... 01.3803 08.68 420027 ..... 01.3581 17.34

390012 ..... 01.2209 19.43 390096 ..... 01.5027 17.87 390185 ..... 01.2232 17.20 400015 ..... 01.3729 .......... 420030 ..... 01.2949 17.49

390013 ..... 01.2405 18.14 390097 ..... 01.2959 22.07 390189 ..... 01.1429 19.19 400016 ..... 01.3717 11.37 420031 ..... 00.9613 12.23

390015 ..... 01.1529 13.06 390100 ..... 01.6655 20.58 390191 ..... 01.2270 16.80 400017 ..... 01.2069 06.56 420033 ..... 01.2721 19.24

390016 ..... 01.2456 17.76 390101 ..... 01.2042 17.62 390192 ..... 01.1586 15.64 400018 ..... 01.2977 09.29 420036 ..... 01.4355 18.46

390017 ..... 01.2175 15.86 390102 ..... 01.3763 19.60 390193 ..... 01.2088 17.26 400019 ..... 01.7668 09.58 420037 ..... 01.1963 21.60

390018 ..... 01.3160 19.26 390103 ..... 01.1383 18.62 390194 ..... 01.1410 18.95 400021 ..... 01.4606 09.43 420038 ..... 01.3331 15.74

390019 ..... 01.1409 16.01 390104 ..... 01.0956 14.75 390195 ..... 01.8448 22.62 400022 ..... 01.3456 11.18 420039 ..... 01.1544 16.21

390022 ..... 01.3648 20.49 390106 ..... 01.0527 15.96 390196 ..... 01.3776 .......... 400024 ..... 01.0267 07.45 420042 ..... 01.1022 14.56

390023 ..... 01.2385 18.03 390107 ..... 01.3456 19.43 390197 ..... 01.3002 17.67 400026 ..... 00.9852 06.04 420043 ..... 01.2299 18.79

390024 ..... 01.0879 23.53 390108 ..... 01.3676 19.21 390198 ..... 01.2119 15.83 400027 ..... 01.1410 08.07 420048 ..... 01.2492 13.44

390025 ..... 00.6397 15.37 390109 ..... 01.2783 14.91 390199 ..... 01.3245 15.86 400028 ..... 01.0099 07.98 420049 ..... 01.1743 16.46

390026 ..... 01.3006 21.98 390110 ..... 01.6319 19.36 390200 ..... 01.0981 17.18 400029 ..... 01.0884 10.05 420051 ..... 01.6278 17.99

390027 ..... 01.8620 28.88 390111 ..... 01.8454 29.97 390201 ..... 01.2808 20.12 400031 ..... 01.2349 09.50 420053 ..... 01.1996 16.08

390028 ..... 01.8946 19.73 390112 ..... 01.2860 13.72 390203 ..... 01.3856 22.12 400032 ..... 01.2495 08.99 420054 ..... 01.2953 17.01

390029 ..... 01.9719 18.87 390113 ..... 01.2274 17.00 390204 ..... 01.3041 20.57 400044 ..... 01.1780 09.84 420055 ..... 01.0131 15.72

390030 ..... 01.2422 18.37 390114 ..... 01.2178 21.25 390206 ..... 01.3925 19.09 400048 ..... 01.1548 08.23 420056 ..... 01.0853 13.21

390031 ..... 01.1866 18.45 390115 ..... 01.3792 23.95 390209 ..... 01.0699 16.37 400061 ..... 01.6558 14.42 420057 ..... 01.1687 14.71

390032 ..... 01.2567 19.11 390116 ..... 01.2709 23.74 390211 ..... 01.2499 18.17 400079 ..... 01.2819 10.43 420059 ..... 00.9796 15.11

390035 ..... 01.2478 17.14 390117 ..... 01.1848 16.64 390213 ..... 01.1615 19.15 400087 ..... 01.4420 10.90 420061 ..... 01.1681 17.58

390036 ..... 01.4518 19.18 390118 ..... 01.1802 16.48 390215 ..... 01.2938 24.51 400094 ..... 01.0401 06.88 420062 ..... 01.4640 15.61

390037 ..... 01.3834 19.24 390119 ..... 01.3516 18.05 390217 ..... 01.2323 20.29 400098 ..... 01.3576 08.48 420064 ..... 01.1124 14.50

390039 ..... 01.1357 16.31 390121 ..... 01.3576 19.61 390219 ..... 01.3267 19.86 400102 ..... 01.1698 04.27 420065 ..... 01.3464 18.10

390040 ..... 00.9663 16.73 390122 ..... 01.1007 18.49 390220 ..... 01.2025 18.22 400103 ..... 01.4518 09.30 420066 ..... 00.9577 16.65

390041 ..... 01.2908 18.92 390123 ..... 01.3805 20.31 390222 ..... 01.2859 20.89 400104 ..... 01.3442 09.05 420067 ..... 01.2622 18.10

390042 ..... 01.5647 21.41 390125 ..... 01.2001 15.48 390223 ..... 01.5318 22.49 400105 ..... 01.2514 08.85 420068 ..... 01.4309 17.58

390043 ..... 01.1558 18.18 390126 ..... 01.2793 19.94 390224 ..... 00.9047 15.35 400106 ..... 01.2522 08.61 420069 ..... 01.0556 18.03

390044 ..... 01.6721 19.24 390127 ..... 01.2446 21.39 390225 ..... 01.1782 17.76 400109 ..... 01.4903 09.61 420070 ..... 01.2279 16.89

390045 ..... 01.8045 17.60 390128 ..... 01.2398 19.93 390226 ..... 01.7896 23.48 400110 ..... 01.0649 08.99 420071 ..... 01.3120 18.25

390046 ..... 01.5550 20.26 390130 ..... 01.1635 16.56 390228 ..... 01.2819 19.19 400111 ..... 01.1917 08.80 420072 ..... 00.9800 11.63

390047 ..... 01.9134 30.25 390131 ..... 01.3311 16.73 390231 ..... 01.4331 24.08 400112 ..... 01.1131 08.91 420073 ..... 01.3017 20.68

390048 ..... 01.1814 18.12 390132 ..... 01.2825 22.21 390233 ..... 01.3151 18.31 400113 ..... 01.2139 08.29 420074 ..... 01.0054 13.73

390049 ..... 01.6700 21.29 390133 ..... 01.8226 22.97 390235 ..... 01.5371 23.51 400114 ..... 01.0730 08.19 420075 ..... 00.9408 13.75

390050 ..... 02.1813 22.47 390135 ..... 01.2353 21.67 390236 ..... 01.1865 16.40 400115 ..... 01.0700 08.58 420078 ..... 01.8491 21.18

390051 ..... 02.1743 25.65 390136 ..... 01.1261 15.10 390237 ..... 01.6160 19.08 400117 ..... 01.1921 09.36 420079 ..... 01.5774 19.07

390052 ..... 01.1794 15.47 390137 ..... 01.5138 16.40 390238 ..... 01.4870 18.78 400118 ..... 01.2634 10.06 420080 ..... 01.3760 24.17
25634 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

PAGE 13 OF 15

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

420082 ..... 01.5220 18.32 440011 ..... 01.3887 17.79 440135 ..... 01.2276 19.84 450039 ..... 01.4508 17.93 450150 ..... 00.9615 10.86

420083 ..... 01.2939 19.79 440012 ..... 01.6038 18.49 440137 ..... 01.0953 13.42 450040 ..... 01.5337 17.64 450151 ..... 01.1421 15.82

420085 ..... 01.4964 17.31 440014 ..... 00.9585 14.66 440141 ..... 01.0489 16.14 450042 ..... 01.7796 17.20 450152 ..... 01.2733 16.88

420086 ..... 01.4475 18.16 440015 ..... 01.7375 15.39 440142 ..... 01.0746 12.75 450044 ..... 01.5602 20.09 450153 ..... 01.5917 18.67

420087 ..... 01.6840 18.21 440016 ..... 01.0127 12.66 440143 ..... 01.0957 17.21 450046 ..... 01.4559 12.99 450154 ..... 01.1522 14.43

420088 ..... 01.1409 16.23 440017 ..... 01.7209 19.76 440144 ..... 01.2961 17.79 450047 ..... 01.1070 11.09 450155 ..... 01.0382 24.42

420089 ..... 01.2826 21.79 440018 ..... 01.3665 16.68 440145 ..... 00.9607 13.88 450050 ..... 00.9968 11.53 450157 ..... 01.1365 15.32

420091 ..... 01.2793 16.06 440019 ..... 01.6964 20.11 440147 ..... 01.5847 16.28 450051 ..... 01.6355 19.77 450160 ..... 00.9535 15.51

420093 ..... 01.0268 .......... 440020 ..... 01.2407 15.60 440148 ..... 01.1655 16.26 450052 ..... 01.0576 13.42 450162 ..... 01.2604 21.24

430004 ..... 01.1554 16.77 440023 ..... 01.1507 14.25 440149 ..... 01.1555 14.35 450053 ..... 01.0823 14.15 450163 ..... 01.0682 16.72

430005 ..... 01.3595 15.32 440024 ..... 01.3297 17.96 440150 ..... 01.3246 18.41 450054 ..... 01.6306 21.89 450164 ..... 01.2194 14.62

430007 ..... 01.0638 13.91 440025 ..... 01.2064 13.85 440151 ..... 01.3017 17.69 450055 ..... 01.0921 12.18 450165 ..... 01.0931 13.25

430008 ..... 01.1481 16.06 440029 ..... 01.3155 17.57 440152 ..... 01.8871 18.01 450056 ..... 01.6523 16.13 450166 ..... 00.9365 10.68

430010 ..... 01.1348 14.54 440030 ..... 01.2445 13.96 440153 ..... 01.2219 16.01 450058 ..... 01.6081 16.97 450169 ..... 00.7896 12.56

430011 ..... 01.2481 15.59 440031 ..... 01.0365 13.97 440156 ..... 01.5838 22.45 450059 ..... 01.3520 13.67 450170 ..... 00.9586 11.25

430012 ..... 01.3134 16.94 440032 ..... 01.0487 14.25 440157 ..... 01.0574 15.33 450063 ..... 00.9136 12.64 450176 ..... 01.3488 14.31

430013 ..... 01.2626 16.44 440033 ..... 01.1447 11.81 440159 ..... 01.3462 13.80 450064 ..... 01.4496 15.32 450177 ..... 01.2792 13.51

430014 ..... 01.3447 18.19 440034 ..... 01.5652 19.30 440161 ..... 01.9004 19.94 450065 ..... 01.1111 19.22 450178 ..... 00.9692 13.80

430015 ..... 01.1468 16.06 440035 ..... 01.2851 17.56 440166 ..... 01.6175 18.67 450068 ..... 01.8913 24.40 450181 ..... 01.0425 19.19

430016 ..... 01.8285 18.86 440039 ..... 01.7990 18.40 440168 ..... 01.0818 16.29 450072 ..... 01.2252 19.03 450184 ..... 01.5030 23.29

430018 ..... 00.9273 14.23 440040 ..... 01.0268 14.47 440173 ..... 01.6639 17.92 450073 ..... 01.2014 18.74 450185 ..... 01.0475 10.84

430022 ..... 00.9234 11.69 440041 ..... 01.0192 12.50 440174 ..... 01.0421 15.12 450076 ..... 01.6720 .......... 450187 ..... 01.2512 19.67

430023 ..... 00.9009 11.59 440046 ..... 01.2308 14.28 440175 ..... 01.1542 17.31 450078 ..... 00.9841 09.74 450188 ..... 01.0367 14.02

430024 ..... 01.0343 14.51 440047 ..... 00.9274 16.03 440176 ..... 01.4262 19.42 450079 ..... 01.4681 20.51 450191 ..... 01.0301 19.15

430027 ..... 01.7770 18.58 440048 ..... 01.8485 16.82 440178 ..... 01.2426 22.63 450080 ..... 01.2200 17.44 450192 ..... 01.2312 17.99

430028 ..... 01.0635 15.50 440049 ..... 01.6623 17.56 440180 ..... 01.2421 16.19 450081 ..... 01.0655 15.61 450193 ..... 02.0166 22.67

430029 ..... 01.0237 15.69 440050 ..... 01.3806 16.99 440181 ..... 01.0545 10.98 450082 ..... 01.0038 13.31 450194 ..... 01.2934 20.99

430031 ..... 00.9251 12.23 440051 ..... 00.9613 14.08 440182 ..... 00.9998 16.20 450083 ..... 01.7323 19.48 450196 ..... 01.4438 17.07

430033 ..... 00.9805 13.99 440052 ..... 01.1465 15.14 440183 ..... 01.5912 20.71 450085 ..... 01.0847 12.24 450200 ..... 01.4043 14.95

430034 ..... 01.0590 12.76 440053 ..... 01.3823 17.37 440184 ..... 01.3803 19.32 450087 ..... 01.4908 17.64 450201 ..... 01.0004 17.33

430036 ..... 01.0975 12.56 440054 ..... 01.1902 13.52 440185 ..... 01.2481 18.83 450090 ..... 01.2450 13.44 450203 ..... 01.2382 18.28

430037 ..... 00.8770 14.57 440056 ..... 01.1204 14.40 440186 ..... 01.0953 17.87 450092 ..... 01.2228 12.47 450209 ..... 01.5951 18.25

430038 ..... 00.9865 11.26 440057 ..... 01.0459 12.35 440187 ..... 01.2081 15.76 450094 ..... 01.3052 .......... 450210 ..... 01.1066 13.17

430040 ..... 01.0299 13.59 440058 ..... 01.2301 15.98 440189 ..... 01.5755 18.56 450096 ..... 01.4605 16.91 450211 ..... 01.3831 16.37

430041 ..... 00.9403 14.87 440059 ..... 01.3550 13.94 440192 ..... 01.2296 16.54 450097 ..... 01.4472 18.03 450213 ..... 01.6843 16.75

430043 ..... 01.1676 12.87 440060 ..... 01.2762 16.56 440193 ..... 01.2803 17.93 450098 ..... 01.1799 16.58 450214 ..... 01.3531 19.24

430044 ..... 00.8239 16.48 440061 ..... 01.2361 17.43 440194 ..... 01.2787 22.50 450099 ..... 01.2415 17.53 450217 ..... 01.0704 11.12

430047 ..... 01.0575 14.80 440063 ..... 01.6979 18.02 440197 ..... 01.3863 19.25 450101 ..... 01.4681 16.40 450219 ..... 01.1743 12.93

430048 ..... 01.2187 17.49 440064 ..... 01.1639 17.44 440200 ..... 01.1095 16.93 450102 ..... 01.7052 17.78 450221 ..... 01.2410 19.52

430049 ..... 00.8976 13.24 440065 ..... 01.2574 19.20 440203 ..... 00.9488 14.18 450104 ..... 01.1807 14.62 450222 ..... 01.5738 17.18

430051 ..... 00.9900 16.00 440067 ..... 01.2538 17.02 440205 ..... 01.1295 14.78 450107 ..... 01.6561 19.78 450224 ..... 01.3931 21.57

430054 ..... 01.0254 13.60 440068 ..... 01.2810 17.51 440206 ..... 01.0269 17.93 450108 ..... 00.9943 13.51 450229 ..... 01.6431 15.88

430056 ..... 00.8484 13.33 440070 ..... 01.0737 15.47 440210 ..... 00.8638 .......... 450109 ..... 00.9201 14.10 450231 ..... 01.6402 17.02

430057 ..... 00.8887 13.52 440071 ..... 01.3827 15.29 440211 ..... 00.8634 .......... 450110 ..... 01.3519 18.61 450234 ..... 01.0158 11.70

430060 ..... 00.9648 09.05 440072 ..... 01.4283 17.03 450002 ..... 01.5007 16.67 450111 ..... 01.2674 19.21 450235 ..... 01.0278 13.81

430064 ..... 01.1062 13.30 440073 ..... 01.3083 18.15 450004 ..... 01.1706 13.46 450112 ..... 01.3283 14.83 450236 ..... 01.1414 12.89

430066 ..... 00.9328 12.75 440078 ..... 01.0126 12.13 450005 ..... 01.2847 14.90 450113 ..... 01.2951 16.69 450237 ..... 01.5569 16.22

430073 ..... 01.0259 15.30 440081 ..... 01.1637 14.99 450007 ..... 01.2371 18.19 450118 ..... 01.5992 18.24 450239 ..... 01.0932 16.23

430076 ..... 00.9397 11.72 440082 ..... 02.0438 21.84 450008 ..... 01.3035 15.35 450119 ..... 01.4448 19.05 450241 ..... 00.9370 17.05

430077 ..... 01.6490 17.05 440083 ..... 01.1524 12.07 450010 ..... 01.3484 15.69 450121 ..... 01.5409 18.89 450243 ..... 00.9835 11.45

430079 ..... 00.9894 13.32 440084 ..... 01.1534 13.82 450011 ..... 01.5105 16.02 450123 ..... 01.1160 18.35 450249 ..... 00.9517 10.86

430081 ..... 00.8564 .......... 440091 ..... 01.6220 18.42 450014 ..... 01.0623 15.48 450124 ..... 01.7023 18.45 450250 ..... 00.9991 15.66

430082 ..... 00.9185 .......... 440100 ..... 01.0732 14.88 450015 ..... 01.6551 16.86 450126 ..... 01.4337 17.01 450253 ..... 01.1681 12.65

430083 ..... 00.7926 .......... 440102 ..... 01.1389 13.79 450016 ..... 01.5914 18.01 450128 ..... 01.2114 13.18 450258 ..... 01.0492 12.74

430084 ..... 00.8631 .......... 440103 ..... 01.2114 17.04 450018 ..... 01.4744 20.02 450130 ..... 01.4736 18.04 450264 ..... 00.8597 15.18

430085 ..... 00.8586 .......... 440104 ..... 01.6329 18.95 450020 ..... 00.9726 16.92 450131 ..... 01.2712 20.21 450269 ..... 01.0555 15.78

430087 ..... 00.7737 10.24 440105 ..... 01.5362 15.40 450021 ..... 01.8369 20.79 450132 ..... 01.6805 17.53 450270 ..... 01.2103 11.06

430089 ..... 00.8702 .......... 440109 ..... 01.1650 13.89 450023 ..... 01.4090 17.41 450133 ..... 01.6198 14.09 450271 ..... 01.2446 15.37

430090 ..... 01.6368 .......... 440110 ..... 01.0533 16.25 450024 ..... 01.3806 17.30 450135 ..... 01.6577 19.58 450272 ..... 01.3032 15.86

430091 ..... 01.2774 .......... 440111 ..... 01.3627 20.00 450025 ..... 01.4884 16.75 450137 ..... 01.5282 21.67 450276 ..... 01.0699 12.98

440001 ..... 01.1359 14.55 440114 ..... 01.0912 14.77 450028 ..... 01.5646 18.21 450140 ..... 00.9498 11.63 450278 ..... 00.9644 12.52

440002 ..... 01.6162 17.64 440115 ..... 01.0532 15.54 450029 ..... 01.5963 15.23 450143 ..... 00.9918 12.21 450280 ..... 01.5125 18.38

440003 ..... 01.2559 17.39 440120 ..... 01.5957 18.89 450031 ..... 01.4996 18.63 450144 ..... 01.0331 12.01 450283 ..... 01.0389 12.79

440006 ..... 01.4841 18.92 440125 ..... 01.5453 18.50 450032 ..... 01.3522 13.79 450145 ..... 00.8532 14.34 450288 ..... 01.1750 15.16

440007 ..... 01.0194 10.84 440130 ..... 01.1768 14.86 450033 ..... 01.6513 17.18 450146 ..... 01.0084 23.62 450289 ..... 01.4006 17.39

440008 ..... 00.9915 14.52 440131 ..... 01.1562 14.49 450034 ..... 01.6287 18.76 450147 ..... 01.3928 16.89 450292 ..... 01.1576 19.69

440009 ..... 01.2565 14.35 440132 ..... 01.1233 13.67 450035 ..... 01.4187 19.20 450148 ..... 01.2800 19.65 450293 ..... 00.9323 12.72

440010 ..... 00.9659 12.64 440133 ..... 01.5603 19.98 450037 ..... 01.6096 18.97 450149 ..... 01.5185 19.99 450296 ..... 01.4152 19.20
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25635

PAGE 14 OF 15

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

450299 ..... 01.4072 17.64 450508 ..... 01.3603 17.56 450666 ..... 01.3312 17.90 450795 ..... 01.1350 11.54 470023 ..... 01.2895 20.23

450303 ..... 01.0154 09.91 450514 ..... 01.1700 21.10 450668 ..... 01.5943 20.06 450796 ..... 01.1114 18.43 470024 ..... 01.1727 19.52

450306 ..... 01.3057 13.64 450517 ..... 00.9399 10.56 450669 ..... 01.4186 18.58 450797 ..... 00.6077 20.39 490001 ..... 01.1946 22.18

450307 ..... 00.8801 14.50 450518 ..... 01.5820 18.69 450670 ..... 01.3482 19.53 450798 ..... 00.8050 13.86 490002 ..... 01.1337 13.48

450309 ..... 01.0743 11.89 450523 ..... 01.5399 20.21 450672 ..... 01.6957 15.51 450801 ..... 01.4763 15.51 490003 ..... 00.6057 17.48

450315 ..... 01.0586 19.19 450530 ..... 01.2367 14.42 450673 ..... 01.0679 13.71 450802 ..... 01.3938 21.70 490004 ..... 01.2252 17.71

450320 ..... 01.2414 18.72 450534 ..... 00.9886 15.40 450674 ..... 01.2022 19.92 450803 ..... 00.9037 14.23 490005 ..... 01.5926 15.95

450321 ..... 00.9614 13.82 450535 ..... 01.2414 21.39 450675 ..... 01.4594 18.09 450804 ..... 01.7378 18.83 490006 ..... 01.1499 14.40

450322 ..... 00.6639 17.10 450537 ..... 01.3383 20.33 450677 ..... 01.3331 18.92 450807 ..... 00.8978 09.72 490007 ..... 02.0606 17.85

450324 ..... 01.6384 16.95 450539 ..... 01.4022 16.04 450678 ..... 01.4407 20.79 450808 ..... 01.2265 20.55 490009 ..... 01.9210 21.78

450327 ..... 01.0202 15.94 450544 ..... 01.2272 18.82 450683 ..... 01.3459 16.70 450809 ..... 01.6064 11.29 490010 ..... 01.1786 18.22

450330 ..... 01.1889 17.95 450545 ..... 01.2791 10.16 450684 ..... 01.2082 18.70 450810 ..... 00.9015 .......... 490011 ..... 01.4566 17.62

450334 ..... 01.0427 12.16 450547 ..... 01.1421 14.03 450686 ..... 01.5023 14.59 450811 ..... 02.1718 .......... 490012 ..... 01.2121 13.77

450337 ..... 01.1368 15.71 450551 ..... 01.0935 11.37 450688 ..... 01.3506 18.63 450812 ..... 01.4107 .......... 490013 ..... 01.2228 16.47

450340 ..... 01.4648 13.10 450558 ..... 01.8402 18.19 450690 ..... 01.4263 17.85 450813 ..... 00.9625 .......... 490014 ..... 01.5159 22.68

450341 ..... 01.0639 17.56 450561 ..... 01.6276 17.05 450694 ..... 01.1099 20.41 460001 ..... 01.7571 20.72 490015 ..... 01.4427 21.35

450346 ..... 01.5308 16.52 450563 ..... 01.2546 26.74 450696 ..... 01.8786 18.73 460003 ..... 01.6596 13.31 490017 ..... 01.3665 14.05

450347 ..... 01.1688 17.43 450565 ..... 01.2517 16.37 450697 ..... 01.5484 15.64 460004 ..... 01.7671 21.27 490018 ..... 01.3418 17.01

450348 ..... 01.0269 11.60 450570 ..... 01.0924 15.62 450698 ..... 00.9596 13.36 460005 ..... 01.6688 17.23 490019 ..... 01.2321 16.49

450351 ..... 01.2346 20.05 450571 ..... 01.4622 16.04 450700 ..... 01.0540 13.52 460006 ..... 01.3436 19.96 490020 ..... 01.2247 16.07

450352 ..... 01.2368 17.88 450573 ..... 01.0277 13.94 450702 ..... 01.5379 17.73 460007 ..... 01.4903 20.38 490021 ..... 01.3831 18.08

450353 ..... 01.2532 18.38 450574 ..... 00.9377 11.77 450703 ..... 01.5073 10.03 460008 ..... 01.4270 16.77 490022 ..... 01.4805 20.25

450355 ..... 01.1328 14.56 450575 ..... 01.0523 17.94 450704 ..... 01.3187 18.39 460009 ..... 01.8533 20.44 490023 ..... 01.2675 18.77

450358 ..... 02.0759 22.13 450578 ..... 00.9641 14.60 450705 ..... 00.8680 17.81 460010 ..... 02.0765 21.33 490024 ..... 01.8219 17.17

450362 ..... 01.0834 14.11 450580 ..... 01.1420 14.05 450706 ..... 01.3743 20.77 460011 ..... 01.4411 15.69 490027 ..... 01.1416 14.52

450369 ..... 01.0290 11.76 450583 ..... 01.0040 11.81 450709 ..... 01.2530 18.28 460013 ..... 01.4727 18.36 490030 ..... 01.1740 11.44

450370 ..... 01.1810 09.42 450584 ..... 01.1354 12.88 450711 ..... 01.6382 26.65 460014 ..... 01.3196 16.46 490031 ..... 01.1290 13.85

450371 ..... 01.3147 12.05 450586 ..... 01.0874 12.54 450712 ..... 00.7382 11.77 460015 ..... 01.2639 19.92 490032 ..... 01.7735 19.88

450372 ..... 01.2321 21.35 450587 ..... 01.2170 17.55 450713 ..... 01.5244 20.73 460016 ..... 00.9270 16.64 490033 ..... 01.1962 17.39

450373 ..... 01.1823 18.71 450591 ..... 01.2310 17.41 450715 ..... 01.4406 18.46 460017 ..... 01.4957 17.56 490035 ..... 01.0236 07.57

450374 ..... 00.9860 12.21 450596 ..... 01.3163 18.97 450716 ..... 01.3997 19.33 460018 ..... 00.9784 16.10 490037 ..... 01.1888 14.88

450378 ..... 01.0667 21.41 450597 ..... 01.0268 13.68 450717 ..... 01.3232 22.11 460019 ..... 01.1733 16.25 490038 ..... 01.2703 14.98

450379 ..... 01.5480 20.94 450603 ..... 00.7219 14.21 450718 ..... 01.2781 17.49 460020 ..... 00.9866 17.05 490040 ..... 01.4415 21.70

450381 ..... 01.0325 13.87 450604 ..... 01.3496 14.64 450723 ..... 01.4075 18.75 460021 ..... 01.3876 20.12 490041 ..... 01.2682 16.01

450388 ..... 01.8150 15.21 450605 ..... 01.2166 16.69 450724 ..... 01.3091 18.28 460022 ..... 00.9246 18.19 490042 ..... 01.3042 16.38

450389 ..... 01.2994 14.80 450609 ..... 00.8719 12.26 450725 ..... 01.0043 19.85 460023 ..... 01.2160 20.38 490043 ..... 01.3803 19.82

450393 ..... 01.3200 11.86 450610 ..... 01.4645 18.06 450727 ..... 01.0811 16.87 460025 ..... 00.8007 20.08 490044 ..... 01.3514 17.17

450395 ..... 01.0597 16.54 450614 ..... 01.0531 12.79 450728 ..... 00.8837 07.46 460026 ..... 01.0552 17.32 490045 ..... 01.2228 19.98

450399 ..... 00.9655 11.15 450615 ..... 01.1326 12.36 450730 ..... 01.2614 21.03 460027 ..... 00.8883 20.44 490046 ..... 01.5215 17.89

450400 ..... 01.1933 13.63 450617 ..... 01.3492 19.91 450733 ..... 01.6021 15.09 460029 ..... 01.0308 17.00 490047 ..... 01.1505 16.65

450403 ..... 01.3197 19.63 450620 ..... 01.1109 12.27 450735 ..... 00.9833 13.78 460030 ..... 01.1423 16.55 490048 ..... 01.5931 17.94

450411 ..... 00.9264 13.09 450623 ..... 01.2008 18.97 450742 ..... 01.2757 20.17 460032 ..... 01.0597 19.39 490050 ..... 01.4805 20.95

450417 ..... 01.2299 15.17 450626 ..... 01.0125 16.38 450743 ..... 01.4277 17.77 460033 ..... 00.9172 17.19 490052 ..... 01.6347 16.26

450418 ..... 01.4876 21.54 450628 ..... 00.9890 17.19 450746 ..... 01.0074 14.71 460035 ..... 00.9441 12.43 490053 ..... 01.3129 15.12

450419 ..... 01.2224 20.33 450630 ..... 01.6105 19.66 450747 ..... 01.3436 17.58 460036 ..... 01.0266 20.56 490054 ..... 01.0153 15.45

450422 ..... 00.8593 25.07 450631 ..... 01.6903 13.59 450749 ..... 00.9909 14.54 460037 ..... 00.9572 18.38 490057 ..... 01.5481 18.87

450423 ..... 01.4768 22.62 450632 ..... 01.0398 11.43 450750 ..... 01.0134 12.54 460039 ..... 01.0909 23.84 490059 ..... 01.6281 19.99

450424 ..... 01.2921 16.39 450633 ..... 01.5622 12.13 450751 ..... 01.3102 19.24 460041 ..... 01.3319 20.51 490060 ..... 01.1169 18.19

450429 ..... 01.0852 12.33 450634 ..... 01.7215 23.78 450754 ..... 00.9192 13.20 460042 ..... 01.4554 14.11 490063 ..... 01.7955 23.28

450431 ..... 01.6026 18.46 450638 ..... 01.5546 25.20 450755 ..... 01.1391 17.26 460043 ..... 00.9829 21.91 490066 ..... 01.2905 20.77

450438 ..... 01.2764 13.12 450639 ..... 01.4457 23.25 450757 ..... 00.9009 13.23 460044 ..... 01.1823 20.42 490067 ..... 01.2750 16.60

450446 ..... 00.7248 15.16 450641 ..... 01.0829 17.56 450758 ..... 01.9407 19.90 460046 ..... 01.9599 17.71 490069 ..... 01.4205 14.56

450447 ..... 01.3800 17.19 450643 ..... 01.2095 15.10 450760 ..... 01.2017 18.55 460047 ..... 01.7392 19.91 490071 ..... 01.4266 17.71

450451 ..... 01.1660 15.20 450644 ..... 01.5151 18.19 450761 ..... 01.0213 11.87 460049 ..... 02.0096 19.97 490073 ..... 01.4914 22.82

450457 ..... 01.7808 18.77 450646 ..... 01.5429 20.32 450763 ..... 00.9975 17.58 460050 ..... 01.3199 19.33 490074 ..... 01.4074 17.39

450460 ..... 01.0157 12.81 450647 ..... 01.9096 20.84 450766 ..... 02.0886 21.59 460051 ..... 01.2227 13.29 490075 ..... 01.4408 18.79

450462 ..... 01.7455 16.26 450648 ..... 00.9381 12.65 450769 ..... 00.8730 11.77 470001 ..... 01.2556 20.25 490077 ..... 01.2421 19.03

450464 ..... 01.0024 12.89 450649 ..... 00.9870 14.53 450770 ..... 01.0213 15.47 470003 ..... 01.8563 19.92 490079 ..... 01.3591 15.64

450465 ..... 01.3399 15.41 450651 ..... 01.7586 19.35 450771 ..... 01.7967 16.42 470004 ..... 01.1211 15.87 490084 ..... 01.2514 16.34

450467 ..... 00.9850 17.15 450652 ..... 00.8798 14.52 450774 ..... 01.6108 20.17 470005 ..... 01.2357 21.12 490085 ..... 01.2505 15.31

450469 ..... 01.4058 19.15 450653 ..... 01.1829 16.63 450775 ..... 01.3187 41.14 470006 ..... 01.2066 17.97 490088 ..... 01.1793 16.50

450473 ..... 01.0205 14.61 450654 ..... 00.9596 10.61 450776 ..... 00.9848 10.16 470008 ..... 01.2542 17.91 490089 ..... 01.1277 16.41

450475 ..... 01.1210 13.56 450656 ..... 01.4624 18.35 450777 ..... 00.9836 16.72 470010 ..... 01.1439 19.71 490090 ..... 01.1658 16.31

450484 ..... 01.4951 19.64 450658 ..... 00.9767 12.49 450779 ..... 01.2890 22.50 470011 ..... 01.1753 20.37 490091 ..... 01.2201 19.80

450488 ..... 01.3238 17.72 450659 ..... 01.5010 21.19 450780 ..... 01.6074 16.21 470012 ..... 01.2872 18.28 490092 ..... 01.2429 15.01

450489 ..... 01.0359 13.90 450661 ..... 01.1973 21.13 450785 ..... 00.9638 18.31 470015 ..... 01.1589 19.34 490093 ..... 01.3892 15.78

450497 ..... 01.1631 14.82 450662 ..... 01.6029 16.56 450788 ..... 01.5172 16.06 470018 ..... 01.2011 20.89 490094 ..... 01.1193 16.40

450498 ..... 00.9818 12.66 450665 ..... 00.9015 13.23 450794 ..... 01.4587 16.66 470020 ..... 00.9543 16.28 490095 ..... 01.4744 17.31
25636 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

PAGE 15 OF 15

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

Provider

Case

mix

index

Avg.

hour

wage

490097 ..... 01.2401 15.08 500055 ..... 01.1102 22.34 510030 ..... 01.0609 15.76 520045 ..... 01.6699 18.60 520144 ..... 01.0176 16.36

490098 ..... 01.2771 13.23 500057 ..... 01.2911 17.73 510031 ..... 01.4605 16.76 520047 ..... 00.9944 17.42 520145 ..... 00.9470 16.85

490099 ..... 00.9704 16.66 500058 ..... 01.5107 21.64 510033 ..... 01.3690 16.31 520048 ..... 01.4624 18.04 520146 ..... 01.0694 15.76

490100 ..... 01.5522 18.36 500059 ..... 01.0873 22.72 510035 ..... 01.3504 18.82 520049 ..... 01.9631 19.12 520148 ..... 01.1567 16.73

490101 ..... 01.2218 23.44 500060 ..... 01.4688 23.67 510036 ..... 01.0367 12.45 520051 ..... 01.8043 15.77 520149 ..... 00.9333 12.72

490104 ..... 00.8484 21.14 500061 ..... 01.0054 20.43 510038 ..... 01.1249 14.36 520053 ..... 01.1564 15.87 520151 ..... 01.0435 16.58

490105 ..... 00.5902 30.04 500062 ..... 01.1028 19.07 510039 ..... 01.3356 15.69 520054 ..... 01.0412 19.44 520152 ..... 01.1259 17.97

490106 ..... 00.8464 21.07 500064 ..... 01.6849 24.85 510043 ..... 00.9429 14.14 520057 ..... 01.1771 18.10 520153 ..... 00.9590 14.95

490107 ..... 01.3556 22.35 500065 ..... 01.2258 20.87 510046 ..... 01.3048 17.25 520058 ..... 01.1268 20.40 520154 ..... 01.1615 18.07

490108 ..... 00.9494 19.84 500068 ..... 01.0622 18.61 510047 ..... 01.2964 18.83 520059 ..... 01.3542 19.76 520156 ..... 01.1721 19.10

490109 ..... 00.9167 20.38 500069 ..... 01.1722 19.05 510048 ..... 01.1292 18.03 520060 ..... 01.4225 17.08 520157 ..... 01.0942 15.30

490110 ..... 01.3455 15.76 500071 ..... 01.3952 20.91 510050 ..... 01.6030 16.38 520062 ..... 01.3120 17.21 520159 ..... 00.9415 19.52

490111 ..... 01.2018 15.96 500072 ..... 01.2463 24.49 510053 ..... 01.0108 14.63 520063 ..... 01.2008 19.95 520160 ..... 01.7765 19.26

490112 ..... 01.6587 19.70 500073 ..... 01.0093 18.07 510055 ..... 01.2826 22.31 520064 ..... 01.5671 20.70 520161 ..... 01.0404 17.96

490113 ..... 01.2995 22.73 500074 ..... 01.0970 18.46 510058 ..... 01.2636 17.21 520066 ..... 01.5292 19.84 520170 ..... 01.2542 21.23

490114 ..... 01.1138 15.90 500077 ..... 01.3337 22.82 510059 ..... 02.4160 15.98 520068 ..... 00.9889 18.59 520171 ..... 00.9070 14.86

490115 ..... 01.1964 16.62 500079 ..... 01.3407 21.42 510060 ..... 01.0691 15.10 520069 ..... 01.1861 18.14 520173 ..... 01.1585 19.58

490116 ..... 01.1887 16.24 500080 ..... 00.8399 13.35 510061 ..... 01.0314 13.59 520070 ..... 01.5734 17.44 520177 ..... 01.6324 19.38

490117 ..... 01.1938 10.57 500084 ..... 01.2536 21.57 510062 ..... 01.2784 17.15 520071 ..... 01.2420 18.44 520178 ..... 01.1172 16.98

490118 ..... 01.7261 20.56 500085 ..... 01.0506 18.46 510066 ..... 01.1573 13.24 520074 ..... 01.0372 16.81 520187 ..... 00.2986 ..........

490119 ..... 01.4062 17.02 500086 ..... 01.3459 21.47 510067 ..... 01.1882 16.39 520075 ..... 01.4602 18.96 530002 ..... 01.2253 21.84

490120 ..... 01.3763 17.93 500088 ..... 01.3211 23.74 510068 ..... 01.1347 15.46 520076 ..... 01.1673 16.36 530003 ..... 00.8835 14.70

490122 ..... 01.4040 22.46 500089 ..... 01.0985 16.55 510070 ..... 01.3876 15.31 520077 ..... 00.9774 14.51 530004 ..... 00.9574 14.14

490123 ..... 01.1230 15.45 500090 ..... 00.9182 14.04 510071 ..... 01.3472 15.76 520078 ..... 01.6274 18.24 530005 ..... 01.0465 14.61

490124 ..... 01.1222 15.81 500092 ..... 00.9896 19.29 510072 ..... 01.0515 13.30 520082 ..... 01.2908 17.60 530006 ..... 01.1196 20.18

490126 ..... 01.4055 16.47 500094 ..... 00.9176 17.96 510077 ..... 01.1535 15.63 520083 ..... 01.7091 21.38 530007 ..... 01.1095 14.87

490127 ..... 01.0287 16.05 500096 ..... 01.0080 18.80 510080 ..... 01.2046 16.32 520084 ..... 01.0866 17.62 530008 ..... 01.2996 13.79

490129 ..... 01.0607 23.65 500097 ..... 01.1573 19.47 510081 ..... 01.1996 13.50 520087 ..... 01.7203 18.61 530009 ..... 00.9922 18.12

490130 ..... 01.2347 15.72 500098 ..... 01.0903 14.96 510082 ..... 01.2149 13.50 520088 ..... 01.2637 18.97 530010 ..... 01.2158 18.65

490132 ..... 01.0026 .......... 500101 ..... 00.9755 19.08 510084 ..... 00.9664 12.91 520089 ..... 01.4904 20.44 530011 ..... 01.1586 17.22

500001 ..... 01.4111 21.97 500102 ..... 00.9657 20.71 510085 ..... 01.3282 17.98 520090 ..... 01.2889 17.51 530012 ..... 01.5605 18.08

500002 ..... 01.4114 21.64 500104 ..... 01.1802 22.63 510086 ..... 01.1820 13.59 520091 ..... 01.3199 19.68 530014 ..... 01.4027 19.27

500003 ..... 01.4119 24.03 500106 ..... 00.9602 19.85 520002 ..... 01.2720 18.86 520092 ..... 01.1556 16.83 530015 ..... 01.2690 19.02

500005 ..... 01.8033 21.24 500107 ..... 01.2297 16.68 520003 ..... 01.0633 15.78 520094 ..... 00.7870 19.19 530016 ..... 01.2999 17.19

500007 ..... 01.3070 23.24 500108 ..... 01.7227 20.48 520004 ..... 01.1862 18.46 520095 ..... 01.3843 19.38 530017 ..... 00.8709 15.80

500008 ..... 01.9296 25.09 500110 ..... 01.1878 20.80 520006 ..... 01.0492 20.59 520096 ..... 01.3993 18.60 530018 ..... 01.0972 16.71

500011 ..... 01.3263 22.98 500118 ..... 01.1808 22.66 520007 ..... 01.0781 14.87 520097 ..... 01.2965 19.05 530019 ..... 01.0350 11.26

500012 ..... 01.5418 22.34 500119 ..... 01.3050 21.86 520008 ..... 01.6437 22.59 520098 ..... 01.8306 20.96 530022 ..... 01.1106 17.60

500014 ..... 01.5358 22.94 500122 ..... 01.2794 22.76 520009 ..... 01.6467 18.07 520100 ..... 01.2826 18.08 530023 ..... 00.8946 19.55

500015 ..... 01.4382 22.41 500123 ..... 00.8946 16.33 520010 ..... 01.2081 20.01 520101 ..... 01.0947 17.84 530025 ..... 01.2196 21.13

500016 ..... 01.5256 24.13 500124 ..... 01.3290 23.72 520011 ..... 01.2493 19.33 520102 ..... 01.1586 09.85 530026 ..... 01.1680 21.55

500019 ..... 01.3845 22.33 500125 ..... 01.1430 15.98 520013 ..... 01.3654 19.29 520103 ..... 01.3295 18.39 530027 ..... 00.9464 32.50

500021 ..... 01.4791 18.72 500129 ..... 01.7655 23.34 520014 ..... 01.1483 16.47 520107 ..... 01.3313 18.69 530029 ..... 01.0347 14.86

500023 ..... 01.2237 21.48 500132 ..... 00.9488 17.26 520015 ..... 01.1656 17.59 520109 ..... 00.9890 18.27 530031 ..... 00.8621 18.36

500024 ..... 01.6929 25.17 500134 ..... 00.5730 17.47 520016 ..... 01.1202 12.53 520110 ..... 01.2401 18.59 530032 ..... 01.0887 20.69

500025 ..... 01.8624 25.48 500138 ..... 06.3328 .......... 520017 ..... 01.1603 18.49 520111 ..... 00.9933 17.44

500026 ..... 01.4298 24.13 500139 ..... 01.4946 20.62 520018 ..... 01.1396 17.51 520112 ..... 01.1309 17.67

500027 ..... 01.6083 25.89 500141 ..... 01.3409 22.31 520019 ..... 01.3102 19.27 520113 ..... 01.2560 19.14

500028 ..... 01.1018 17.84 500143 ..... 00.5980 15.77 520021 ..... 01.3145 19.71 520114 ..... 01.1466 15.59

500029 ..... 00.9778 17.28 500146 ..... 01.1943 17.52 520024 ..... 01.1085 13.94 520115 ..... 01.2493 17.57

500030 ..... 01.4685 23.64 510001 ..... 01.8062 18.22 520025 ..... 01.1185 16.59 520116 ..... 01.2386 19.24

500031 ..... 01.3076 22.42 510002 ..... 01.3476 17.07 520026 ..... 01.0738 18.95 520117 ..... 01.0212 17.30

500033 ..... 01.3568 20.98 510005 ..... 00.9799 14.53 520027 ..... 01.2317 20.05 520118 ..... 00.8786 12.73

500036 ..... 01.3789 20.93 510006 ..... 01.2876 17.40 520028 ..... 01.4023 20.17 520120 ..... 00.8917 16.22

500037 ..... 01.1777 20.35 510007 ..... 01.5321 19.91 520029 ..... 00.9252 17.80 520121 ..... 00.9810 16.30

500039 ..... 01.3856 22.97 510008 ..... 01.2363 16.30 520030 ..... 01.6637 20.22 520122 ..... 01.0140 16.52

500041 ..... 01.2891 24.11 510012 ..... 01.0194 15.51 520031 ..... 01.1181 15.70 520123 ..... 01.0617 17.45

500042 ..... 01.4113 21.93 510013 ..... 01.1629 16.85 520032 ..... 01.1645 16.87 520124 ..... 01.0920 16.50

500043 ..... 01.0687 19.43 510015 ..... 01.0179 13.81 520033 ..... 01.2055 17.42 520130 ..... 01.0256 14.89

500044 ..... 01.9209 23.59 510018 ..... 01.1368 14.07 520034 ..... 01.0827 17.18 520131 ..... 01.0431 17.56

500045 ..... 01.0517 22.10 510020 ..... 01.0662 12.22 520035 ..... 01.3492 17.15 520132 ..... 01.1994 17.01

500048 ..... 00.9665 19.03 510022 ..... 01.8733 19.32 520037 ..... 01.6601 19.33 520134 ..... 01.0791 16.37

500049 ..... 01.5515 22.21 510023 ..... 01.2461 15.36 520038 ..... 01.3396 17.69 520135 ..... 00.9793 24.20

500050 ..... 01.3757 20.94 510024 ..... 01.4907 18.04 520039 ..... 01.0178 18.09 520136 ..... 01.5411 19.31

500051 ..... 01.6476 24.14 510026 ..... 01.0369 13.05 520040 ..... 01.4388 19.39 520138 ..... 01.8963 19.63

500052 ..... 01.2052 .......... 510027 ..... 00.9899 16.49 520041 ..... 01.1377 15.58 520139 ..... 01.2903 20.36

500053 ..... 01.3356 21.20 510028 ..... 01.1102 14.91 520042 ..... 01.1067 17.13 520140 ..... 01.6170 19.69

500054 ..... 01.8578 22.51 510029 ..... 01.2666 16.61 520044 ..... 01.4365 17.04 520142 ..... 00.8928 16.53

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.
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25637

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS

Urban area

(Constituent counties)

Wage

index GAF

0040 Abilene, TX ........ 0.8081 0.8642

Taylor, TX

0060 Aguadilla, PR ..... 0.4772 0.6025

Aguada, PR

Aguadilla, PR

Moca, PR

0080 Akron, OH .......... 1.0011 1.0008

Portage, OH

Summit, OH

0120 Albany, GA ........ 0.8098 0.8655

Dougherty, GA

Lee, GA

0160 2Albany-Schenectady-Troy, NY ...... 0.8640 0.9047

Albany, NY

Montgomery, NY

Rensselaer, NY

Saratoga, NY

Schenectady, NY

Schoharie, NY

0200 Albuquerque, NM 0.8813 0.9171

Bernalillo, NM

Sandoval, NM

Valencia, NM

0220 Alexandria, LA ... 0.8598 0.9017

Rapides, LA

0240 Allentown-Bethlehem-Easton, PA ..... 1.0219 1.0149

Carbon, PA

Lehigh, PA

Northampton, PA

0280 Altoona, PA ....... 0.9398 0.9584

Blair, PA

0320 Amarillo, TX ....... 0.8483 0.8935

Potter, TX

Randall, TX

0380 Anchorage, AK .. 1.3088 1.2024

Anchorage, AK

0440 Ann Arbor, MI .... 1.1127 1.0759

Lenawee, MI

Livingston, MI

Washtenaw, MI

0450 Anniston, AL ...... 0.8731 0.9113

Calhoun, AL

0460 Appleton-Oshkosh-Neenah, WI ....... 0.8899 0.9232

Calumet, WI

Outagamie, WI

Winnebago, WI

0470 Arecibo, PR ....... 0.4915 0.6148

Arecibo, PR

Camuy, PR

Hatillo, PR

0480 Asheville, NC ..... 0.9016 0.9315

Buncombe, NC

Madison, NC

0500 Athens, GA ........ 0.8746 0.9123

Clarke, GA

Madison, GA

Oconee, GA

0520 1Atlanta, GA ...... 1.0024 1.0016

Barrow, GA

Bartow, GA

Carroll, GA

Cherokee, GA

Clayton, GA

Cobb, GA

Coweta, GA

DeKalb, GA

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

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 ..................... 1.0442 1.0301

Atlantic, NJ

Cape May, NJ

0600 Augusta-Aiken,

GA–SC ...................... 0.9309 0.9521

Columbia, GA

McDuffie, GA

Richmond, GA

Aiken, SC

Edgefield, SC

0640 1Austin-San

Marcos, TX ................ 0.8158 0.8699

Bastrop, TX

Caldwell, TX

Hays, TX

Travis, TX

Williamson, TX

0680 2Bakersfield, CA 0.9976 0.9984

Kern, CA

0720 1Baltimore, MD 0.9760 0.9835

Anne Arundel, MD

Baltimore, MD

Baltimore City, MD

Carroll, MD

Harford, MD

Howard, MD

Queen Anne’s, MD

0733 2Bangor, ME ..... 0.8538 0.8974

Penobscot, ME

0743 Barnstable-Yarmouth, MA ................. 1.5644 1.3586

Barnstable, MA

0760 Baton Rouge, LA 0.8940 0.9261

Ascension, LA

East Baton Rouge, LA

Livingston, LA

West Baton Rouge,

LA

0840 Beaumont-Port

Arthur, TX .................. 0.8660 0.9062

Hardin, TX

Jefferson, TX

Orange, TX

0860 Bellingham, WA 1.1475 1.0988

Whatcom, WA

0870 2Benton Harbor,

MI ............................... 0.8988 0.9295

Berrien, MI

0875 1Bergen-Passaic, NJ ...................... 1.1845 1.1229

Bergen, NJ

Passaic, NJ

0880 Billings, MT ........ 0.9220 0.9459

Yellowstone, MT

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

0920 Biloxi-GulfportPascagoula, MS ........ 0.8291 0.8796

Hancock, MS

Harrison, MS

Jackson, MS

0960 Binghamton, NY 0.9103 0.9377

Broome, NY

Tioga, NY

1000 Birmingham, AL 0.9150 0.9410

Blount, AL

Jefferson, AL

St. Clair, AL

Shelby, AL

1010 Bismarck, ND .... 0.8015 0.8594

Burleigh, ND

Morton, ND

1020 Bloomington, IN 0.9041 0.9333

Monroe, IN

1040 Bloomington-Normal, IL ........................ 0.8926 0.9251

McLean, IL

1080 Boise City, ID .... 0.9267 0.9492

Ada, ID

Canyon, ID

1123 1 2BostonWorcester-LawrenceLowell-Brockton, MA–

NH (Massachusetts

Hospitals) ................... 1.0917 1.0619

Bristol, MA

Essex, MA

Middlesex, MA

Norfolk, MA

Plymouth, MA

Suffolk, MA

Worcester, MA

Hillsborough, NH

Merrimack, NH

Rockingham, NH

Strafford, NH

1123 1Boston-Worcester-Lawrence-LowellBrockton, MA–NH

(New Hampshire Hospitals) ......................... 1.0885 1.0598

Bristol, MA

Essex, MA

Middlesex, MA

Norfolk, MA

Plymouth, MA

Suffolk, MA

Worcester, MA

Hillsborough, NH

Merrimack, NH

Rockingham, NH

Strafford, NH

1125 BoulderLongmont, CO ........... 1.0122 1.0083

Boulder, CO

1145 Brazoria, TX ...... 0.8895 0.9229

Brazoria, TX

1150 Bremerton, WA .. 1.1148 1.0773

Kitsap, WA

1240 Brownsville-Harlingen-San Benito, TX 0.8291 0.8796

Cameron, TX

1260 Bryan-College

Station, TX ................. 0.7962 0.8555
25638 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

Brazos, TX

1280 1Buffalo-Niagara

Falls, NY .................... 0.9592 0.9719

Erie, NY

Niagara, NY

1303 Burlington, VT .... 0.9612 0.9733

Chittenden, VT

Franklin, VT

Grand Isle, VT

1310 Caguas, PR ....... 0.4445 0.5739

Caguas, PR

Cayey, PR

Cidra, PR

Gurabo, PR

San Lorenzo, PR

1320 CantonMassillon, OH ............ 0.8895 0.9229

Carroll, OH

Stark, OH

1350 Casper, WY ....... 0.9227 0.9464

Natrona, WY

1360 Cedar Rapids, IA 0.8888 0.9224

Linn, IA

1400 Champaign-Urbana, IL ..................... 0.8844 0.9193

Champaign, IL

1440 Charleston-North

Charleston, SC .......... 0.8931 0.9255

Berkeley, SC

Charleston, SC

Dorchester, SC

1480 Charleston, WV 0.9042 0.9334

Kanawha, WV

Putnam, WV

1520 1 Charlotte-Gastonia-Rock Hill, NC–

SC .............................. 0.9568 0.9702

Cabarrus, NC

Gaston, NC

Lincoln, NC

Mecklenburg, NC

Rowan, NC

Stanly, NC

Union, NC

York, SC

1540 Charlottesville,

VA .............................. 1.0359 1.0244

Albemarle, VA

Charlottesville City,

VA

Fluvanna, VA

Greene, VA

1560 Chattanooga,

TN–GA ....................... 0.9123 0.9391

Catoosa, GA

Dade, GA

Walker, GA

Hamilton, TN

Marion, TN

1580 Cheyenne, WY .. 0.9354 0.9553

Laramie, WY

1600 1 Chicago, IL ...... 1.0507 1.0344

Cook, IL

DeKalb, IL

DuPage, IL

Grundy, IL

Kane, IL

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

Kendall, IL

Lake, IL

McHenry, IL

Will, IL

1620 Chico-Paradise,

CA .............................. 1.0231 1.0158

Butte, CA

1640 1 Cincinnati, OH–

KY–IN ........................ 0.9465 0.9630

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 ........ 0.8204 0.8732

Christian, KY

Montgomery, TN

1680 1 Cleveland-Lorain-Elyria, OH ........... 0.9970 0.9979

Ashtabula, OH

Cuyahoga, OH

Geauga, OH

Lake, OH

Lorain, OH

Medina, OH

1720 Colorado

Springs, CO ............... 0.9469 0.9633

El Paso, CO

1740 Columbia, MO ... 0.9678 0.9778

Boone, MO

1760 Columbia, SC .... 0.9368 0.9563

Lexington, SC

Richland, SC

1800 Columbus, GAAL .............................. 0.8573 0.8999

Russell, AL

Chattahoochee, GA

Harris, GA

Muscogee, GA

1840 1 Columbus, OH 0.9929 0.9951

Delaware, OH

Fairfield, OH

Franklin, OH

Licking, OH

Madison, OH

Pickaway, OH

1880 Corpus Christi,

TX .............................. 0.8112 0.8665

Nueces, TX

San Patricio, TX

1900 2 Cumberland,

MD–WV (Maryland

Hospitals) ................... 0.8627 0.9038

Allegany, MD

Mineral, WV

1900 Cumberland,

MD–WV (West Virginia Hospital) ............ 0.8407 0.8880

Allegany, MD

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

Mineral, WV

1920 1 Dallas, TX ........ 0.9149 0.9409

Collin, TX

Dallas, TX

Denton, TX

Ellis, TX

Henderson, TX

Hunt, TX

Kaufman, TX

Rockwall, TX

1950 Danville, VA ....... 0.9121 0.9389

Danville City, VA

Pittsylvania, VA

1960 Davenport-Moline-Rock Island, IA–

IL ................................ 0.8496 0.8944

Scott, IA

Henry, IL

Rock Island, IL

2000 Dayton-Springfield, OH .................... 0.9670 0.9773

Clark, OH

Greene, OH

Miami, OH

Montgomery, OH

2020 Daytona Beach,

FL .............................. 0.9211 0.9453

Flagler, FL

Volusia, FL

2030 Decatur, AL ....... 0.8302 0.8804

Lawrence, AL

Morgan, AL

2040 Decatur, IL ......... 0.8140 0.8686

Macon, IL

2080 1 Denver, CO ..... 1.0532 1.0361

Adams, CO

Arapahoe, CO

Denver, CO

Douglas, CO

Jefferson, CO

2120 Des Moines, IA .. 0.8576 0.9001

Dallas, IA

Polk, IA

Warren, IA

2160 1 Detroit, MI ........ 1.0601 1.0408

Lapeer, MI

Macomb, MI

Monroe, MI

Oakland, MI

St. Clair, MI

Wayne, MI

2180 Dothan, AL ........ 0.7827 0.8455

Dale, AL

Houston, AL

2190 Dover, DE .......... 0.9441 0.9614

Kent, DE

2200 Dubuque, IA ...... 0.8292 0.8796

Dubuque, IA

2240 Duluth-Superior,

MN–WI ....................... 1.0133 1.0091

St. Louis, MN

Douglas, WI

2281 Dutchess County, NY ......................... 0.9860 0.9904

Dutchess, NY

2290 Eau Claire, WI ... 0.8755 0.9130

Chippewa, WI
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25639

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

Eau Claire, WI

2320 El Paso, TX ....... 0.8978 0.9288

El Paso, TX

2330 Elkhart-Goshen,

IN ............................... 0.9168 0.9422

Elkhart, IN

2335 2Elmira, NY ....... 0.8640 0.9047

Chemung, NY

2340 Enid, OK ............ 0.8050 0.8620

Garfield, OK

2360 Erie, PA ............. 0.9343 0.9545

Erie, PA

2400 Eugene-Springfield, OR .................... 1.1288 1.0865

Lane, OR

2440 Evansville-Henderson, IN–KY ........... 0.8505 0.8950

Posey, IN

Vanderburgh, IN

Warrick, IN

Henderson, KY

2520 Fargo-Moorhead,

ND–MN (North Dakota Hospitals) ........... 0.7905 0.8513

Clay, MN

Cass, ND

2520 2Fargo-Moorhead, ND–MN (Minnesota Hospitals) ....... 0.8665 0.9065

Clay, MN

Cass, ND

2560 Fayetteville, NC 0.8460 0.8918

Cumberland, NC

2580 FayettevilleSpringdale-Rogers,

AR .............................. 0.8686 0.9080

Benton, AR

Washington, AR

2620 Flagstaff, AZ–UT 0.9602 0.9726

Coconino, AZ

Kane, UT

2640 Flint, MI .............. 1.1106 1.0745

Genesee, MI

2650 Florence, AL ...... 0.7740 0.8391

Colbert, AL

Lauderdale, AL

2655 Florence, SC ..... 0.8368 0.8851

Florence, SC

2670 Fort CollinsLoveland, CO ............ 1.0383 1.0261

Larimer, CO

2680 1Ft. Lauderdale,

FL .............................. 1.0534 1.0363

Broward, FL

2700 Fort Myers-Cape

Coral, FL .................... 0.9017 0.9316

Lee, FL

2710 Fort Pierce-Port

St. Lucie, FL .............. 0.9847 0.9895

Martin, FL

St. Lucie, FL

2720 Fort Smith, AR–

OK ............................. 0.7687 0.8352

Crawford, AR

Sebastian, AR

Sequoyah, OK

2750 2Fort Walton

Beach, FL .................. 0.8947 0.9266

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

Okaloosa, FL

2760 Fort Wayne, IN .. 0.8896 0.9230

Adams, IN

Allen, IN

De Kalb, IN

Huntington, IN

Wells, IN

Whitley, IN

2800 1Forth Worth-Arlington, TX ................. 0.9192 0.9439

Hood, TX

Johnson, TX

Parker, TX

Tarrant, TX

2840 Fresno, CA ........ 1.0491 1.0334

Fresno, CA

Madera, CA

2880 Gadsden, AL ..... 0.8854 0.9200

Etowah, AL

2900 Gainesville, FL ... 0.9542 0.9684

Alachua, FL

2920 Galveston-Texas

City, TX ...................... 0.9549 0.9689

Galveston, TX

2960 Gary, IN ............. 0.9542 0.9684

Lake, IN

Porter, IN

2975 2Glens Falls, NY 0.8640 0.9047

Warren, NY

Washington, NY

2980 Goldsboro, NC ... 0.8523 0.8963

Wayne, NC

2985 Grand Forks,

ND–MN ...................... 0.8996 0.9301

Polk, MN

Grand Forks, ND

2995 Grand Junction,

CO ............................. 0.9110 0.9382

Mesa, CO

3000 1Grand RapidsMuskegon-Holland, MI 1.0018 1.0012

Allegan, MI

Kent, MI

Muskegon, MI

Ottawa, MI

3040 Great Falls, MT 0.9362 0.9559

Cascade, MT

3060 Greeley, CO ...... 0.9856 0.9901

Weld, CO

3080 Green Bay, WI ... 0.9323 0.9531

Brown, WI

3120 1GreensboroWinston-Salem-High

Point, NC ................... 0.9418 0.9598

Alamance, NC

Davidson, NC

Davie, NC

Forsyth, NC

Guilford, NC

Randolph, NC

Stokes, NC

Yadkin, NC

3150 Greenville, NC ... 0.9034 0.9328

Pitt, NC

3160 GreenvilleSpartanburg-Anderson, SC ...................... 0.9318 0.9528

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

Anderson, SC

Cherokee, SC

Greenville, SC

Pickens, SC

Spartanburg, SC

3180 Hagerstown, MD 1.0268 1.0183

Washington, MD

3200 Hamilton-Middletown, OH ................... 0.9292 0.9510

Butler, OH

3240 Harrisburg-Lebanon-Carlisle, PA ...... 0.9572 0.9705

Cumberland, PA

Dauphin, PA

Lebanon, PA

Perry, PA

3283 1 2 Hartford, CT .. 1.2175 1.1443

Hartford, CT

Litchfield, CT

Middlesex, CT

Tolland, CT

3285 2 Hattiesburg, MS 0.7359 0.8106

Forrest, MS

Lamar, MS

3290 Hickory-Morganton-Lenoir, NC ........... 0.8687 0.9081

Alexander, NC

Burke, NC

Caldwell, NC

Catawba, NC

3320 Honolulu, HI ....... 1.1628 1.1088

Honolulu, HI

3350 Houma, LA ........ 0.8266 0.8777

Lafourche, LA

Terrebonne, LA

3360 1 Houston, TX .... 1.0017 1.0012

Chambers, TX

Fort Bend, TX

Harris, TX

Liberty, TX

Montgomery, TX

Waller, TX

3400 Huntington-Ashland, WV–KY–OH ...... 0.9728 0.9813

Boyd, KY

Carter, KY

Greenup, KY

Lawrence, OH

Cabell, WV

Wayne, WV

3440 Huntsville, AL .... 0.8428 0.8895

Limestone, AL

Madison, AL

3480 1 Indianapolis, IN 0.9901 0.9932

Boone, IN

Hamilton, IN

Hancock, IN

Hendricks, IN

Johnson, IN

Madison, IN

Marion, IN

Morgan, IN

Shelby, IN

3500 Iowa City, IA ...... 0.9561 0.9697

Johnson, IA

3520 Jackson, MI ....... 0.9302 0.9517

Jackson, MI
25640 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

3560 Jackson, MS ...... 0.8279 0.8787

Hinds, MS

Madison, MS

Rankin, MS

3580 Jackson, TN ...... 0.8632 0.9042

Madison, TN

Chester, TN

3600 1 2 Jacksonville,

FL .............................. 0.8947 0.9266

Clay, FL

Duval, FL

Nassau, FL

St. Johns, FL

3605 2 Jacksonville,

NC ............................. 0.8162 0.8702

Onslow, NC

3610 2 Jamestown, NY 0.8640 0.9047

Chautauqua, NY

3620 Janesville-Beloit,

WI .............................. 0.9128 0.9394

Rock, WI

3640 Jersey City, NJ .. 1.1372 1.0920

Hudson, NJ

3660 Johnson CityKingsport-Bristol, TN–

VA .............................. 0.8847 0.9195

Carter, TN

Hawkins, TN

Sullivan, TN

Unicoi, TN

Washington, TN

Bristol City, VA

Scott, VA

Washington, VA

3680 Johnstown, PA .. 0.8671 0.9070

Cambria, PA

Somerset, PA

3700 Jonesboro, AR ... 0.7643 0.8319

Craighead, AR

3710 Joplin, MO ......... 0.7933 0.8534

Jasper, MO

Newton, MO

3720 KalamazooBattlecreek, MI .......... 1.2009 1.1336

Calhoun, MI

Kalamazoo, MI

Van Buren, MI

3740 Kankakee, IL ..... 0.9175 0.9427

Kankakee, IL

3760 1Kansas City,

KS–MO ...................... 0.9672 0.9774

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 ...... 0.9206 0.9449

Kenosha, WI

3810 Killeen-Temple,

TX .............................. 1.0180 1.0123

Bell, TX

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

Coryell, TX

3840 Knoxville, TN ..... 0.8569 0.8996

Anderson, TN

Blount, TN

Knox, TN

Loudon, TN

Sevier, TN

Union, TN

3850 Kokomo, IN ........ 0.9350 0.9550

Howard, IN

Tipton, IN

3870 La Crosse, WI–

MN ............................. 0.8989 0.9296

Houston, MN

La Crosse, WI

3880 Lafayette, LA ..... 0.8363 0.8848

Acadia, LA

Lafayette, LA

St. Landry, LA

St. Martin, LA

3920 Lafayette, IN ...... 0.8984 0.9293

Clinton, IN

Tippecanoe, IN

3960 Lake Charles, LA 0.7738 0.8389

Calcasieu, LA

3980 Lakeland-Winter

Haven, FL .................. 0.8947 0.9266

Polk, FL

4000 Lancaster, PA .... 0.9646 0.9756

Lancaster, PA

4040 Lansing-East

Lansing, MI ................ 1.0130 1.0089

Clinton, MI

Eaton, MI

Ingham, MI

4080 2 Laredo, TX ...... 0.7404 0.8140

Webb, TX

4100 Las Cruces, NM 0.9045 0.9336

Dona Ana, NM

4120 1 Las Vegas,

NV–AZ ....................... 1.1349 1.0905

Mohave, AZ

Clark, NV

Nye, NV

4150 Lawrence, KS .... 0.8728 0.9110

Douglas, KS

4200 Lawton, OK ........ 0.8770 0.9140

Comanche, OK

4243 Lewiston-Auburn,

ME ............................. 0.9226 0.9463

Androscoggin, ME

4280 Lexington, KY .... 0.8579 0.9004

Bourbon, KY

Clark, KY

Fayette, KY

Jessamine, KY

Madison, KY

Scott, KY

Woodford, KY

4320 Lima, OH ........... 0.8885 0.9222

Allen, OH

Auglaize, OH

4360 Lincoln, NE ........ 0.9082 0.9362

Lancaster, NE

4400 Little Rock-North

Little Rock, AR .......... 0.8598 0.9017

Faulkner, AR

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

Lonoke, AR

Pulaski, AR

Saline, AR

4420 Longview-Marshall, TX .................... 0.8583 0.9007

Gregg, TX

Harrison, TX

Upshur, TX

4480 1 Los AngelesLong Beach, CA ........ 1.2124 1.1410

Los Angeles, CA

4520 Louisville, KY–IN 0.9212 0.9453

Clark, IN

Floyd, IN

Harrison, IN

Scott, IN

Bullitt, KY

Jefferson, KY

Oldham, KY

4600 Lubbock, TX ...... 0.8460 0.8918

Lubbock, TX

4640 Lynchburg, VA ... 0.8680 0.9076

Amherst, VA

Bedford, VA

Bedford City, VA

Campbell, VA

Lynchburg City, VA

4680 Macon, GA ........ 0.9109 0.9381

Bibb, GA

Houston, GA

Jones, GA

Peach, GA

Twiggs, GA

4720 Madison, WI ...... 1.0103 1.0070

Dane, WI

4800 Mansfield, OH .... 0.8606 0.9023

Crawford, OH

Richland, OH

4840 Mayaguez, PR ... 0.4360 0.5664

Anasco, PR

Cabo Rojo, PR

Hormigueros, PR

Mayaguez, PR

Sabana Grande, PR

San German, PR

4880 McAllen-Edinburg-Mission, TX ....... 0.8541 0.8976

Hidalgo, TX

4890 Medford-Ashland, OR .................... 1.0109 1.0075

Jackson, OR

4900 MelbourneTitusville-Palm Bay,

FL .............................. 0.9289 0.9507

Brevard, Fl

4920 1 Memphis, TN–

AR–MS ...................... 0.8423 0.8891

Crittenden, AR

DeSoto, MS

Fayette, TN

Shelby, TN

Tipton, TN

4940 Merced, CA ....... 1.0304 1.0207

Merced, CA

5000 1 Miami, FL ........ 0.9427 0.9604

Dade, FL

5015 1 Middlesex-Somerset-Hunterdon, NJ .. 1.0871 1.0589
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25641

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

Hunterdon, NJ

Middlesex, NJ

Somerset, NJ

5080 1 MilwaukeeWaukesha, WI ........... 0.9470 0.9634

Milwaukee, WI

Ozaukee, WI

Washington, WI

Waukesha, WI

5120 1 Minneapolis-St.

Paul, MN–WI ............. 1.0956 1.0645

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 ......... 0.7942 0.8540

Baldwin, AL

Mobile, AL

5170 Modesto, CA ...... 1.0406 1.0276

Stanislaus, CA

5190 1 MonmouthOcean, NJ ................. 1.1285 1.0863

Monmouth, NJ

Ocean, NJ

5200 Monroe, LA ........ 0.8288 0.8793

Ouachita, LA

5240 Montgomery, AL 0.7919 0.8523

Autauga, AL

Elmore, AL

Montgomery, AL

5280 Muncie, IN ......... 0.9493 0.9650

Delaware, IN

5330 2 Myrtle Beach,

SC .............................. 0.8110 0.8664

Horry, SC

5345 Naples, FL ......... 1.0205 1.0140

Collier, FL

5360 1 Nashville, TN ... 0.9336 0.9540

Cheatham, TN

Davidson, TN

Dickson, TN

Robertson, TN

Rutherford TN

Sumner, TN

Williamson, TN

Wilson, TN

5380 1 Nassau-Suffolk,

NY .............................. 1.3123 1.2046

Nassau, NY

Suffolk, NY

5483 1 2 New HavenBridgeport-StamfordWaterbury-Danbury,

CT .............................. 1.2175 1.1443

Fairfield, CT

New Haven, CT

5523 2 New LondonNorwich, CT ............... 1.2175 1.1443

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

New London, CT

5560 1 New Orleans,

LA .............................. 0.9397 0.9583

Jefferson, LA

Orleans, LA

Plaquemines, LA

St. Bernard, LA

St. Charles, LA

St. James, LA

St. John The Baptist,

LA

St. Tammany, LA

5600 1 New York, NY 1.4537 1.2920

Bronx, NY

Kings, NY

New York, NY

Putnam, NY

Queens, NY

Richmond, NY

Rockland, NY

Westchester, NY

5640 1 Newark, NJ ...... 1.0899 1.0607

Essex, NJ

Morris, NJ

Sussex, NJ

Union, NJ

Warren, NJ

5660 Newburgh, NYPA .............................. 1.1226 1.0824

Orange, NY

Pike, PA

5720 1 Norfolk-Virginia

Beach-Newport News,

VA–NC ....................... 0.8235 0.8755

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 1Oakland, CA .... 1.5309 1.3386

Alameda, CA

Contra Costa, CA

5790 Ocala, FL ........... 0.9229 0.9465

Marion, FL

5800 Odessa-Midland,

TX .............................. 0.7773 0.8415

Ector, TX

Midland, TX

5880 1Oklahoma City,

OK ............................. 0.8764 0.9136

Canadian, OK

Cleveland, OK

Logan, OK

McClain, OK

Oklahoma, OK

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

Pottawatomie, OK

5910 Olympia, WA ..... 1.1605 1.1073

Thurston, WA

5920 Omaha, NE–IA .. 0.9938 0.9958

Pottawattamie, IA

Cass, NE

Douglas, NE

Sarpy, NE

Washington, NE

5945 1Orange County,

CA .............................. 1.1153 1.0776

Orange, CA

5960 1Orlando, FL ..... 0.9933 0.9954

Lake, FL

Orange, FL

Osceola, FL

Seminole, FL

5990 2Owensboro, KY 0.7902 0.8511

Daviess, KY

6015 2Panama City,

FL .............................. 0.8947 0.9266

Bay, FL

6020 ParkersburgMarietta, WV–OH

(West Virginia Hospitals) ......................... 0.8118 0.8669

Washington, OH

Wood, WV

6020 2ParkersburgMarietta, WV–OH

(Ohio Hospitals) ......... 0.8576 0.9001

Washington, OH

Wood, WV

6080 2Pensacola, FL 0.8947 0.9266

Escambia, FL

Santa Rosa, FL

6120 Peoria-Pekin, IL 0.8157 0.8698

Peoria, IL

Tazewell, IL

Woodford, IL

6160 1Philadelphia,

PA–NJ ....................... 1.1427 1.0957

Burlington, NJ

Camden, NJ

Gloucester, NJ

Salem, NJ

Bucks, PA

Chester, PA

Delaware, PA

Montgomery, PA

Philadelphia, PA

6200 1Phoenix-Mesa,

AZ .............................. 0.9759 0.9834

Maricopa, AZ

Pinal, AZ

6240 Pine Bluff, AR .... 0.8003 0.8585

Jefferson, AR

6280 1Pittsburgh, PA 0.9896 0.9929

Allegheny, PA

Beaver, PA

Butler, PA

Fayette, PA

Washington, PA

Westmoreland, PA

6323 2Pittsfield, MA ... 1.0917 1.0619

Berkshire, MA

6340 Pocatello, ID ...... 0.8760 0.9133
25642 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

Bannock, ID

6360 Ponce, PR ......... 0.4740 0.5998

Guayanilla, PR

Juana Diaz, PR

Penuelas, PR

Ponce, PR

Villalba, PR

Yauco, PR

6403 Portland, ME ...... 0.9537 0.9681

Cumberland, ME

Sagadahoc, ME

York, ME

6440 1Portland-Vancouver, OR–WA ........ 1.1274 1.0856

Clackamas, OR

Columbia, OR

Multnomah, OR

Washington, OR

Yamhill, OR

Clark, WA

6483 1ProvidenceWarwick-Pawtucket,

RI ............................... 1.0888 1.0600

Bristol, RI

Kent, RI

Newport, RI

Providence, RI

Washington, RI

6520 Provo-Orem, UT 0.9910 0.9938

Utah, UT

6560 Pueblo, CO ........ 0.8785 0.9151

Pueblo, CO

6580 Punta Gorda, FL 0.8994 0.9300

Charlotte, FL

6600 Racine, WI ......... 0.9207 0.9450

Racine, WI

6640 1 Raleigh-Durham-Chapel Hill, NC 0.9909 0.9938

Chatham, NC

Durham, NC

Franklin, NC

Johnston, NC

Orange, NC

Wake, NC

6660 Rapid City, SD ... 0.8277 0.8785

Pennington, SD

6680 Reading, PA ...... 0.9282 0.9503

Berks, PA

6690 Redding, CA ...... 1.2017 1.1341

Shasta, CA

6720 Reno, NV ........... 1.0169 1.0115

Washoe, NV

6740 2 RichlandKennewick-Pasco,

WA ............................. 1.0577 1.0392

Benton, WA

Franklin, WA

6760 Richmond-Petersburg, VA .............. 0.9257 0.9485

Charles City County,

VA

Chesterfield, VA

Colonial Heights City,

VA

Dinwiddie, VA

Goochland, VA

Hanover, VA

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

Henrico, VA

Hopewell City, VA

New Kent, VA

Petersburg City, VA

Powhatan, VA

Prince George, VA

Richmond City, VA

6780 1 Riverside-San

Bernardino, CA .......... 1.0151 1.0103

Riverside, CA

San Bernardino, CA

6800 Roanoke, VA ..... 0.8581 0.9005

Botetourt, VA

Roanoke, VA

Roanoke City, VA

Salem City, VA

6820 Rochester, MN .. 1.1797 1.1198

Olmsted, MN

6840 1 Rochester, NY 0.9678 0.9778

Genesee, NY

Livingston, NY

Monroe, NY

Ontario, NY

Orleans, NY

Wayne, NY

6880 Rockford, IL ....... 0.8703 0.9093

Boone, IL

Ogle, IL

Winnebago, IL

6895 Rocky Mount,

NC ............................. 0.8214 0.8740

Edgecombe, NC

Nash, NC

6920 1Sacramento,

CA .............................. 1.1952 1.1299

El Dorado, CA

Placer, CA

Sacramento, CA

6960 Saginaw-Bay

City-Midland, MI ........ 0.9567 0.9701

Bay, MI

Midland, MI

Saginaw, MI

6980 St. Cloud, MN .... 0.9667 0.9771

Benton, MN

Stearns, MN

7000 St. Joseph, MO 0.9972 0.9981

Andrew, MO

Buchanan, MO

7040 1St. Louis, MO–

IL ................................ 0.9063 0.9348

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 ......... 0.9987 0.9991

Marion, OR

Polk, OR

7120 Salinas, CA ........ 1.5270 1.3363

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

Monterey, CA

7160 1Salt Lake CityOgden, UT ................. 0.9458 0.9626

Davis, UT

Salt Lake, UT

Weber, UT

7200 San Angelo, TX 0.7512 0.8221

Tom Green, TX

7240 1San Antonio,

TX .............................. 0.7744 0.8394

Bexar, TX

Comal, TX

Guadalupe, TX

Wilson, TX

7320 1San Diego, CA 1.2388 1.1579

San Diego, CA

7360 1San Francisco,

CA .............................. 1.3621 1.2357

Marin, CA

San Francisco, CA

San Mateo, CA

7400 1San Jose, CA .. 1.3783 1.2457

Santa Clara, CA

7440 1San Juan-Bayamon, PR .................... 0.4521 0.5806

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 ObispoAtascadero-Paso

Robles, CA ................ 1.0825 1.0558

San Luis Obispo, CA

7480 Santa BarbaraSanta Maria-Lompoc,

CA .............................. 1.1233 1.0829

Santa Barbara, CA

7485 Santa CruzWatsonville, CA ......... 1.4099 1.2652

Santa Cruz, CA

7490 Santa Fe, NM .... 0.9525 0.9672
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25643

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

Los Alamos, NM

Santa Fe, NM

7500 Santa Rosa, CA 1.3167 1.2073

Sonoma, CA

7510 Sarasota-Bradenton, FL ................. 0.9567 0.9701

Manatee, FL

Sarasota, FL

7520 Savannah, GA ... 0.8776 0.9145

Bryan, GA

Chatham, GA

Effingham, GA

7560 2ScrantonWilkes-Barre-Hazleton, PA ....................... 0.8615 0.9029

Columbia, PA

Lackawanna, PA

Luzerne, PA

Wyoming, PA

7600 1Seattle-Bellevue-Everett, WA ........ 1.1634 1.1092

Island, WA

King, WA

Snohomish, WA

7610 Sharon, PA ........ 0.8948 0.9267

Mercer, PA

7620 2Sheboygan, WI 0.8557 0.8988

Sheboygan, WI

7640 ShermanDenison, TX ............... 0.8229 0.8750

Grayson, TX

7680 Shreveport-Bossier City, LA ............... 0.9436 0.9610

Bossier, LA

Caddo, LA

Webster, LA

7720 Sioux City, IA–

NE .............................. 0.8530 0.8968

Woodbury, IA

Dakota, NE

7760 Sioux Falls, SD .. 0.8988 0.9295

Lincoln, SD

Minnehaha, SD

7800 South Bend, IN .. 0.9939 0.9958

St. Joseph, IN

7840 Spokane, WA .... 1.1020 1.0688

Spokane, WA

7880 Springfield, IL .... 0.8793 0.9157

Menard, IL

Sangamon, IL

7920 Springfield, MO .. 0.8151 0.8694

Christian, MO

Greene, MO

Webster, MO

8003 Springfield, MA .. 1.0917 1.0619

Hampden, MA

Hampshire, MA

8050 State College,

PA .............................. 0.9528 0.9674

Centre, PA

8080 2SteubenvilleWeirton, OH–WV

(Ohio Hospitals) ......... 0.8576 0.9001

Jefferson, OH

Brooke, WV

Hancock, WV

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

8080 SteubenvilleWeirton, OH–WV

(West Virginia Hospitals) ......................... 0.8476 0.8929

Jefferson, OH

Brooke, WV

Hancock, WV

8120 Stockton-Lodi,

CA .............................. 1.1157 1.0779

San Joaquin, CA

8140 Sumter, SC ........ 0.8195 0.8726

Sumter, SC

8160 Syracuse, NY .... 0.9410 0.9592

Cayuga, NY

Madison, NY

Onondaga, NY

Oswego, NY

8200 2Tacoma, WA ... 1.0577 1.0392

Pierce, WA

8240 2Tallahassee, FL 0.8947 0.9266

Gadsden, FL

Leon, FL

8280 1Tampa-St. Petersburg-Clearwater,

FL .............................. 0.9179 0.9430

Hernando, FL

Hillsborough, FL

Pasco, FL

Pinellas, FL

8320 Terre Haute, IN 0.9063 0.9348

Clay, IN

Vermillion, IN

Vigo, IN

8360 Texarkana, ARTexarkana, TX ........... 0.7538 0.8240

Miller, AR

Bowie, TX

8400 Toledo, OH ........ 1.0132 1.0090

Fulton, OH

Lucas, OH

Wood, OH

8440 Topeka, KS ........ 0.9894 0.9927

Shawnee, KS

8480 Trenton, NJ ........ 1.0399 1.0272

Mercer, NJ

8520 Tucson, AZ ........ 0.9104 0.9377

Pima, AZ

8560 Tulsa, OK .......... 0.8520 0.8961

Creek, OK

Osage, OK

Rogers, OK

Tulsa, OK

Wagoner, OK

8600 Tuscaloosa, AL .. 0.7706 0.8366

Tuscaloosa, AL

8640 Tyler, TX ............ 0.8792 0.9156

Smith, TX

8680 2 Utica-Rome,

NY .............................. 0.8640 0.9047

Herkimer, NY

Oneida, NY

8720 Vallejo-FairfieldNapa, CA ................... 1.3458 1.2255

Napa, CA

Solano, CA

8735 Ventura, CA ....... 1.0764 1.0517

Ventura, CA

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

8750 Victoria, TX ........ 0.8451 0.8911

Victoria, TX

8760 Vineland-MillvilleBridgeton, NJ ............. 1.0460 1.0313

Cumberland, NJ

8780 Visalia-TularePorterville, CA ........... 1.0168 1.0115

Tulare, CA

8800 Waco, TX ........... 0.8027 0.8603

McLennan, TX

8840 1Washington,

DC–MD–VA–WV ....... 1.0863 1.0583

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 ..................... 0.8402 0.8876

Black Hawk, IA

8940 Wausau, WI ....... 0.9814 0.9872

Marathon, WI

8960 West Palm

Beach-Boca Raton,

FL .............................. 1.0288 1.0196

Palm Beach, FL

9000 2Wheeling, WV–

OH (West Virginia

Hospitals) ................... 0.7938 0.8537

Belmont, OH

Marshall, WV

Ohio, WV

9000 2Wheeling, WV–

OH (Ohio Hospitals) .. 0.8576 0.9001

Belmont, OH

Marshall, WV

Ohio, WV

9040 Wichita, KS ........ 0.8990 0.9297

Butler, KS

Harvey, KS

Sedgwick, KS

9080 Wichita Falls, TX 0.7864 0.8483

Archer, TX

Wichita, TX
25644 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area

(Constituent counties)

Wage

index GAF

9140 2Williamsport,

PA .............................. 0.8615 0.9029

Lycoming, PA

9160 Wilmington-Newark, DE–MD ............... 1.1968 1.1309

New Castle, DE

Cecil, MD

9200 Wilmington, NC 0.9427 0.9604

New Hanover, NC

Brunswick, NC

9260 2Yakima, WA .... 1.0577 1.0392

Yakima, WA

9270 Yolo, CA ............ 1.0702 1.0476

Yolo, CA

9280 York, PA ............ 0.9509 0.9661

York, PA

9320 YoungstownWarren, OH ............... 0.9897 0.9929

Columbiana, OH

Mahoning, OH

Trumbull, OH

9340 Yuba City, CA .... 1.0957 1.0646

Sutter, CA

Yuba, CA

9360 Yuma, AZ .......... 1.0143 1.0098

Yuma, AZ

1 Large Urban Area

2 Hospitals geographically located in the

area are assigned the statewide rural wage

index for FY 1999.

TABLE 4B.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR RURAL AREAS

Nonurban area Wage

index GAF

Alabama ........................ 0.7385 0.8125

Alaska ........................... 1.2534 1.1673

Arizona .......................... 0.8082 0.8643

Arkansas ....................... 0.7274 0.8042

California ....................... 0.9976 0.9984

Colorado ........................ 0.8454 0.8914

Connecticut ................... 1.2175 1.1443

Delaware ....................... 0.8590 0.9012

Florida ........................... 0.8947 0.9266

Georgia ......................... 0.7933 0.8534

Hawaii ........................... 1.1011 1.0682

Idaho ............................. 0.8548 0.8981

Illinois ............................ 0.7985 0.8572

Indiana .......................... 0.8429 0.8896

Iowa ............................... 0.7846 0.8469

Kansas .......................... 0.7334 0.8087

Kentucky ....................... 0.7902 0.8511

Louisiana ....................... 0.7517 0.8225

Maine ............................ 0.8538 0.8974

Maryland ....................... 0.8627 0.9038

Massachusetts .............. 1.0917 1.0619

Michigan ........................ 0.8988 0.9295

Minnesota ...................... 0.8665 0.9065

Mississippi ..................... 0.7359 0.8106

Missouri ......................... 0.7510 0.8219

Montana ........................ 0.8645 0.9051

Nebraska ....................... 0.7683 0.8349

Nevada .......................... 0.9267 0.9492

TABLE 4B.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR RURAL AREAS—Continued

Nonurban area Wage

index GAF

New Hampshire ............ 1.0324 1.0221

New Jersey 1 ................. .............. ..............

New Mexico .................. 0.7927 0.8529

New York ...................... 0.8640 0.9047

North Carolina ............... 0.8162 0.8702

North Dakota ................. 0.7471 0.8190

Ohio ............................... 0.8576 0.9001

Oklahoma ...................... 0.7207 0.7991

Oregon .......................... 0.9957 0.9971

Pennsylvania ................. 0.8615 0.9029

Puerto Rico ................... 0.4083 0.5415

Rhode Island 1 ............... .............. ..............

South Carolina .............. 0.8110 0.8664

South Dakota ................ 0.7564 0.8260

Tennessee .................... 0.7483 0.8199

Texas ............................ 0.7404 0.8140

Utah ............................... 0.8851 0.9198

Vermont ......................... 0.9489 0.9647

Virginia .......................... 0.7890 0.8502

Washington ................... 1.0577 1.0392

West Virginia ................. 0.7938 0.8537

Wisconsin ...................... 0.8557 0.8988

Wyoming ....................... 0.8763 0.9135

All counties within the State are classified

as urban.

TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT

FACTOR (GAF) FOR HOSPITALS

THAT ARE RECLASSIFIED

Area Wage

index GAF

Abilene, TX ................... 0.8081 0.8642

Albany, GA .................... 0.7933 0.8534

Albuquerque, NM .......... 0.8813 0.9171

Alexandria, LA ............... 0.8598 0.9017

Allentown-BethlehemEaston, PA ................ 1.0219 1.0149

Amarillo, TX .................. 0.8483 0.8935

Anchorage, AK .............. 1.3088 1.2024

Asheville, NC ................ 0.9016 0.9315

Atlanta, GA .................... 1.0024 1.0016

Augusta-Aiken, GA–SC 0.9309 0.9521

Baltimore, MD ............... 0.9760 0.9835

Barnstable-Yarmouth,

MA ............................. 1.4646 1.2986

Baton Rouge, LA .......... 0.8940 0.9261

Benton Harbor, MI ........ 0.8988 0.9295

Bergen-Passaic, NJ ...... 1.1845 1.1229

Billings, MT ................... 0.9220 0.9459

Binghamton, NY ............ 0.8989 0.9296

Birmingham, AL ............ 0.9150 0.9410

Bismarck, ND ................ 0.7838 0.8464

Boise City, ID ................ 0.9267 0.9492

Boston-Worcester-Lawrence-Lowell-Brockton, MA–NH ............... 1.0885 1.0598

Brazoria, TX .................. 0.8895 0.9229

Bryan-College Station,

TX .............................. 0.7962 0.8555

Buffalo-Niagara Falls,

NY .............................. 0.9592 0.9719

Burlington, VT ............... 0.9612 0.9733

Caguas, PR ................... 0.4445 0.5739

TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT

FACTOR (GAF) FOR HOSPITALS

THAT ARE RECLASSIFIED—Continued

Area Wage

index GAF

Canton-Massillon, OH ... 0.8895 0.9229

Casper, WY ................... 0.9227 0.9464

Champaign-Urbana, IL .. 0.8844 0.9193

Charleston-North

Charleston, SC .......... 0.8931 0.9255

Charleston, WV ............. 0.8819 0.9175

Charlotte-Gastonia-Rock

Hill, NC–SC ............... 0.9568 0.9702

Charlottesville, VA ......... 0.9803 0.9865

Chattanooga, TN–GA ... 0.8885 0.9222

Chicago, IL .................... 1.0507 1.0344

Cincinnati, OH–KY–IN .. 0.9465 0.9630

Clarksville-Hopkinsville,

TN–KY ....................... 0.8204 0.8732

Cleveland-Lorain-Elyria,

OH ............................. 0.9970 0.9979

Columbia, MO ............... 0.9331 0.9537

Columbus, GA–AL ........ 0.8573 0.8999

Columbus, OH .............. 0.9929 0.9951

Corpus Christi, TX ........ 0.8112 0.8665

Dallas, TX ..................... 0.9149 0.9409

Danville, VA .................. 0.8779 0.9147

Davenport-Moline-Rock

Island, IA–IL .............. 0.8496 0.8944

Dayton-Springfield, OH 0.9670 0.9773

Denver, CO ................... 1.0532 1.0361

Des Moines, IA ............. 0.8576 0.9001

Duluth-Superior, MN–WI 1.0133 1.0091

Dutchess County, NY ... 0.9860 0.9904

Elkhart-Goshen, IN ....... 0.9168 0.9422

Eugene-Springfield, OR 1.1141 1.0768

Evansville-Henderson,

IN–KY ........................ 0.8505 0.8950

Fargo-Moorhead, ND–

MN (Minnesota Hospital) ........................... 0.8665 0.9065

Fargo-Moorhead, ND–

MN (South Dakota

Hospital) .................... 0.7905 0.8513

Fayetteville, NC ............. 0.8460 0.8918

Flagstaff, AZ–UT ........... 0.9602 0.9726

Flint, MI ......................... 1.1106 1.0745

Fort Collins-Loveland,

CO ............................. 1.0383 1.0261

Ft. Lauderdale, FL ........ 1.0534 1.0363

Fort Pierce-Port St.

Lucie, FL .................... 0.9847 0.9895

Fort Smith, AR–OK ....... 0.7582 0.8273

Fort Walton Beach, FL .. 0.8694 0.9086

Forth Worth-Arlington,

TX .............................. 0.9192 0.9439

Gadsden, AL ................. 0.8854 0.9200

Gainesville, FL .............. 0.9542 0.9684

Goldsboro, NC .............. 0.8366 0.8850

Grand Forks, ND–MN ... 0.8996 0.9301

Grand Junction, CO ...... 0.9110 0.9382

Grand Rapids-Muskegon-Holland, MI ......... 0.9908 0.9937

Great Falls, MT ............. 0.9362 0.9559

Greeley, CO .................. 0.9663 0.9768

Green Bay, WI .............. 0.9323 0.9531

Greenville, NC ............... 0.8844 0.9193

Greenville-SpartanburgAnderson, SC ............ 0.9318 0.9528

Harrisburg-LebanonCarlisle, PA ................ 0.9572 0.9705
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25645

TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT

FACTOR (GAF) FOR HOSPITALS

THAT ARE RECLASSIFIED—Continued

Area Wage

index GAF

Hartford, CT .................. 1.1152 1.0775

Hattiesburg, MS ............ 0.7359 0.8106

Hickory-MorgantonLenoir, NC ................. 0.8687 0.9081

Honolulu, HI .................. 1.1628 1.1088

Houston, TX .................. 1.0017 1.0012

Huntington-Ashland,

WV–KY–OH ............... 0.9353 0.9552

Huntsville, AL ................ 0.8269 0.8780

Indianapolis, IN ............. 0.9901 0.9932

Iowa City, IA .................. 0.9441 0.9614

Jackson, MS ................. 0.8279 0.8787

Jackson, TN .................. 0.8632 0.9042

Jacksonville, FL ............ 0.8915 0.9244

Johnson City-KingsportBristol, TN–VA ........... 0.8847 0.9195

Jonesboro, AR .............. 0.7643 0.8319

Joplin, MO ..................... 0.7710 0.8369

Kalamazoo-Battlecreek,

MI ............................... 1.1713 1.1144

Kansas City, KS–MO .... 0.9672 0.9774

Knoxville, TN ................. 0.8569 0.8996

Lafayette, LA ................. 0.8363 0.8848

Lansing-East Lansing,

MI ............................... 1.0025 1.0017

Las Cruces, NM ............ 0.9045 0.9336

Las Vegas, NV–AZ ....... 1.1349 1.0905

Lexington, KY ................ 0.8579 0.9004

Lima, OH ....................... 0.8715 0.9101

Lincoln, NE .................... 0.8900 0.9233

Little Rock-North Little

Rock, AR ................... 0.8598 0.9017

Los Angeles-Long

Beach, CA ................. 1.2124 1.1410

Louisville, KY–IN ........... 0.9212 0.9453

Macon, GA .................... 0.8886 0.9223

Madison, WI .................. 1.0103 1.0070

Mansfield, OH ............... 0.8606 0.9023

Memphis, TN–AR–MS .. 0.8423 0.8891

Merced, CA ................... 1.0304 1.0207

Milwaukee-Waukesha,

WI .............................. 0.9289 0.9507

Minneapolis-St. Paul,

MN–WI ....................... 1.0956 1.0645

Modesto, CA ................. 1.0406 1.0276

Monroe, LA ................... 0.8148 0.8691

Montgomery, AL ............ 0.7919 0.8523

Myrtle Beach, SC .......... 0.8162 0.8702

Nashville, TN ................. 0.9336 0.9540

New Haven-BridgeportStamford-WaterburyDanbury, CT .............. 1.2175 1.1443

New London-Norwich,

CT .............................. 1.1738 1.1160

New Orleans, LA ........... 0.9397 0.9583

New York, NY ............... 1.4537 1.2920

Newark, NJ ................... 1.0899 1.0607

Newburgh, NY–PA ........ 1.1356 1.0910

Oakland, CA .................. 1.5309 1.3386

Odessa-Midland, TX ..... 0.7773 0.8415

Oklahoma City, OK ....... 0.8764 0.9136

Omaha, NE–IA .............. 0.9938 0.9958

Orange County, CA ...... 1.1153 1.0776

Orlando, FL ................... 0.9933 0.9954

Peoria-Pekin, IL ............ 0.8157 0.8698

Philadelphia, PA–NJ ..... 1.1427 1.0957

TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT

FACTOR (GAF) FOR HOSPITALS

THAT ARE RECLASSIFIED—Continued

Area Wage

index GAF

Pittsburgh, PA ............... 0.9740 0.9821

Pocatello, ID (Idaho

Hospital) .................... 0.8760 0.9133

Pocatello, ID (Wyoming

Hospitals) ................... 0.8763 0.9135

Portland, ME ................. 0.9537 0.9681

Portland-Vancouver,

OR–WA ..................... 1.1274 1.0856

Provo-Orem, UT ............ 0.9910 0.9938

Raleigh-Durham-Chapel

Hill, NC ...................... 0.9909 0.9938

Rapid City, SD .............. 0.8277 0.8785

Reno, NV ...................... 1.0169 1.0115

Rochester, MN .............. 1.1797 1.1198

Rockford, IL ................... 0.8703 0.9093

Sacramento, CA ............ 1.1952 1.1299

Saginaw-Bay City-Midland, MI ...................... 0.9567 0.9701

St. Cloud, MN ............... 0.9667 0.9771

St. Louis, MO–IL ........... 0.9063 0.9348

Salt Lake City-Ogden,

UT .............................. 0.9458 0.9626

San Diego, CA .............. 1.2388 1.1579

Santa Fe, NM ................ 0.9414 0.9595

Santa Rosa, CA ............ 1.3003 1.1970

Seattle-Bellevue-Everett,

WA ............................. 1.1634 1.1092

Sharon, PA .................... 0.8835 0.9187

Sherman-Denison, TX .. 0.8061 0.8628

Sioux City, IA–NE ......... 0.8530 0.8968

Sioux Falls, SD ............. 0.8885 0.9222

South Bend, IN ............. 0.9939 0.9958

Spokane, WA ................ 1.0819 1.0554

Springfield, IL ................ 0.8793 0.9157

Springfield, MO ............. 0.8151 0.8694

State College, PA ......... 0.8845 0.9194

Syracuse, NY ................ 0.9410 0.9592

Tallahassee, FL ............ 0.8566 0.8994

Tampa-St. PetersburgClearwater, FL ........... 0.9179 0.9430

Texarkana, AR-Texarkana, TX ................. 0.7538 0.8240

Topeka, KS ................... 0.9667 0.9771

Tucson, AZ .................... 0.9104 0.9377

Tulsa, OK ...................... 0.8418 0.8888

Tuscaloosa, AL ............. 0.7706 0.8366

Tyler, TX ....................... 0.8792 0.9156

Vallejo-Fairfield-Napa,

CA .............................. 1.3458 1.2255

Victoria, TX ................... 0.8451 0.8911

Washington, DC–MD–

VA–WV ...................... 1.0863 1.0583

Waterloo-Cedar Falls, IA 0.8402 0.8876

Wausau, WI .................. 0.9501 0.9656

Wichita, KS ................... 0.8853 0.9200

Wichita Falls, TX ........... 0.7695 0.8357

Rural Alabama .............. 0.7385 0.8125

Rural Illinois .................. 0.7985 0.8572

Rural Louisiana ............. 0.7517 0.8225

Rural Massachusetts .... 1.0481 1.0327

Rural Michigan .............. 0.8988 0.9295

Rural Minnesota ............ 0.8665 0.9065

Rural Missouri ............... 0.7510 0.8219

Rural Nevada ................ 0.8855 0.9201

Rural New Mexico ......... 0.7927 0.8529

Rural Oregon ................ 0.9957 0.9971

TABLE 4C.—WAGE INDEX AND CAPITAL GEOGRAPHIC ADJUSTMENT

FACTOR (GAF) FOR HOSPITALS

THAT ARE RECLASSIFIED—Continued

Area Wage

index GAF

Rural Washington ......... 1.0577 1.0392

Rural Wyoming ............. 0.8763 0.9135

TABLE 4D.—AVERAGE HOURLY WAGE

FOR URBAN AREAS

Urban area

Average

hourly

wage

Abilene, TX ................................... 16.4503

Aguadilla, PR ................................ 9.8326

Akron, OH ..................................... 20.5582

Albany, GA .................................... 16.6839

Albany-Schenectady-Troy, NY ..... 17.3615

Albuquerque, NM .......................... 18.1579

Alexandria, LA .............................. 17.7146

Allentown-Bethlehem-Easton, PA 21.0540

Altoona, PA ................................... 19.3623

Amarillo, TX .................................. 17.4756

Anchorage, AK .............................. 26.6324

Ann Arbor, MI ............................... 22.9259

Anniston, AL ................................. 17.9884

Appleton-Oshkosh-Neenah, WI .... 18.3354

Arecibo, PR ................................... 10.1277

Asheville, NC ................................ 18.5755

Athens, GA ................................... 18.0203

Atlanta, GA ................................... 20.6523

Atlantic-Cape May, NJ .................. 23.3952

Augusta-Aiken, GA–SC ................ 19.1799

Austin-San Marcos, TX ................. 16.8088

Bakersfield, CA ............................. 18.4123

Baltimore, MD ............................... 20.1089

Bangor, ME ................................... 16.5207

Barnstable-Yarmouth, MA ............ 32.2329

Baton Rouge, LA .......................... 18.4192

Beaumont-Port Arthur, TX ............ 17.8430

Bellingham, WA ............................ 23.6418

Benton Harbor, MI ........................ 17.7241

Bergen-Passaic, NJ ...................... 25.1292

Billings, MT ................................... 18.9960

Biloxi-Gulfport-Pascagoula, MS .... 17.0828

Binghamton, NY ............................ 18.7554

Birmingham, AL ............................ 18.8514

Bismarck, ND ................................ 16.5132

Bloomington,IN ............................. 18.6271

Bloomington-Normal, IL ................ 18.3900

Boise City, ID ................................ 19.0323

Boston-Worcester-Lawrence-Lowell-Brockton, MA–NH ................. 22.3344

Boulder-Longmont, CO ................. 20.8550

Brazoria, TX .................................. 18.3273

Bremerton, WA ............................. 22.9686

Brownsville-Harlingen-San Benito,

TX .............................................. 17.0823

Bryan-College Station, TX ............ 16.3918

Buffalo-Niagara Falls, NY ............. 19.7621

Burlington, VT ............................... 19.7504

Caguas, PR .................................. 9.1371

Canton-Massillon, OH ................... 18.3270

Casper, WY .................................. 18.0774

Cedar Rapids, IA .......................... 18.3134

Champaign-Urbana, IL ................. 18.1242

Charleston-North Charleston, SC 18.4009

Charleston, WV ............................. 18.6306
25646 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 4D.—AVERAGE HOURLY WAGE

FOR URBAN AREAS—Continued

Urban area

Average

hourly

wage

Charlotte-Gastonia-Rock Hill, NC–

SC ............................................. 19.7132

Charlottesville, VA ........................ 21.3425

Chattanooga, TN–GA ................... 18.7967

Cheyenne, WY .............................. 19.2719

Chicago, IL .................................... 21.6476

Chico-Paradise, CA ...................... 21.0787

Cincinnati, OH–KY–IN .................. 19.5020

Clarksville-Hopkinsville, TN–KY ... 16.6908

Cleveland-Lorain-Elyria, OH ......... 20.5422

Colorado Springs, CO .................. 19.5098

Columbia, MO ............................... 19.9392

Columbia, SC ................................ 19.3016

Columbus, GA–AL ........................ 17.6626

Columbus, OH .............................. 20.4569

Corpus Christi, TX ........................ 16.6221

Cumberland, MD–WV ................... 17.3219

Dallas, TX ..................................... 18.9048

Danville, VA .................................. 18.7936

Davenport-Moline-Rock Island,

IA–IL .......................................... 17.5045

Dayton-Springfield, OH ................. 19.9239

Daytona Beach, FL ....................... 18.9775

Decatur, AL ................................... 17.1051

Decatur, IL .................................... 16.7703

Denver, CO ................................... 21.6957

Des Moines, IA ............................. 17.5941

Detroit, MI ..................................... 21.8417

Dothan, AL .................................... 16.1254

Dover, DE ..................................... 19.4527

Dubuque, IA .................................. 17.0843

Duluth-Superior, MN–WI ............... 20.7877

Dutchess County, NY ................... 21.5269

Eau Claire, WI .............................. 18.0385

El Paso, TX ................................... 18.4982

Elkhart-Goshen, IN ....................... 18.7060

Elmira, NY ..................................... 17.5584

Enid, OK ....................................... 16.5863

Erie, PA ......................................... 19.2498

Eugene-Springfield, OR ................ 23.2566

Evansville, Henderson, IN–KY ..... 17.5235

Fargo-Moorhead, ND–MN ............ 15.4103

Fayetteville, NC ............................ 17.4302

Fayetteville-Springdale-Rogers,

AR ............................................. 17.8965

Flagstaff, AZ–UT ........................... 19.7008

Flint, MI ......................................... 22.8823

Florence, AL ................................. 15.9479

Florence, SC ................................. 17.2402

Fort Collins-Loveland, CO ............ 21.3936

Fort Lauderdale, FL ...................... 20.3768

Fort Myers-Cape Coral, FL ........... 18.5790

Fort Pierce-Port St. Lucie, FL ....... 19.9753

Fort Smith, AR–OK ....................... 15.8375

Fort Walton Beach, FL ................. 17.8995

Fort Wayne, IN ............................. 18.3283

Fort Worth-Arlington, TX ............... 18.8266

Fresno, CA .................................... 21.6143

Gadsden, AL ................................. 18.2411

Gainesville, FL .............................. 19.6396

Galveston-Texas City, TX ............. 19.6738

Gary, IN ........................................ 19.5496

Glens Falls, NY ............................. 17.6404

Goldsboro, NC .............................. 17.5612

Grand Forks, ND–MN ................... 18.4172

Grand Junction, CO ...................... 17.0997

Grand Rapids-Muskegon-Holland,

MI .............................................. 20.6411

Great Falls, MT ............................. 18.4336

TABLE 4D.—AVERAGE HOURLY WAGE

FOR URBAN AREAS—Continued

Urban area

Average

hourly

wage

Greeley, CO .................................. 20.3075

Green Bay, WI .............................. 19.0230

Greensboro-Winston-Salem-High

Point, NC ................................... 19.4045

Greenville, NC .............................. 18.6140

Greenville-Spartanburg-Anderson,

SC ............................................. 19.1991

Hagerstown, MD ........................... 21.1564

Hamilton-Middletown, OH ............. 19.1458

Harrisburg-Lebanon-Carlisle, PA .. 19.7220

Hartford, CT .................................. 22.8114

Hattiesburg, MS ............................ 15.0868

Hickory-Morganton-Lenoir, NC ..... 18.4430

Honolulu, HI .................................. 23.9579

Houma, LA .................................... 17.0314

Houston, TX .................................. 20.6380

Huntington-Ashland, WV–KY–OH 20.0441

Huntsville, AL ................................ 17.3657

Indianapolis, IN ............................. 20.3998

Iowa City, IA ................................. 19.6992

Jackson, MI ................................... 19.1645

Jackson, MS ................................. 17.0541

Jackson, TN .................................. 17.7852

Jacksonville, FL ............................ 18.3674

Jacksonville, NC ........................... 15.6996

Jamestown, NY ............................. 15.9060

Janesville-Beloit, WI ..................... 18.8060

Jersey City, NJ ............................. 23.4307

Johnson City-Kingsport-Bristol,

TN–VA ....................................... 18.2276

Johnstown, PA .............................. 17.8659

Jonesboro, AR .............................. 15.3904

Joplin, MO ..................................... 16.3448

Kalamazoo-Battlecreek, MI ........... 24.7428

Kankakee, IL ................................. 18.9037

Kansas City, KS–MO .................... 19.9286

Kenosha, WI ................................. 18.9676

Killeen-Temple, TX ....................... 20.9746

Knoxville, TN ................................. 17.6557

Kokomo, IN ................................... 19.2639

La Crosse, WI–MN ....................... 18.5196

Lafayette, LA ................................. 17.1506

Lafayette, IN ................................. 18.3693

Lake Charles, LA .......................... 15.9437

Lakeland-Winter Haven, FL .......... 18.5691

Lancaster, PA ............................... 19.8739

Lansing-East Lansing, MI ............. 20.8707

Laredo, TX .................................... 15.2064

Las Cruces, NM ............................ 18.4298

Las Vegas, NV–AZ ....................... 23.3827

Lawrence, KS ............................... 17.9827

Lawton, OK ................................... 18.0698

Lewiston-Auburn, ME ................... 19.0090

Lexington, KY ............................... 17.6767

Lima, OH ....................................... 18.3062

Lincoln, NE ................................... 18.7127

Little Rock-North Little Rock, AR .. 17.6667

Longview-Marshall, TX ................. 17.6848

Los Angeles-Long Beach, CA ...... 24.9118

Louisville, KY–IN ........................... 18.9791

Lubbock, TX .................................. 17.4301

Lynchburg, VA .............................. 17.8831

Macon, GA .................................... 18.7672

Madison, WI .................................. 20.8155

Mansfield, OH ............................... 17.7321

Mayaguez, PR .............................. 8.9825

McAllen-Edinburg-Mission, TX ..... 17.5983

Medford-Ashland, OR ................... 20.8288

Melbourne-Titusville-Palm Bay, FL 19.1394

TABLE 4D.—AVERAGE HOURLY WAGE

FOR URBAN AREAS—Continued

Urban area

Average

hourly

wage

Memphis, TN–AR–MS .................. 17.3550

Merced, CA ................................... 20.8449

Miami, FL ...................................... 20.7248

Middlesex-Somerset-Hunterdon,

NJ .............................................. 23.1938

Milwaukee-Waukesha, WI ............ 19.5106

Minneapolis-St. Paul, MN–WI ....... 22.5733

Mobile, AL ..................................... 16.3627

Modesto, CA ................................. 21.4409

Monmouth-Ocean, NJ ................... 23.2510

Monroe, LA ................................... 17.0762

Montgomery, AL ........................... 16.2493

Muncie, IN ..................................... 19.5589

Myrtle Beach, SC .......................... 16.4379

Naples, FL .................................... 21.0253

Nashville, TN ................................ 19.2358

Nassau-Suffolk, NY ...................... 28.5558

New Haven-Bridgeport-StamfordWaterbury-Danbury, CT ............ 24.7905

New London-Norwich, CT ............ 24.1351

New Orleans, LA .......................... 19.3612

New York, NY ............................... 29.9516

Newark, NJ ................................... 24.1961

Newburgh, NY–PA ........................ 23.1287

Norfolk-Virginia Beach-Newport

News, VA–NC ........................... 16.9674

Oakland, CA ................................. 31.0918

Ocala, FL ...................................... 19.0159

Odessa-Midland, TX ..................... 16.0153

Oklahoma City, OK ....................... 18.0573

Olympia, WA ................................. 23.9108

Omaha, NE–IA .............................. 20.4749

Orange County, CA ...................... 23.1127

Orlando, FL ................................... 20.4664

Owensboro, KY ............................. 16.1460

Panama City, FL ........................... 17.6753

Parkersburg-Marietta, WV–OH ..... 16.7267

Pensacola, FL ............................... 16.9466

Peoria-Pekin, IL ............................ 16.7415

Philadelphia, PA–NJ ..................... 23.5434

Phoenix-Mesa, AZ ........................ 20.1062

Pine Bluff, AR ............................... 16.4882

Pittsburgh, PA ............................... 20.3893

Pittsfield, MA ................................. 22.4781

Pocatello, ID ................................. 18.0491

Ponce, PR ..................................... 9.7656

Portland, ME ................................. 19.6358

Portland-Vancouver, OR–WA ....... 23.2280

Providence-Warwick, RI ............... 22.4328

Provo-Orem, UT ........................... 20.4158

Pueblo, CO ................................... 18.1010

Punta Gorda, FL ........................... 18.5303

Racine, WI .................................... 18.9689

Raleigh-Durham-Chapel Hill, NC .. 20.4162

Rapid City, SD .............................. 17.0546

Reading, PA .................................. 19.1241

Redding, CA ................................. 24.7586

Reno, NV ...................................... 20.9521

Richland-Kennewick-Pasco, WA .. 21.3732

Richmond-Petersburg, VA ............ 19.0728

Riverside-San Bernardino, CA ..... 21.3055

Roanoke, VA ................................. 17.6802

Rochester, MN .............................. 24.3054

Rochester, NY .............................. 19.9396

Rockford, IL .................................. 17.9308

Rocky Mount, NC ......................... 18.5969

Sacramento, CA ........................... 24.6188

Saginaw-Bay City-Midland, MI ..... 19.7109

St. Cloud, MN ............................... 19.9167
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25647

TABLE 4D.—AVERAGE HOURLY WAGE

FOR URBAN AREAS—Continued

Urban area

Average

hourly

wage

St. Joseph, MO ............................. 20.5465

St. Louis, MO–IL ........................... 18.6721

Salem, OR .................................... 20.5776

Salinas, CA ................................... 31.4614

Salt Lake City-Ogden, UT ............ 19.4515

San Angelo, TX ............................ 15.4776

San Antonio, TX ........................... 15.9548

San Diego, CA .............................. 25.4297

San Francisco, CA ........................ 28.9991

San Jose, CA ................................ 28.6758

San Juan-Bayamon, PR ............... 9.3148

San Luis Obispo-Atascadero-Paso

Robles, CA ................................ 22.3026

Santa Barbara-Santa MariaLompoc, CA .............................. 23.1439

Santa Cruz-Watsonville, CA ......... 29.0487

Santa Fe, NM ............................... 19.6247

Santa Rosa, CA ............................ 28.2324

Sarasota-Bradenton, FL ............... 19.7119

Savannah, GA .............................. 18.0808

Scranton-Wilkes Barre-Hazleton,

PA .............................................. 17.5663

Seattle-Bellevue-Everett, WA ....... 23.9527

Sharon, PA ................................... 18.4366

Sheboygan, WI ............................. 17.0899

Sherman-Denison, TX .................. 16.9538

Shreveport-Bossier City, LA ......... 19.4408

Sioux City, IA–NE ......................... 17.5754

Sioux Falls, SD ............................. 18.5187

South Bend, IN ............................. 20.4772

Spokane, WA ................................ 22.7055

Springfield, IL ................................ 18.1176

Springfield, MO ............................. 16.7941

Springfield, MA ............................. 22.7477

State College, PA ......................... 19.6319

Steubenville-Weirton, OH–WV ..... 17.4636

Stockton-Lodi, CA ......................... 22.9869

Sumter, SC ................................... 16.8850

Syracuse, NY ................................ 19.3881

Tacoma, WA ................................. 21.5661

Tallahassee, FL ............................ 17.5545

Tampa-St. Petersburg-Clearwater,

FL .............................................. 18.7444

Terre Haute, IN ............................. 18.6722

Texarkana, AR-Texarkana, TX ..... 14.8193

Toledo, OH ................................... 20.8755

Topeka, KS ................................... 20.3862

TABLE 4D.—AVERAGE HOURLY WAGE

FOR URBAN AREAS—Continued

Urban area

Average

hourly

wage

Trenton, NJ ................................... 21.4255

Tucson, AZ ................................... 18.7576

Tulsa, OK ...................................... 17.5538

Tuscaloosa, AL ............................. 15.8762

Tyler, TX ....................................... 18.1141

Utica-Rome, NY ............................ 17.2785

Vallejo-Fairfield-Napa, CA ............ 27.9551

Ventura, CA .................................. 22.7487

Victoria, TX ................................... 17.4131

Vineland-Millville-Bridgeton, NJ .... 21.5511

Visalia-Tulare-Porterville, CA ........ 20.9493

Waco, TX ...................................... 16.5375

Washington, DC–MD–VA–WV ..... 22.3812

Waterloo-Cedar Falls, IA .............. 16.5347

Wausau, WI .................................. 20.2214

West Palm Beach-Boca Raton, FL 21.2686

Wheeling, OH–WV ........................ 15.8460

Wichita, KS ................................... 18.5231

Wichita Falls, TX ........................... 16.2020

Williamsport, PA ........................... 17.5305

Wilmington-Newark, DE–MD ........ 24.6591

Wilmington, NC ............................. 19.4232

Yakima, WA .................................. 21.4371

Yolo, CA ........................................ 22.0507

York, PA ........................................ 19.5923

Youngstown-Warren, OH .............. 20.3921

Yuba City, CA ............................... 22.5751

Yuma, AZ ...................................... 20.8977

TABLE 4E.—AVERAGE HOURLY WAGE

FOR RURAL AREAS

Nonurban area

Average

hourly

wage

Alabama ........................................ 15.1489

Alaska ........................................... 25.8250

Arizona .......................................... 16.6528

Arkansas ....................................... 14.9880

California ....................................... 20.5534

Colorado ....................................... 17.4187

Connecticut ................................... 25.0854

Delaware ....................................... 17.6976

Florida ........................................... 18.4340

TABLE 4E.—AVERAGE HOURLY WAGE

FOR RURAL AREAS—Continued

Nonurban area

Average

hourly

wage

Georgia ......................................... 16.3451

Hawaii ........................................... 22.6872

Idaho ............................................. 17.6124

Illinois ............................................ 16.4317

Indiana .......................................... 17.3659

Iowa .............................................. 16.1658

Kansas .......................................... 15.1110

Kentucky ....................................... 16.2801

Louisiana ....................................... 15.4622

Maine ............................................ 17.5914

Maryland ....................................... 17.7750

Massachusetts .............................. 22.4920

Michigan ........................................ 18.5026

Minnesota ..................................... 17.8522

Mississippi ..................................... 15.1615

Missouri ......................................... 15.4743

Montana ........................................ 17.8114

Nebraska ....................................... 15.8291

Nevada .......................................... 19.0933

New Hampshire ............................ 21.2716

New Jersey 1 ................................. ................

New Mexico .................................. 16.3322

New York ...................................... 17.8012

North Carolina ............................... 16.8177

North Dakota ................................. 15.3932

Ohio .............................................. 17.6689

Oklahoma ...................................... 14.8488

Oregon .......................................... 20.5099

Pennsylvania ................................. 17.7499

Puerto Rico ................................... 8.4134

Rhode Island 1 .............................. ................

South Carolina .............................. 16.7085

South Dakota ................................ 15.5851

Tennessee .................................... 15.4168

Texas ............................................ 15.2542

Utah .............................................. 18.2372

Vermont ........................................ 19.5500

Virginia .......................................... 16.2563

Washington ................................... 21.7931

West Virginia ................................. 16.3543

Wisconsin ...................................... 17.6308

Wyoming ....................................... 18.0559

1All counties within the State are classified

as urban.

TABLE 4F.—PUERTO RICO WAGE INDEX AND CAPITAL GEOGAPHIC ADJUSTMENT FACTOR (GAF)

Area Wage

index GAF

Wage

index—

Reclass.

hospitals

GAF—

Reclass.

hospitals

Aguadilla, PR .................................................................................................................... 1.0534 1.0363 .................... ....................

Arecibo, PR ...................................................................................................................... 1.0850 1.0575 .................... ....................

Caguas, PR ...................................................................................................................... 0.9812 0.9871 0.9812 0.9871

Mayaguez, PR .................................................................................................................. 0.9624 0.9741 .................... ....................

Ponce, PR ........................................................................................................................ 1.0462 1.0314 .................... ....................

San Juan-Bayamon, PR ................................................................................................... 0.9980 0.9986 .................... ....................

Rural Puerto Rico ............................................................................................................. 0.9014 0.9314 .................... ....................
25648 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC AND ARITHMETIC

MEAN LENGTH OF STAY

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

1 ....... 01 SURG CRANIOTOMY AGE >17 EXCEPT FOR TRAUMA .................................... 3.0645 6.8 9.6

2 ....... 01 SURG CRANIOTOMY FOR TRAUMA AGE >17 ................................................... 3.1009 7.5 10.1

3 ....... 01 SURG *CRANIOTOMY AGE 0–17 ......................................................................... 1.9573 12.7 12.7

4 ....... 01 SURG SPINAL PROCEDURES .............................................................................. 2.3259 5.1 7.7

5 ....... 01 SURG EXTRACRANIAL VASCULAR PROCEDURES .......................................... 1.4845 2.7 3.6

6 ....... 01 SURG CARPAL TUNNEL RELEASE ..................................................................... .7763 2.1 3.0

7 ....... 01 SURG PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC W CC ........ 2.3911 6.8 10.1

8 ....... 01 SURG PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC W/O CC .... 1.2891 2.2 3.2

9 ....... 01 MED SPINAL DISORDERS & INJURIES ............................................................ 1.2867 4.8 6.6

10 ..... 01 MED NERVOUS SYSTEM NEOPLASMS W CC ................................................. 1.2113 5.1 7.0

11 ..... 01 MED NERVOUS SYSTEM NEOPLASMS W/O CC ............................................. .8233 3.1 4.2

12 ..... 01 MED DEGENERATIVE NERVOUS SYSTEM DISORDERS ............................... .9034 4.8 6.7

13 ..... 01 MED MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA ................................... .7792 4.4 5.5

14 ..... 01 MED SPECIFIC CEREBROVASCULAR DISORDERS EXCEPT TIA ................. 1.1973 4.9 6.4

15 ..... 01 MED TRANSIENT ISCHEMIC ATTACK & PRECEREBRAL OCCLUSIONS ...... .7327 3.1 3.9

16 ..... 01 MED NONSPECIFIC CEREBROVASCULAR DISORDERS W CC ..................... 1.0715 4.5 5.9

17 ..... 01 MED NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC ................. .6186 2.7 3.4

18 ..... 01 MED CRANIAL & PERIPHERAL NERVE DISORDERS W CC ........................... .9285 4.3 5.6

19 ..... 01 MED CRANIAL & PERIPHERAL NERVE DISORDERS W/O CC ....................... .6463 3.0 3.8

20 ..... 01 MED NERVOUS SYSTEM INFECTION EXCEPT VIRAL MENINGITIS ............. 2.6134 7.9 10.5

21 ..... 01 MED VIRAL MENINGITIS .................................................................................... 1.4785 5.1 6.8

22 ..... 01 MED HYPERTENSIVE ENCEPHALOPATHY ...................................................... .8984 3.6 4.7

23 ..... 01 MED NONTRAUMATIC STUPOR & COMA ........................................................ .7776 3.2 4.3

24 ..... 01 MED SEIZURE & HEADACHE AGE >17 W CC .................................................. .9579 3.8 5.1

25 ..... 01 MED SEIZURE & HEADACHE AGE >17 W/O CC .............................................. .5905 2.7 3.4

26 ..... 01 MED SEIZURE & HEADACHE AGE 0–17 ........................................................... .6950 2.4 3.1

27 ..... 01 MED TRAUMATIC STUPOR & COMA, COMA >1 HR ........................................ 1.3017 3.4 5.3

28 ..... 01 MED TRAUMATIC STUPOR & COMA, COMA <1 HR AGE >17 W CC ............ 1.1699 4.3 6.0

29 ..... 01 MED TRAUMATIC STUPOR & COMA, COMA <1 HR AGE >17 W/O CC ......... .6370 2.7 3.6

30 ..... 01 MED *TRAUMATIC STUPOR & COMA, COMA <1 HR AGE 0–17 .................... .3310 2.0 2.0

31 ..... 01 MED CONCUSSION AGE >17 W CC .................................................................. .8039 3.2 4.4

32 ..... 01 MED CONCUSSION AGE >17 W/O CC .............................................................. .5138 2.2 3.0

33 ..... 01 MED *CONCUSSION AGE 0–17 ......................................................................... .2080 1.6 1.6

34 ..... 01 MED OTHER DISORDERS OF NERVOUS SYSTEM W CC .............................. 1.0067 4.1 5.5

35 ..... 01 MED OTHER DISORDERS OF NERVOUS SYSTEM W/O CC .......................... .5915 2.7 3.6

36 ..... 02 SURG RETINAL PROCEDURES ........................................................................... .6873 1.3 1.5

37 ..... 02 SURG ORBITAL PROCEDURES ........................................................................... .9614 2.5 3.7

38 ..... 02 SURG PRIMARY IRIS PROCEDURES .................................................................. .4876 1.9 2.6

39 ..... 02 SURG LENS PROCEDURES WITH OR WITHOUT VITRECTOMY ..................... .5686 1.5 2.0

40 ..... 02 SURG EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE >17 .................... .7937 2.1 3.2

41 ..... 02 SURG *EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE 0–17 ................ .3369 1.6 1.6

42 ..... 02 SURG INTRAOCULAR PROCEDURES EXCEPT RETINA, IRIS & LENS ........... .6034 1.6 2.1

43 ..... 02 MED HYPHEMA ................................................................................................... .4370 2.7 3.4

44 ..... 02 MED ACUTE MAJOR EYE INFECTIONS ............................................................ .6100 4.2 5.1

45 ..... 02 MED NEUROLOGICAL EYE DISORDERS ......................................................... .6822 2.8 3.5

46 ..... 02 MED OTHER DISORDERS OF THE EYE AGE >17 W CC ................................ .7546 3.6 4.7

47 ..... 02 MED OTHER DISORDERS OF THE EYE AGE >17 W/O CC ............................ .4618 2.5 3.3

48 ..... 02 MED *OTHER DISORDERS OF THE EYE AGE 0–17 ....................................... .2969 2.9 2.9

49 ..... 03 SURG MAJOR HEAD & NECK PROCEDURES .................................................... 1.7597 3.7 5.0

50 ..... 03 SURG SIALOADENECTOMY ................................................................................. .8288 1.6 2.0

51 ..... 03 SURG SALIVARY GLAND PROCEDURES EXCEPT SIALOADENECTOMY ....... .8590 1.8 2.8

52 ..... 03 SURG CLEFT LIP & PALATE REPAIR .................................................................. .9567 2.0 2.8

53 ..... 03 SURG SINUS & MASTOID PROCEDURES AGE >17 .......................................... 1.1402 2.3 3.7

54 ..... 03 SURG *SINUS & MASTOID PROCEDURES AGE 0–17 ....................................... .4812 3.2 3.2

55 ..... 03 SURG MISCELLANEOUS EAR, NOSE, MOUTH & THROAT PROCEDURES .... .8886 2.0 3.0

56 ..... 03 SURG RHINOPLASTY ............................................................................................ .9008 2.1 2.8

57 ..... 03 SURG T&A PROC, EXCEPT TONSILLECTOMY &/OR ADENOIDECTOMY

ONLY, AGE >17.

.9381 2.6 3.7

58 ..... 03 SURG *T&A PROC, EXCEPT TONSILLECTOMY &/OR ADENOIDECTOMY

ONLY, AGE 0–17.

.2732 1.5 1.5

59 ..... 03 SURG TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17 ................ .6750 1.8 2.4

60 ..... 03 SURG *TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0–17 ............ .2081 1.5 1.5

61 ..... 03 SURG MYRINGOTOMY W TUBE INSERTION AGE >17 ..................................... 1.1456 2.6 4.5

62 ..... 03 SURG *MYRINGOTOMY W TUBE INSERTION AGE 0–17 .................................. .2946 1.3 1.3

63 ..... 03 SURG OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES ............. 1.3248 3.0 4.4

64 ..... 03 MED EAR, NOSE, MOUTH & THROAT MALIGNANCY ..................................... 1.2201 4.4 6.8

65 ..... 03 MED DYSEQUILIBRIUM ...................................................................................... .5173 2.4 3.0

66 ..... 03 MED EPISTAXIS .................................................................................................. .5418 2.6 3.3

67 ..... 03 MED EPIGLOTTITIS ............................................................................................. .8230 3.0 3.8

68 ..... 03 MED OTITIS MEDIA & URI AGE >17 W CC ....................................................... .6733 3.4 4.2
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25649

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC AND ARITHMETIC

MEAN LENGTH OF STAY—Continued

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

69 ..... 03 MED OTITIS MEDIA & URI AGE >17 W/O CC ................................................... .5076 2.7 3.3

70 ..... 03 MED OTITIS MEDIA & URI AGE 0–17 ................................................................ .3860 2.1 2.5

71 ..... 03 MED LARYNGOTRACHEITIS .............................................................................. .7663 3.2 4.0

72 ..... 03 MED NASAL TRAUMA & DEFORMITY ............................................................... .6534 2.8 3.8

73 ..... 03 MED OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES AGE >17 .......... .7507 3.3 4.4

74 ..... 03 MED *OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES AGE 0–17 ....... .3347 2.1 2.1

75 ..... 04 SURG MAJOR CHEST PROCEDURES ................................................................ 3.1785 8.1 10.2

76 ..... 04 SURG OTHER RESP SYSTEM O.R. PROCEDURES W CC ............................... 2.6860 8.4 11.3

77 ..... 04 SURG OTHER RESP SYSTEM O.R. PROCEDURES W/O CC ............................ 1.1569 3.4 4.9

78 ..... 04 MED PULMONARY EMBOLISM .......................................................................... 1.4068 6.3 7.4

79 ..... 04 MED RESPIRATORY INFECTIONS & INFLAMMATIONS AGE >17 W CC ....... 1.6331 6.7 8.4

80 ..... 04 MED RESPIRATORY INFECTIONS & INFLAMMATIONS AGE >17 W/O CC ... .9177 4.7 5.9

81 ..... 04 MED *RESPIRATORY INFECTIONS & INFLAMMATIONS AGE 0–17 ............... 1.5160 6.1 6.1

82 ..... 04 MED RESPIRATORY NEOPLASMS .................................................................... 1.3628 5.3 7.2

83 ..... 04 MED MAJOR CHEST TRAUMA W CC ................................................................ .9508 4.4 5.6

84 ..... 04 MED MAJOR CHEST TRAUMA W/O CC ............................................................ .5041 2.7 3.3

85 ..... 04 MED PLEURAL EFFUSION W CC ...................................................................... 1.2361 5.1 6.7

86 ..... 04 MED PLEURAL EFFUSION W/O CC .................................................................. .6843 3.0 3.9

87 ..... 04 MED PULMONARY EDEMA & RESPIRATORY FAILURE ................................. 1.3672 4.8 6.4

88 ..... 04 MED CHRONIC OBSTRUCTIVE PULMONARY DISEASE ................................. .9558 4.4 5.4

89 ..... 04 MED SIMPLE PNEUMONIA & PLEURISY AGE >17 W CC ............................... 1.0865 5.2 6.3

90 ..... 04 MED SIMPLE PNEUMONIA & PLEURISY AGE >17 W/O CC ........................... .6669 3.8 4.5

91 ..... 04 MED SIMPLE PNEUMONIA & PLEURISY AGE 0–17 ........................................ .7210 3.3 4.0

92 ..... 04 MED INTERSTITIAL LUNG DISEASE W CC ...................................................... 1.2047 5.1 6.4

93 ..... 04 MED INTERSTITIAL LUNG DISEASE W/O CC .................................................. .7722 3.5 4.4

94 ..... 04 MED PNEUMOTHORAX W CC ........................................................................... 1.1904 4.9 6.5

95 ..... 04 MED PNEUMOTHORAX W/O CC ....................................................................... .6060 3.1 3.9

96 ..... 04 MED BRONCHITIS & ASTHMA AGE >17 W CC ................................................ .7917 4.0 4.9

97 ..... 04 MED BRONCHITIS & ASTHMA AGE >17 W/O CC ............................................ .5942 3.2 3.8

98 ..... 04 MED BRONCHITIS & ASTHMA AGE 0–17 ......................................................... .6921 3.6 4.9

99 ..... 04 MED RESPIRATORY SIGNS & SYMPTOMS W CC .......................................... .6739 2.3 3.0

100 ... 04 MED RESPIRATORY SIGNS & SYMPTOMS W/O CC ....................................... .5155 1.7 2.1

101 ... 04 MED OTHER RESPIRATORY SYSTEM DIAGNOSES W CC ............................ .8304 3.3 4.4

102 ... 04 MED OTHER RESPIRATORY SYSTEM DIAGNOSES W/O CC ........................ .5402 2.2 2.8

103 ... 05 SURG HEART TRANSPLANT ................................................................................ 16.8723 30.4 48.1

104 ... 05 SURG CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W CARD

CATH.

7.2756 9.9 12.5

105 ... 05 SURG CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC W/O CARD

CATH.

5.7011 7.9 9.7

106 ... 05 SURG CORONARY BYPASS WITH PTCA ........................................................... 7.3400 9.2 10.9

107 ... 05 SURG CORONARY BYPASS W CARDIAC CATH ................................................ 5.4891 9.5 10.7

108 ... 05 SURG OTHER CARDIOTHORACIC PROCEDURES ............................................ 5.9512 8.6 11.3

109 ... 05 SURG CORONARY BYPASS W/O CARDIAC CATH ............................................ 4.0670 7.0 8.0

110 ... 05 SURG MAJOR CARDIOVASCULAR PROCEDURES W CC ................................ 4.1419 7.4 9.7

111 ... 05 SURG MAJOR CARDIOVASCULAR PROCEDURES W/O CC ............................. 2.2188 5.1 5.9

112 ... 05 SURG PERCUTANEOUS CARDIOVASCULAR PROCEDURES .......................... 1.9862 2.8 3.9

113 ... 05 SURG AMPUTATION FOR CIRC SYSTEM DISORDERS EXCEPT UPPER

LIMB & TOE.

2.7407 9.8 13.0

114 ... 05 SURG UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS 1.5023 6.0 8.4

115 ... 05 SURG PERM PACE IMPLNT W AMI, HRT FAIL OR SHOCK OR AICD LEAD

OR GEN PROC.

3.5531 6.4 8.8

116 ... 05 SURG OTH PERM CARDIAC PACEMAKER IMPLANT OR PTCA W CORONARY ART STENT.2.4811 3.0 4.2

117 ... 05 SURG CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT 1.2368 2.7 4.0

118 ... 05 SURG CARDIAC PACEMAKER DEVICE REPLACEMENT .................................. 1.5711 2.0 2.9

119 ... 05 SURG VEIN LIGATION & STRIPPING .................................................................. 1.2960 3.2 5.4

120 ... 05 SURG OTHER CIRCULATORY SYSTEM O.R. PROCEDURES .......................... 1.9568 4.9 8.2

121 ... 05 MED CIRCULATORY DISORDERS W AMI & MAJOR COMP DISCH ALIVE ... 1.6354 5.7 7.0

122 ... 05 MED CIRCULATORY DISORDERS W AMI W/O MAJOR COMP DISCH ALIVE 1.1299 3.6 4.4

123 ... 05 MED CIRCULATORY DISORDERS W AMI, EXPIRED ...................................... 1.4874 2.7 4.4

124 ... 05 MED CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH & COMPLEX DIAG.1.3790 3.5 4.5

125 ... 05 MED CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O COMPLEX DIAG.1.0130 2.2 2.9

126 ... 05 MED ACUTE & SUBACUTE ENDOCARDITIS .................................................... 2.5820 9.7 12.7

127 ... 05 MED HEART FAILURE & SHOCK ....................................................................... 1.0143 4.3 5.5

128 ... 05 MED DEEP VEIN THROMBOPHLEBITIS ............................................................ .7671 5.3 6.0

129 ... 05 MED CARDIAC ARREST, UNEXPLAINED ......................................................... 1.0878 1.8 3.0

130 ... 05 MED PERIPHERAL VASCULAR DISORDERS W CC ........................................ .9435 4.9 6.0

131 ... 05 MED PERIPHERAL VASCULAR DISORDERS W/O CC .................................... .6077 3.9 4.7
25650 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC AND ARITHMETIC

MEAN LENGTH OF STAY—Continued

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

132 ... 05 MED ATHEROSCLEROSIS W CC ...................................................................... .6711 2.5 3.2

133 ... 05 MED ATHEROSCLEROSIS W/O CC ................................................................... .5562 2.0 2.5

134 ... 05 MED HYPERTENSION ......................................................................................... .5838 2.7 3.5

135 ... 05 MED CARDIAC CONGENITAL & VALVULAR DISORDERS AGE >17 W CC ... .8519 3.3 4.4

136 ... 05 MED CARDIAC CONGENITAL & VALVULAR DISORDERS AGE >17 W/O CC .5766 2.4 3.0

137 ... 05 MED *CARDIAC CONGENITAL & VALVULAR DISORDERS AGE 0–17 ........... .8168 3.3 3.3

138 ... 05 MED CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC ............. .8012 3.1 4.1

139 ... 05 MED CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC ......... .4981 2.1 2.6

140 ... 05 MED ANGINA PECTORIS .................................................................................... .5973 2.4 3.0

141 ... 05 MED SYNCOPE & COLLAPSE W CC ................................................................. .7029 3.0 3.9

142 ... 05 MED SYNCOPE & COLLAPSE W/O CC ............................................................. .5316 2.2 2.8

143 ... 05 MED CHEST PAIN ............................................................................................... .5265 1.8 2.3

144 ... 05 MED OTHER CIRCULATORY SYSTEM DIAGNOSES W CC ............................ 1.1123 3.8 5.3

145 ... 05 MED OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC ........................ .6305 2.2 2.9

146 ... 06 SURG RECTAL RESECTION W CC ...................................................................... 2.7210 9.0 10.3

147 ... 06 SURG RECTAL RESECTION W/O CC .................................................................. 1.5887 6.1 6.7

148 ... 06 SURG MAJOR SMALL & LARGE BOWEL PROCEDURES W CC ....................... 3.4239 10.3 12.3

149 ... 06 SURG MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC ................... 1.5698 6.3 6.9

150 ... 06 SURG PERITONEAL ADHESIOLYSIS W CC ........................................................ 2.7465 8.9 10.9

151 ... 06 SURG PERITONEAL ADHESIOLYSIS W/O CC .................................................... 1.2832 4.8 5.9

152 ... 06 SURG MINOR SMALL & LARGE BOWEL PROCEDURES W CC ....................... 1.9427 7.0 8.3

153 ... 06 SURG MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC .................... 1.1905 5.1 5.6

154 ... 06 SURG STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W

CC.

4.1849 10.3 13.4

155 ... 06 SURG STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W/

O CC.

1.3570 3.6 4.7

156 ... 06 SURG *STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE 0–17 .. .8412 6.0 6.0

157 ... 06 SURG ANAL & STOMAL PROCEDURES W CC .................................................. 1.2071 3.9 5.4

158 ... 06 SURG ANAL & STOMAL PROCEDURES W/O CC ............................................... .6434 2.1 2.6

159 ... 06 SURG HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W

CC.

1.2873 3.7 5.0

160 ... 06 SURG HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W/

O CC.

.7413 2.2 2.7

161 ... 06 SURG INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W CC ......... 1.0742 2.9 4.1

162 ... 06 SURG INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W/O CC ...... .6129 1.7 2.0

163 ... 06 SURG *HERNIA PROCEDURES AGE 0–17 ......................................................... .8700 2.1 2.1

164 ... 06 SURG APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC .............. 2.3206 7.3 8.5

165 ... 06 SURG APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC .......... 1.2301 4.3 5.0

166 ... 06 SURG APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC .......... 1.4518 4.0 5.1

167 ... 06 SURG APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC ...... .8548 2.4 2.8

168 ... 03 SURG MOUTH PROCEDURES W CC .................................................................. 1.1593 3.1 4.6

169 ... 03 SURG MOUTH PROCEDURES W/O CC .............................................................. .7155 1.9 2.5

170 ... 06 SURG OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC ...................... 2.8008 7.9 11.3

171 ... 06 SURG OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC .................. 1.1668 3.6 4.8

172 ... 06 MED DIGESTIVE MALIGNANCY W CC .............................................................. 1.3152 5.2 7.1

173 ... 06 MED DIGESTIVE MALIGNANCY W/O CC .......................................................... .7316 2.8 4.0

174 ... 06 MED G.I. HEMORRHAGE W CC ......................................................................... .9945 4.0 4.9

175 ... 06 MED G.I. HEMORRHAGE W/O CC ..................................................................... .5305 2.5 3.0

176 ... 06 MED COMPLICATED PEPTIC ULCER ............................................................... 1.1068 4.3 5.5

177 ... 06 MED UNCOMPLICATED PEPTIC ULCER W CC ............................................... .8646 3.7 4.6

178 ... 06 MED UNCOMPLICATED PEPTIC ULCER W/O CC ........................................... .6344 2.7 3.2

179 ... 06 MED INFLAMMATORY BOWEL DISEASE ......................................................... 1.1084 5.0 6.4

180 ... 06 MED G.I. OBSTRUCTION W CC ......................................................................... .9184 4.2 5.4

181 ... 06 MED G.I. OBSTRUCTION W/O CC ..................................................................... .5254 2.9 3.5

182 ... 06 MED ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17

W CC.

.7709 3.4 4.4

183 ... 06 MED ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17

W/O CC.

.5594 2.4 3.0

184 ... 06 MED ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE 0–17 .5224 2.5 3.2

185 ... 03 MED DENTAL & ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS,

AGE >17.

.8303 3.3 4.5

186 ... 03 MED *DENTAL & ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS,

AGE 0–17.

.3207 2.9 2.9

187 ... 03 MED DENTAL EXTRACTIONS & RESTORATIONS ........................................... .7415 3.0 4.0

188 ... 06 MED OTHER DIGESTIVE SYSTEM DIAGNOSES AGE >17 W CC .................. 1.0758 4.1 5.6

189 ... 06 MED OTHER DIGESTIVE SYSTEM DIAGNOSES AGE >17 W/O CC ............... .5600 2.4 3.2

190 ... 06 MED OTHER DIGESTIVE SYSTEM DIAGNOSES AGE 0–17 ........................... .7636 3.8 5.3

191 ... 07 SURG PANCREAS, LIVER & SHUNT PROCEDURES W CC .............................. 4.4088 10.8 14.6

192 ... 07 SURG PANCREAS, LIVER & SHUNT PROCEDURES W/O CC .......................... 1.7111 5.4 6.7
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25651

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC AND ARITHMETIC

MEAN LENGTH OF STAY—Continued

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

193 ... 07 SURG BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O

C.D.E. W CC.

3.3324 10.4 12.5

194 ... 07 SURG BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O

C.D.E. W/O CC.

1.6689 5.8 6.9

195 ... 07 SURG CHOLECYSTECTOMY W C.D.E. W CC .................................................... 2.7947 8.3 9.8

196 ... 07 SURG CHOLECYSTECTOMY W C.D.E. W/O CC ................................................ 1.6378 4.9 5.7

197 ... 07 SURG CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC 2.3864 7.1 8.6

198 ... 07 SURG CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O

CC.

1.2024 4.0 4.6

199 ... 07 SURG HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR MALIGNANCY ....... 2.3873 7.7 10.2

200 ... 07 SURG HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR NON-MALIGNANCY.3.2791 7.4 11.5

201 ... 07 SURG OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES ............ 3.5903 10.4 14.4

202 ... 07 MED CIRRHOSIS & ALCOHOLIC HEPATITIS .................................................... 1.3123 5.1 6.8

203 ... 07 MED MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS .............. 1.2979 5.1 6.9

204 ... 07 MED DISORDERS OF PANCREAS EXCEPT MALIGNANCY ............................ 1.2114 4.7 6.1

205 ... 07 MED DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W CC ........ 1.2109 4.9 6.6

206 ... 07 MED DISORDERS OF LIVER EXCEPT MALIG, CIRR, ALC HEPA W/O CC .... .6932 3.1 4.1

207 ... 07 MED DISORDERS OF THE BILIARY TRACT W CC .......................................... 1.0711 4.0 5.2

208 ... 07 MED DISORDERS OF THE BILIARY TRACT W/O CC ...................................... .6178 2.3 2.9

209 ... 08 SURG MAJOR JOINT & LIMB REATTACHMENT PROCEDURES OF LOWER

EXTREMITY.

2.1818 4.9 5.5

210 ... 08 SURG HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W CC 1.8153 6.1 7.1

211 ... 08 SURG HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W/O

CC.

1.2530 4.7 5.2

212 ... 08 SURG HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE 0–17 ........ .8679 3.2 3.8

213 ... 08 SURG AMPUTATION FOR MUSCULOSKELETAL SYSTEM & CONN TISSUE

DISORDERS.

1.6323 6.2 8.4

214 ... 08 SURG NO LONGER VALID .................................................................................... .0000 .0 .0

215 ... 08 SURG NO LONGER VALID .................................................................................... .0000 .0 .0

216 ... 08 SURG BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE.2.1241 7.0 9.8

217 ... 08 SURG WND DEBRID & SKN GRFT EXCEPT HAND,FOR MUSCSKELET &

CONN TISS DIS.

2.7825 8.7 13.0

218 ... 08 SURG LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR AGE

>17 W CC.

1.4630 4.2 5.3

219 ... 08 SURG LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR AGE

>17 W/O CC.

.9926 2.8 3.3

220 ... 08 SURG *LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT, FEMUR

AGE 0–17.

.5827 5.3 5.3

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, OR OTHER UPPER EXTREMITY

PROC W CC.

.9257 2.0 2.6

224 ... 08 SURG SHOULDER, ELBOW OR FOREARM PROC, EXC MAJOR JOINT

PROC, W/O CC.

.7876 1.7 2.1

225 ... 08 SURG FOOT PROCEDURES ................................................................................ 1.0120 3.0 4.4

226 ... 08 SURG SOFT TISSUE PROCEDURES W CC ........................................................ 1.4076 4.0 5.9

227 ... 08 SURG SOFT TISSUE PROCEDURES W/O CC .................................................... .7916 2.1 2.7

228 ... 08 SURG MAJOR THUMB OR JOINT PROC, OR OTH HAND OR WRIST PROC

W CC.

1.0048 2.3 3.4

229 ... 08 SURG HAND OR WRIST PROC, EXCEPT MAJOR JOINT PROC, W/O CC ....... .7055 1.8 2.4

230 ... 08 SURG LOCAL EXCISION & REMOVAL OF INT FIX DEVICES OF HIP &

FEMUR.

1.1097 3.1 4.5

231 ... 08 SURG LOCAL EXCISION & REMOVAL OF INT FIX DEVICES EXCEPT HIP &

FEMUR.

1.2922 3.0 4.6

232 ... 08 SURG ARTHROSCOPY ......................................................................................... 1.0895 2.3 3.8

233 ... 08 SURG OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC ....... 2.0599 5.4 7.7

234 ... 08 SURG OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC .... 1.1712 2.8 3.6

235 ... 08 MED FRACTURES OF FEMUR ........................................................................... .7526 3.9 5.4

236 ... 08 MED FRACTURES OF HIP & PELVIS ................................................................ .7260 4.1 5.3

237 ... 08 MED SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH ....... .5367 2.9 3.6

238 ... 08 MED OSTEOMYELITIS ........................................................................................ 1.3382 6.7 8.9

239 ... 08 MED PATHOLOGICAL FRACTURES & MUSCULOSKELETAL & CONN TISS

MALIGNANCY.

.9661 5.0 6.4

240 ... 08 MED CONNECTIVE TISSUE DISORDERS W CC .............................................. 1.2253 5.0 6.7

241 ... 08 MED CONNECTIVE TISSUE DISORDERS W/O CC .......................................... .5875 3.1 4.0

242 ... 08 MED SEPTIC ARTHRITIS .................................................................................... 1.0391 5.2 6.8

243 ... 08 MED MEDICAL BACK PROBLEMS ..................................................................... .7159 3.8 4.9

244 ... 08 MED BONE DISEASES & SPECIFIC ARTHROPATHIES W CC ........................ .7056 3.9 5.0
25652 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC AND ARITHMETIC

MEAN LENGTH OF STAY—Continued

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

245 ... 08 MED BONE DISEASES & SPECIFIC ARTHROPATHIES W/O CC .................... .4961 2.9 3.8

246 ... 08 MED NON-SPECIFIC ARTHROPATHIES ........................................................... .5662 3.1 3.9

247 ... 08 MED SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN

TISSUE.

.5542 2.6 3.5

248 ... 08 MED TENDONITIS, MYOSITIS & BURSITIS ...................................................... .7487 3.6 4.7

249 ... 08 MED AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE .6514 2.6 3.6

250 ... 08 MED FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W CC .6776 3.2 4.2

251 ... 08 MED FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W/O

CC.

.4622 2.3 3.0

252 ... 08 MED *FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE 0–17 ...... .2532 1.8 1.8

253 ... 08 MED FX, SPRN, STRN & DISL OF UPARM, LOWLEG EX FOOT AGE >17 W

CC.

.7188 3.7 4.9

254 ... 08 MED FX, SPRN, STRN & DISL OF UPARM, LOWLEG EX FOOT AGE >17 W/

O CC.

.4315 2.7 3.4

255 ... 08 MED *FX, SPRN, STRN & DISL OF UPARM, LOWLEG EX FOOT AGE 0–17 .2947 2.9 2.9

256 ... 08 MED OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES..7564 3.8 5.1

257 ... 09 SURG TOTAL MASTECTOMY FOR MALIGNANCY W CC .................................. .9219 2.4 3.0

258 ... 09 SURG TOTAL MASTECTOMY FOR MALIGNANCY W/O CC .............................. .7237 1.9 2.1

259 ... 09 SURG SUBTOTAL MASTECTOMY FOR MALIGNANCY W CC ........................... .8840 2.0 3.1

260 ... 09 SURG SUBTOTAL MASTECTOMY FOR MALIGNANCY W/O CC ....................... .6238 1.4 1.5

261 ... 09 SURG BREAST PROC FOR NON-MALIGNANCY EXCEPT BIOPSY & LOCAL

EXCISION.

.9138 1.7 2.2

262 ... 09 SURG BREAST BIOPSY & LOCAL EXCISION FOR NON-MALIGNANCY .......... .8738 2.9 4.2

263 ... 09 SURG SKIN GRAFT &/OR DEBRID FOR SKN ULCER OR CELLULITIS W CC 2.0055 8.8 11.9

264 ... 09 SURG SKIN GRAFT &/OR DEBRID FOR SKN ULCER OR CELLULITIS W/O

CC.

1.1061 5.4 7.2

265 ... 09 SURG SKIN GRAFT &/OR DEBRID EXCEPT FOR SKIN ULCER OR

CELLULITIS W CC.

1.4806 4.2 6.5

266 ... 09 SURG SKIN GRAFT &/OR DEBRID EXCEPT FOR SKIN ULCER OR

CELLULITIS W/O CC.

.8252 2.5 3.4

267 ... 09 SURG PERIANAL & PILONIDAL PROCEDURES ................................................. .9378 3.0 4.6

268 ... 09 SURG SKIN, SUBCUTANEOUS TISSUE & BREAST PLASTIC PROCEDURES 1.0673 2.3 3.6

269 ... 09 SURG OTHER SKIN, SUBCUT TISS & BREAST PROC W CC ........................... 1.5778 5.6 7.9

270 ... 09 SURG OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC ....................... .7218 2.2 3.2

271 ... 09 MED SKIN ULCERS ............................................................................................. 1.0023 5.7 7.2

272 ... 09 MED MAJOR SKIN DISORDERS W CC ............................................................. 1.0465 4.9 6.4

273 ... 09 MED MAJOR SKIN DISORDERS W/O CC ......................................................... .6251 3.6 4.8

274 ... 09 MED MALIGNANT BREAST DISORDERS W CC ............................................... 1.1170 4.8 6.8

275 ... 09 MED MALIGNANT BREAST DISORDERS W/O CC ........................................... .5288 2.6 3.6

276 ... 09 MED NON-MALIGANT BREAST DISORDERS ................................................... .6416 3.6 4.5

277 ... 09 MED CELLULITIS AGE >17 W CC ...................................................................... .8345 4.8 5.9

278 ... 09 MED CELLULITIS AGE >17 W/O CC .................................................................. .5561 3.8 4.5

279 ... 09 MED CELLULITIS AGE 0–17 ............................................................................... .6697 4.3 5.0

280 ... 09 MED TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE >17 W CC ..... .6624 3.3 4.3

281 ... 09 MED TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE >17 W/O CC .4540 2.5 3.2

282 ... 09 MED *TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE 0–17 ............. .2563 2.2 2.2

283 ... 09 MED MINOR SKIN DISORDERS W CC .............................................................. .6961 3.6 4.8

284 ... 09 MED MINOR SKIN DISORDERS W/O CC .......................................................... .4419 2.6 3.3

285 ... 10 SURG AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT, & METABOL

DISORDERS.

2.0445 8.1 11.0

286 ... 10 SURG ADRENAL & PITUITARY PROCEDURES .................................................. 2.2173 5.5 7.0

287 ... 10 SURG SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB

DISORDERS.

1.8652 8.0 11.3

288 ... 10 SURG O.R. PROCEDURES FOR OBESITY ......................................................... 2.0156 4.7 5.9

289 ... 10 SURG PARATHYROID PROCEDURES ................................................................ 1.0132 2.2 3.2

290 ... 10 SURG THYROID PROCEDURES .......................................................................... .9181 1.9 2.5

291 ... 10 SURG THYROGLOSSAL PROCEDURES ............................................................. .5752 1.5 1.8

292 ... 10 SURG OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC .................. 2.5779 7.5 10.7

293 ... 10 SURG OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W/O CC .............. 1.2954 3.9 5.5

294 ... 10 MED DIABETES AGE >35 ................................................................................... .7500 3.8 4.9

295 ... 10 MED DIABETES AGE 0–35 ................................................................................. .7234 3.0 4.0

296 ... 10 MED NUTRITIONAL & MISC METABOLIC DISORDERS AGE >17 W CC ........ .8511 4.1 5.4

297 ... 10 MED NUTRITIONAL & MISC METABOLIC DISORDERS AGE >17 W/O CC .... .5206 2.9 3.7

298 ... 10 MED NUTRITIONAL & MISC METABOLIC DISORDERS AGE 0–17 ................. .5479 2.4 3.7

299 ... 10 MED INBORN ERRORS OF METABOLISM ....................................................... .8774 3.9 5.4

300 ... 10 MED ENDOCRINE DISORDERS W CC .............................................................. 1.0807 4.8 6.3

301 ... 10 MED ENDOCRINE DISORDERS W/O CC .......................................................... .6023 2.9 3.8

302 ... 11 SURG KIDNEY TRANSPLANT ............................................................................... 3.6251 8.6 10.1
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25653

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC AND ARITHMETIC

MEAN LENGTH OF STAY—Continued

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

303 ... 11 SURG KIDNEY, URETER & MAJOR BLADDER PROCEDURES FOR NEOPLASM.2.6598 7.5 9.2

304 ... 11 SURG KIDNEY, URETER & MAJOR BLADDER PROC FOR NON-NEOPL W

CC.

2.3331 6.5 9.0

305 ... 11 SURG KIDNEY, URETER & MAJOR BLADDER PROC FOR NON-NEOPL W/O

CC.

1.1358 3.2 3.9

306 ... 11 SURG PROSTATECTOMY W CC .......................................................................... 1.2407 3.8 5.5

307 ... 11 SURG PROSTATECTOMY W/O CC ...................................................................... .6423 2.0 2.4

308 ... 11 SURG MINOR BLADDER PROCEDURES W CC ................................................. 1.5218 4.1 6.0

309 ... 11 SURG MINOR BLADDER PROCEDURES W/O CC .............................................. .9101 2.1 2.6

310 ... 11 SURG TRANSURETHRAL PROCEDURES W CC ................................................ 1.0630 3.0 4.3

311 ... 11 SURG TRANSURETHRAL PROCEDURES W/O CC ............................................ .6087 1.6 2.0

312 ... 11 SURG URETHRAL PROCEDURES, AGE >17 W CC ........................................... .9880 2.9 4.3

313 ... 11 SURG URETHRAL PROCEDURES, AGE >17 W/O CC ....................................... .6269 1.8 2.4

314 ... 11 SURG *URETHRAL PROCEDURES, AGE 0–17 ................................................... .4939 2.3 2.3

315 ... 11 SURG OTHER KIDNEY & URINARY TRACT O.R. PROCEDURES ..................... 2.0691 4.6 8.0

316 ... 11 MED RENAL FAILURE ......................................................................................... 1.3318 5.0 6.9

317 ... 11 MED ADMIT FOR RENAL DIALYSIS .................................................................. .6194 2.0 2.9

318 ... 11 MED KIDNEY & URINARY TRACT NEOPLASMS W CC ................................... 1.0973 4.4 6.1

319 ... 11 MED KIDNEY & URINARY TRACT NEOPLASMS W/O CC ............................... .6170 2.2 3.0

320 ... 11 MED KIDNEY & URINARY TRACT INFECTIONS AGE >17 W CC ................... .8675 4.5 5.6

321 ... 11 MED KIDNEY & URINARY TRACT INFECTIONS AGE >17 W/O CC ................ .5826 3.4 4.0

322 ... 11 MED KIDNEY & URINARY TRACT INFECTIONS AGE 0–17 ............................ .5394 3.3 4.1

323 ... 11 MED URINARY STONES W CC, &/OR ESW LITHOTRIPSY ............................. .7679 2.4 3.2

324 ... 11 MED URINARY STONES W/O CC ...................................................................... .4360 1.6 1.9

325 ... 11 MED KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE >17 W CC ..... .6246 3.0 4.0

326 ... 11 MED KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE >17 W/O CC .4152 2.1 2.7

327 ... 11 MED *KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE 0–17 ............ .3532 3.1 3.1

328 ... 11 MED URETHRAL STRICTURE AGE >17 W CC ................................................. .7189 2.8 3.7

329 ... 11 MED URETHRAL STRICTURE AGE >17 W/O CC ............................................. .4911 1.7 2.3

330 ... 11 MED *URETHRAL STRICTURE AGE 0–17 ........................................................ .3182 1.6 1.6

331 ... 11 MED OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE >17 W CC ...... .9946 4.2 5.6

332 ... 11 MED OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE >17 W/O CC .. .6236 2.7 3.6

333 ... 11 MED OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE 0–17 ............... .7891 3.5 5.0

334 ... 12 SURG MAJOR MALE PELVIC PROCEDURES W CC .......................................... 1.5998 4.4 5.0

335 ... 12 SURG MAJOR MALE PELVIC PROCEDURES W/O CC ...................................... 1.2055 3.4 3.7

336 ... 12 SURG TRANSURETHRAL PROSTATECTOMY W CC ......................................... .8873 2.8 3.6

337 ... 12 SURG TRANSURETHRAL PROSTATECTOMY W/O CC ..................................... .6186 2.0 2.3

338 ... 12 SURG TESTES PROCEDURES, FOR MALIGNANCY .......................................... 1.0888 3.2 4.8

339 ... 12 SURG TESTES PROCEDURES, NON-MALIGNANCY AGE >17 ......................... .9811 2.9 4.2

340 ... 12 SURG *TESTES PROCEDURES, NON-MALIGNANCY AGE 0–17 ...................... .2828 2.4 2.4

341 ... 12 SURG PENIS PROCEDURES ................................................................................ 1.1213 2.1 3.0

342 ... 12 SURG CIRCUMCISION AGE >17 .......................................................................... .8601 2.6 3.5

343 ... 12 SURG *CIRCUMCISION AGE 0–17 ....................................................................... .1536 1.7 1.7

344 ... 12 SURG OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR

MALIGNANCY.

1.0395 1.8 2.6

345 ... 12 SURG OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXCEPT FOR

MALIGNANCY.

.8659 2.5 3.6

346 ... 12 MED MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W CC ........................ .9541 4.3 5.8

347 ... 12 MED MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W/O CC .................... .5764 2.3 3.1

348 ... 12 MED BENIGN PROSTATIC HYPERTROPHY W CC .......................................... .6894 3.2 4.3

349 ... 12 MED BENIGN PROSTATIC HYPERTROPHY W/O CC ...................................... .4142 2.1 2.8

350 ... 12 MED INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM ................... .6931 3.6 4.4

351 ... 12 MED *STERILIZATION, MALE ............................................................................. .2358 1.3 1.3

352 ... 12 MED OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES ......................... .6279 2.7 3.6

353 ... 13 SURG PELVIC EVISCERATION, RADICAL HYSTERECTOMY & RADICAL

VULVECTOMY.

1.9243 5.6 6.9

354 ... 13 SURG UTERINE, ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W

CC.

1.4969 4.8 5.8

355 ... 13 SURG UTERINE, ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W/O

CC.

.9332 3.2 3.5

356 ... 13 SURG FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES..7878 2.3 2.6

357 ... 13 SURG UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY.2.4468 7.3 9.0

358 ... 13 SURG UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC ................ 1.2133 3.7 4.4

359 ... 13 SURG UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC ............ .8676 2.8 3.0

360 ... 13 SURG VAGINA, CERVIX & VULVA PROCEDURES ............................................. .8910 2.6 3.2

361 ... 13 SURG LAPAROSCOPY & INCISIONAL TUBAL INTERRUPTION ........................ 1.2140 2.3 3.3

362 ... 13 SURG *ENDOSCOPIC TUBAL INTERRUPTION .................................................. .3014 1.4 1.4
25654 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC AND ARITHMETIC

MEAN LENGTH OF STAY—Continued

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

363 ... 13 SURG D&C, CONIZATION & RADIO-IMPLANT, FOR MALIGNANCY ................. .7481 2.5 3.3

364 ... 13 SURG D&C, CONIZATION EXCEPT FOR MALIGNANCY .................................... .7290 2.6 3.6

365 ... 13 SURG OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES ........ 1.7398 4.6 6.9

366 ... 13 MED MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC .................... 1.1946 4.8 6.9

367 ... 13 MED MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W/O CC ................ .5666 2.2 2.9

368 ... 13 MED INFECTIONS, FEMALE REPRODUCTIVE SYSTEM ................................. 1.0553 5.0 6.4

369 ... 13 MED MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS..5264 2.3 3.1

370 ... 14 SURG CESAREAN SECTION W CC ..................................................................... 1.0533 4.3 5.5

371 ... 14 SURG CESAREAN SECTION W/O CC ................................................................. .7197 3.2 3.5

372 ... 14 MED VAGINAL DELIVERY W COMPLICATING DIAGNOSES ........................... .5679 2.4 3.2

373 ... 14 MED VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES ....................... .3987 1.8 2.1

374 ... 14 SURG VAGINAL DELIVERY W STERILIZATION &/OR D&C ............................... .7188 2.1 3.0

375 ... 14 SURG *VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C ........ .6840 4.4 4.4

376 ... 14 MED POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE..4925 2.4 2.9

377 ... 14 SURG POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE.1.4598 3.4 4.5

378 ... 14 MED ECTOPIC PREGNANCY ............................................................................. .8441 2.2 2.6

379 ... 14 MED THREATENED ABORTION ......................................................................... .4401 2.2 3.6

380 ... 14 MED ABORTION W/O D&C ................................................................................. .4235 1.7 2.0

381 ... 14 SURG ABORTION W D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY .. .5583 1.6 2.1

382 ... 14 MED FALSE LABOR ............................................................................................ .1917 1.1 1.3

383 ... 14 MED OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS ... .4732 2.7 3.7

384 ... 14 MED OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS .3576 1.9 2.7

385 ... 15 *NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE

FACILITY.

1.3728 1.8 1.8

386 ... 15 *EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME,

NEONATE.

4.5269 17.9 17.9

387 ... 15 *PREMATURITY W MAJOR PROBLEMS .................................................. 3.0918 13.3 13.3

388 ... 15 *PREMATURITY W/O MAJOR PROBLEMS .............................................. 1.8655 8.6 8.6

389 ... 15 *FULL TERM NEONATE W MAJOR PROBLEMS ..................................... 1.4930 4.7 4.7

390 ... 15 NEONATE W OTHER SIGNIFICANT PROBLEMS .................................... 1.6281 4.2 6.0

391 ... 15 *NORMAL NEWBORN ................................................................................ .1522 3.1 3.1

392 ... 16 SURG SPLENECTOMY AGE >17 .......................................................................... 3.2630 7.8 10.4

393 ... 16 SURG *SPLENECTOMY AGE 0–17 ...................................................................... 1.3447 9.1 9.1

394 ... 16 SURG OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING

ORGANS.

1.6349 4.1 7.1

395 ... 16 MED RED BLOOD CELL DISORDERS AGE >17 ............................................... .8209 3.4 4.7

396 ... 16 MED RED BLOOD CELL DISORDERS AGE 0–17 ............................................. 2.2655 5.5 18.5

397 ... 16 MED COAGULATION DISORDERS .................................................................... 1.2544 4.0 5.5

398 ... 16 MED RETICULOENDOTHELIAL & IMMUNITY DISORDERS W CC .................. 1.2457 4.7 6.0

399 ... 16 MED RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC .............. .6933 3.0 3.7

400 ... 17 SURG LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE ...................... 2.6552 6.1 9.4

401 ... 17 SURG LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W CC 2.5729 7.7 11.0

402 ... 17 SURG LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W/O

CC.

1.0126 2.7 3.9

403 ... 17 MED LYMPHOMA & NON-ACUTE LEUKEMIA W CC ........................................ 1.6817 5.8 8.2

404 ... 17 MED LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC .................................... .8288 3.2 4.5

405 ... 17 *ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE 0–17 ........... 1.9065 4.9 4.9

406 ... 17 SURG MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC

W CC.

2.5701 6.9 9.5

407 ... 17 SURG MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC

W/O CC.

1.1786 3.4 4.3

408 ... 17 SURG MYELOPROLIF DISORD OR POORLY DIFF NEOPL W OTHER

O.R.PROC.

1.8039 4.6 7.5

409 ... 17 MED RADIOTHERAPY ......................................................................................... 1.0112 4.3 5.8

410 ... 17 MED CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS..8403 2.7 3.4

411 ... 17 MED HISTORY OF MALIGNANCY W/O ENDOSCOPY ..................................... .3229 2.0 2.9

412 ... 17 MED HISTORY OF MALIGNANCY W ENDOSCOPY ......................................... .5222 1.9 2.3

413 ... 17 MED OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC .... 1.3511 5.4 7.5

414 ... 17 MED OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W/O CC .7210 3.1 4.2

415 ... 18 SURG O.R. PROCEDURE FOR INFECTIOUS & PARASITIC DISEASES ........... 3.5656 10.5 14.4

416 ... 18 MED SEPTICEMIA AGE >17 ............................................................................... 1.4885 5.7 7.4

417 ... 18 MED SEPTICEMIA AGE 0–17 ............................................................................. 1.3566 4.5 6.0

418 ... 18 MED POSTOPERATIVE & POST-TRAUMATIC INFECTIONS ........................... .9882 4.9 6.2

419 ... 18 MED FEVER OF UNKNOWN ORIGIN AGE >17 W CC ...................................... .8779 4.0 5.0

420 ... 18 MED FEVER OF UNKNOWN ORIGIN AGE >17 W/O CC .................................. .6351 3.2 4.0

421 ... 18 MED VIRAL ILLNESS AGE >17 .......................................................................... .6757 3.1 4.0
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25655

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC AND ARITHMETIC

MEAN LENGTH OF STAY—Continued

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

422 ... 18 MED VIRAL ILLNESS & FEVER OF UNKNOWN ORIGIN AGE 0–17 ................ .5729 2.6 3.3

423 ... 18 MED OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES ................ 1.6011 5.8 7.8

424 ... 19 SURG O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS 2.3280 9.0 14.3

425 ... 19 MED ACUTE ADJUST REACT & DISTURBANCES OF PSYCHOSOCIAL

DYSFUNCTION.

.6791 3.0 4.1

426 ... 19 MED DEPRESSIVE NEUROSES ......................................................................... .5537 3.5 4.9

427 ... 19 MED NEUROSES EXCEPT DEPRESSIVE ......................................................... .5609 3.4 4.8

428 ... 19 MED DISORDERS OF PERSONALITY & IMPULSE CONTROL ........................ .7031 4.5 7.2

429 ... 19 MED ORGANIC DISTURBANCES & MENTAL RETARDATION ......................... .8721 5.2 7.4

430 ... 19 MED PSYCHOSES ............................................................................................... .8073 6.2 8.8

431 ... 19 MED CHILDHOOD MENTAL DISORDERS ......................................................... .7541 4.6 7.3

432 ... 19 MED OTHER MENTAL DISORDER DIAGNOSES .............................................. .7008 3.4 5.2

433 ... 20 ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA ...................... .3024 2.3 3.2

434 ... 20 ALC/DRUG ABUSE OR DEPEND, DETOX OR OTH SYMPT TREAT W

CC.

.6998 3.9 5.2

435 ... 20 ALC/DRUG ABUSE OR DEPEND, DETOX OR OTH SYMPT TREAT W/

O CC.

.4143 3.5 4.4

436 ... 20 ALC/DRUG DEPENDENCE W REHABILITATION THERAPY ................... .8189 11.4 14.1

437 ... 20 ALC/DRUG DEPENDENCE, COMBINED REHAB & DETOX THERAPY .. .7027 7.7 9.2

438 ... ............ NO LONGER VALID .................................................................................... .0000 .0 .0

439 ... 21 SURG SKIN GRAFTS FOR INJURIES .................................................................. 1.5601 5.0 7.7

440 ... 21 SURG WOUND DEBRIDEMENTS FOR INJURIES ............................................... 1.7978 5.7 8.9

441 ... 21 SURG HAND PROCEDURES FOR INJURIES ...................................................... 1.0114 2.3 3.4

442 ... 21 SURG OTHER O.R. PROCEDURES FOR INJURIES W CC ................................ 2.2637 5.2 8.1

443 ... 21 SURG OTHER O.R. PROCEDURES FOR INJURIES W/O CC ............................ .9271 2.5 3.3

444 ... 21 MED TRAUMATIC INJURY AGE >17 W CC ....................................................... .7110 3.5 4.5

445 ... 21 MED TRAUMATIC INJURY AGE >17 W/O CC ................................................... .4790 2.6 3.4

446 ... 21 MED *TRAUMATIC INJURY AGE 0–17 .............................................................. .2955 2.4 2.4

447 ... 21 MED ALLERGIC REACTIONS AGE >17 ............................................................. .4935 1.9 2.5

448 ... 21 MED *ALLERGIC REACTIONS AGE 0–17 .......................................................... .0972 2.9 2.9

449 ... 21 MED POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W CC ................ .7848 2.7 3.8

450 ... 21 MED POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W/O CC ............ .4333 1.6 2.1

451 ... 21 MED *POISONING & TOXIC EFFECTS OF DRUGS AGE 0–17 ....................... .2625 2.1 2.1

452 ... 21 MED COMPLICATIONS OF TREATMENT W CC ............................................... .9785 3.6 5.0

453 ... 21 MED COMPLICATIONS OF TREATMENT W/O CC ........................................... .4855 2.2 2.9

454 ... 21 MED OTHER INJURY, POISONING & TOXIC EFFECT DIAG W CC ................ .8478 3.2 4.7

455 ... 21 MED OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/O CC ............ .4694 2.0 2.7

456 ... ............ NO LONGER VALID .................................................................................... .0000 .0 .0

457 ... ............ NO LONGER VALID .................................................................................... .0000 .0 .0

458 ... ............ NO LONGER VALID .................................................................................... .0000 .0 .0

459 ... ............ NO LONGER VALID .................................................................................... .0000 .0 .0

460 ... ............ NO LONGER VALID .................................................................................... .0000 .0 .0

461 ... 23 SURG O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES.1.0644 2.4 4.4

462 ... 23 MED REHABILITATION ....................................................................................... 1.3849 10.1 12.6

463 ... 23 MED SIGNS & SYMPTOMS W CC ..................................................................... .6757 3.3 4.4

464 ... 23 MED SIGNS & SYMPTOMS W/O CC .................................................................. .5006 2.6 3.4

465 ... 23 MED AFTERCARE W HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS..5238 1.9 2.9

466 ... 23 MED AFTERCARE W/O HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS..6193 2.3 4.1

467 ... 23 MED OTHER FACTORS INFLUENCING HEALTH STATUS .............................. .4944 2.3 4.4

468 ... ............ EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS.3.6566 9.5 13.5

469 ... ............ **PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS ......... .0000 .0 .0

470 ... ............ **UNGROUPABLE ....................................................................................... .0000 .0 .0

471 ... 08 SURG BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY.3.3201 5.3 6.1

472 ... ............ NO LONGER VALID .................................................................................... .0000 .0 .0

473 ... 17 ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE >17 .............. 3.4688 7.6 13.0

474 ... ............ NO LONGER VALID .................................................................................... .0000 .0 .0

475 ... 04 MED RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT 3.7373 8.1 11.3

476 ... ............ SURG PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS.2.2226 8.9 11.9

477 ... ............ SURG NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS.1.7581 5.3 8.2

478 ... 05 SURG OTHER VASCULAR PROCEDURES W CC .............................................. 2.3334 5.1 7.5

479 ... 05 SURG OTHER VASCULAR PROCEDURES W/O CC .......................................... 1.4224 3.0 3.8

480 ... ............ SURG LIVER TRANSPLANT .................................................................................. 10.6455 19.4 26.8

481 ... ............ SURG BONE MARROW TRANSPLANT ................................................................ 9.7725 24.5 27.2
25656 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC AND ARITHMETIC

MEAN LENGTH OF STAY—Continued

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

482 ... ............ SURG TRACHEOSTOMY FOR FACE, MOUTH & NECK DIAGNOSES .............. 3.5950 10.0 12.8

483 ... ............ SURG TRACHEOSTOMY EXCEPT FOR FACE, MOUTH & NECK DIAGNOSES 16.2677 33.9 42.1

484 ... 24 SURG CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA ......................... 5.3170 9.5 14.8

485 ... 24 SURG LIMB REATTACHMENT, HIP AND FEMUR PROC FOR MULTIPLE SIGNIFICANT TR.3.0440 7.7 9.6

486 ... 24 SURG OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 4.9559 8.4 12.4

487 ... 24 MED OTHER MULTIPLE SIGNIFICANT TRAUMA ............................................. 1.9036 5.4 7.5

488 ... 25 SURG HIV W EXTENSIVE O.R. PROCEDURE .................................................... 4.5576 11.9 17.2

489 ... 25 MED HIV W MAJOR RELATED CONDITION ..................................................... 1.7700 6.2 8.9

490 ... 25 MED HIV W OR W/O OTHER RELATED CONDITION ....................................... .9720 3.9 5.4

491 ... 08 SURG MAJOR JOINT & LIMB REATTACHMENT PROCEDURES OF UPPER

EXTREMITY.

1.6670 3.1 3.7

492 ... 17 MED CHEMOTHERAPY W ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS.4.5197 11.4 17.2

493 ... 07 SURG LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC ................... 1.7952 4.2 5.6

494 ... 07 SURG LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC ............... .9989 1.9 2.4

495 ... ............ SURG LUNG TRANSPLANT .................................................................................. 9.0247 13.7 17.0

496 ... 08 SURG COMBINED ANTERIOR/POSTERIOR SPINAL FUSION ........................... 5.4507 8.6 10.6

497 ... 08 SURG SPINAL FUSION W CC .............................................................................. 2.7585 5.0 6.3

498 ... 08 SURG SPINAL FUSION W/O CC ........................................................................... 1.6870 2.9 3.5

499 ... 08 SURG BACK & NECK PROCS EXCEPT SPINAL FUSION W CC ....................... 1.4669 3.8 5.0

500 ... 08 SURG BACK & NECK PROCS EXCEPT SPINAL FUSION W/O CC ................... .9709 2.4 2.9

501 ... 08 SURG KNEE PROC W PDX OF INFECTION W CC ............................................. 2.5459 8.4 10.4

502 ... 08 SURG KNEE PROC W PDX OF INFECTION W/O CC ......................................... 1.5548 5.5 6.6

503 ... 08 SURG KNEE PROCEDURES W/O PDX OF INFECTION ..................................... 1.2316 3.2 4.2

504 ... 22 SURG EXTENSIVE 3RD DEGREE BURN W SKIN GRAFT ................................. 13.9440 23.1 31.6

505 ... 22 EXTENSIVE 3RD DEGREE BURN W/O SKIN GRAFT ............................. 1.7871 2.3 5.9

506 ... 22 FULL THICK BURN W SK GRAFT OR INHAL INJ W CC OR SIG TR ..... 4.2300 12.2 16.8

507 ... 22 FULL THICK BURN W SK GRAFT OR INHAL INJ W/O CC OR SIG TR 1.7017 6.5 9.0

508 ... 22 FULL THICK BURN W/O SK GRAFT OR INHAL INJ W CC OR SIG TR 1.3792 5.2 7.8

509 ... 22 FULL THICK BURN W/O SK GRAFT OR INHAL INJ W/O CC OR SIG

TR.

.7376 3.3 4.9

510 ... 22 NON-EXTENSIVE BURNS W CC OR SIGNIFICANT TRAUMA ................ 1.1408 4.8 6.9

511 ... 22 NON-EXTENSIVE BURNS W/O CC OR SIGNIFICANT TRAUMA ............ .6001 3.5 4.8

* Medicare data have been supplemented by data from 19 states for low volume DRGs.

** DRGs 469 and 470 contain cases which could not be assigned to valid DRGs.

Note: Geometric mean is used only to determine payment for transfer cases.

Note: Arithmetic mean is used only to determine payment for outlier cases.

Note: Relative weights are based on medicare patient data and may not be appropriate for other patients.

TABLE 6A.—NEW DIAGNOSIS CODES

Diagnosis

codes Description CC MDC DRG

337.3 Autonomic dysreflexia ................................................................................. N 1 18,19

438.53 Other paralytic syndrome, bilateral ............................................................. N 1 12

482.40 Pneumonia due to Staphyloccus, unspecified ............................................ Y 4

5

15

25

79, 80, 81 1

121

387, 389,2 489 3

482.41 Pneumonia due to Staphylococcus aureus ................................................ Y 4

5

15

25

79, 80, 81

121 1

387, 389 2

489 3

482.49 Other Staphylococcus pneumonia .............................................................. Y 4

5

15

25

79, 80, 81

121 1

387, 389 2

489 3

518.83 Chronic respiratory failure ........................................................................... Y 4 87

518.84 Acute and chronic respiratory ..................................................................... Y 4

22

87

506, 507

519.00 Unspecified tracheostomy complication ..................................................... Y Pre

4

482

101, 102

519.01 Infection of tracheostomy ............................................................................ Y Pre

4

482

101, 102

519.02 Mechanical complication of tracheostomy .................................................. Y Pre

4

482

101, 102

519.09 Other tracheostomy complication ............................................................... Y Pre

4

482

101, 102
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25657

TABLE 6A.—NEW DIAGNOSIS CODES—Continued

Diagnosis

codes Description CC MDC DRG

536.40 Unspecified gastrostomy complication ....................................................... Y 6 188, 189, 190

536.41 Infection of gastrostomy .............................................................................. Y 6 188, 189, 190

536.42 Mechanical complication of gastrostomy .................................................... Y 6 188, 189, 190

536.49 Other gastrostomy complication ................................................................. Y 6 188, 189, 190

564.81 Neurogenic bowel ....................................................................................... N 6 182, 183, 184

564.89 Other functional disorders of intestine ........................................................ N 6 182, 183, 184

569.62 Mechanical complication of colostomy and enterostomy ........................... Y 6 188, 189, 190

659.70 Abnormality in fetal heart rate/rhythm, unspecified as to episode of care

or not applicable.

N 14 370, 371, 372, 373, 374,

375

659.71 Abnormality in fetal heart rate/rhythm, delivered, with or without mention

of antepartum condition.

N 14 370, 371, 372, 373, 374,

375

659.73 Abnormality in fetal heart rate/rhythm, antepartum condition or complication.N 14 383, 384

763.81 Abnormality in fetal heart rate or rhythm before the onset of labor ........... N 15 390

763.82 Abnormality in fetal heart rate or rhythm during labor ............................... N 15 390

763.83 √Abnormality in fetal heart rate or rhythm, unspecified as to time of

onset.

N 15 390

763.89 Other specified complications of labor and delivery affecting fetus and

newborn.

N 15 390

780.71 Chronic fatigue syndrome ........................................................................... N 23

25

463, 464

490

780.79 √Other malaise and fatigue ........................................................................ N 23

25

463, 464

490

786.03 Apnea .......................................................................................................... Y 4

25

99, 100

490

786.04 Cheyne-Stokes respiration .......................................................................... Y 4

25

99, 100

490

786.05 Shortness of breath .................................................................................... N 4

25

99, 100

490

786.06 Tachypnea .................................................................................................. N 4

25

99, 100

490

786.07 Wheezing .................................................................................................... N 4

25

99, 100

490

965.61 Poisoning by propionic acid derivatives ..................................................... N 21 449, 450, 451

965.69 Poisoning by other antirheumatics ............................................................. N 21 449, 450, 451

995.86 Malignant hyperthermia .............................................................................. Y 21 454, 455

996.55 Mechanical complications due to artificial skin graft and decellularized

allodermis.

Y 21 452, 453

996.56 Mechanical complications due to peritoneal dialysis catheter ................... Y 21 452, 453

996.68 Infection and inflammatory reaction due to peritoneal dialysis catheter .... Y 21 452, 453

V02.51 Carrier or suspected carrier of Group B streptococcus ............................. N 23 467

V02.52 Carrier or suspected carrier of other streptococcus ................................... N 23 467

V02.59 Carrier or suspected carrier of other specified bacterial diseases ............. N 23 467

V10.48 Personal history of malignant neoplasm of epididymis .............................. N 17 411, 412

V13.61 Personal history of hypospadias ................................................................. N 23 467

V13.69 Personal history other congenital malformation ......................................... N 23 467

V16.51 Family history of malignant neoplasm of kidney ........................................ N 23 467

V16.59 Family history of malignant neoplasm of other urinary organs .................. N 23 467

V18.61 Family history of polycystic kidney ............................................................. N 23 467

V18.69 Family history of other kidney diseases ..................................................... N 23 467

V23.81 Supervision of high-risk pregnancy of elderly primigravida ........................ Y 14 469

V23.82 Supervision of high-risk pregnancy of elderly multigravida ........................ Y 14 469

V23.83 Supervision of high-risk pregnancy of young primigravida ........................ Y 14 469

V23.84 Supervision of high-risk pregnancy of young multigravida ......................... Y 14 469

V23.89 Supervision of other high-risk pregnancy ................................................... Y 14 469

V26.51 Tubal ligation status .................................................................................... N 23 467

V26.52 Vasectomy status ........................................................................................ N 23 467

V29.3 Observation for suspected genetic or metabolic condition ........................ N 23 467

V43.83 Organ or tissue replaced by artificial skin .................................................. N 23 467

V44.50 Unspecified cystostomy status ................................................................... N 23 467

V44.51 Cutaneous-vesicostomy status ................................................................... N 23 467

V44.52 Appendico-vesicostomy status ................................................................... N 23 467

V44.59 Other cystostomy status ............................................................................. N 23 467

V56.2 Fitting and adjustment of peritoneal dialysis catheter ................................ N 11 317

V58.62 Encounter for aftercare for long-term (current) use of antibiotics .............. N 23 465, 466

V76.44 Special screening for malignant neoplasm of prostate .............................. N 23 467

V76.45 Special screening for malignant neoplasm of testis ................................... N 23 467

1 Classified as a ‘‘major complication’’ in this DRG.

2 Classified as a ‘‘major problem’’ in these DRGs.

3 HIV major related condition in this DRG.
25658 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 6B.—NEW PROCEDURE CODES

Procedure

code Description OR MDC DRG

36.31 Open chest transmyocardial revascularization ........................................... Y 5 108

36.32 Other transmyocardial revascularization .................................................... Y 5 108

36.39 Other heart revascularization ...................................................................... Y 5 108

37.67 Implantation of cardiomyostimulation system ............................................. Y 5

21

24

110, 111

442, 443

486

75.37 Amnioinfusion .............................................................................................. N

86.67 Dermal regenerative graft ........................................................................... Y 1

3

5

6

8

9

10

21

22

24

7, 8

63

120

170, 171

217

263, 264, 265,

266

287

439

458, 472

504, 506, 507

486

92.30 Stereotactic radiosurgery, not otherwise specified ..................................... N 1 1

10

17

7, 8

292, 293

401, 402, 408

92.31 Single source photon radiosurgery ............................................................. N 1

10

17

7, 8

292, 293

401, 402, 408

92.32 Multi-source photon radiosurgery ............................................................... N 1

10

17

7, 8

292, 293

401, 402, 408

92.33 Particulate radiosurgery .............................................................................. N 1

10

17

7, 8

292, 293

401, 402, 408

92.39 Stereotactic radiosurgery, not elsewhere classified ................................... N 1

10

17

7, 8

292, 293

401, 402, 408

96.29 Reduction of intussusception of alimentary tract ........................................ N

99.10 Injection or infusion of thrombolytic agent .................................................. N

99.20 Injection or infusion of platelet inhibitor ...................................................... N

1 Nonoperating room, but affecting DRG

TABLE 6C.—INVALID DIAGNOSIS CODE

Diagnosis

codes Description CC MDC DRG

482.4 Pneumonia due to Staphylococcus ............................................................ Y 4

5

15

25

79, 80, 81

121 1

387, 389 2

489 3

519.0 Tracheostomy complication ........................................................................ Y PRE

4

482

101, 102

564.8 Other specified functional disorders of intestine ........................................ N 6 182, 183, 184

763.8 Other specified complications of labor and delivery affecting fetus and

newborn.

N 15 390

780.7 Malaise and fatigue ..................................................................................... N 23

25

463, 464

490

965.6 Poisoning by antirheumatics [antiphlogistics] ............................................. N 21 449, 450, 451

V02.5 Carrier or suspected carrier of other specified bacterial diseases ............. N 23 467

V13.6 Personal history of congenital malformations ............................................. N 23 467

V16.5 Family history of malignant neoplasm of urinary organs ........................... N 23 467

V18.6 Family history of kidney diseases ............................................................... N 23 467

V23.8 Supervision of other high-risk pregnancy ................................................... Y 14 469

V44.5 Cystostomy status ....................................................................................... N 23 467

1 Classified as a ‘‘major complication’’ in this DRG.

2 Classified as a ‘‘major problem’’ in these DRGs.

3 HIV major related condition in this DRG.
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25659

TABLE 6D.—INVALID PROCEDURE CODES

Procedure

code Description OR MDC DRG

36.3 Other heart revascularization ...................................................................... Y 5 108

92.3 Stereotactic radiosurgery ............................................................................ N 1 1

10

17

7, 8

292, 293

401, 402, 408

1 Nonoperation room but effecting DRG.

TABLE 6E.—REVISED DIAGNOSIS CODE TITLES

Diagnosis

code Description CC MDC DRG

518.81 Acute respiratory failure .............................................................................. Y 4

22

87

506, 507

659.60 Elderly multigravida unspecified as to episode of care or not applicable .. N 14 370, 371, 372, 373, 374,

375

659.61 Elderly multigravida delivered, with mention of antepartum condition ....... N 14 370, 371, 372, 373, 374,

375

659.63 Elderly multigravida with antepartum condition or complication ................ N 14 383, 384

V56.1 Fitting and adjustment of extracorporeal dialysis catheter ......................... N 11 317

V82.4 Maternal postnatal screening of chromosomal anomalies ......................... N 23 467
25660 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 6F.—ADDITIONS TO THE CC EXCLUSIONS LIST

PAGE 1 OF 3 PAGES

CCs that are added to the list are in Table 6F—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.

*01100 *01123 *01146 *01172 *01195 *01281 *11515 48249

48240 48240 48240 48240 48240 48240 48240 *48230

48241 48241 48241 48241 48241 48241 48241 48240

48249 48249 48249 48249 48249 48249 48249 48241

*01101 *01124 *01150 *01173 *01196 *01282 *11595 48249

48240 48240 48240 48240 48240 48240 48240 *48231

48241 48241 48241 48241 48241 48241 48241 48240

48249 48249 48249 48249 48249 48249 48249 48241

*01102 *01125 *01151 *01174 *01200 *01283 *1221 48249

48240 48240 48240 48240 48240 48240 48240 *48232

48241 48241 48241 48241 48241 48241 48241 48240

48249 48249 48249 48249 48249 48249 48249 48241

*01103 *01126 *01152 *01175 *01201 *01284 *1304 48249

48240 48240 48240 48240 48240 48240 48240 *48239

48241 48241 48241 48241 48241 48241 48241 48240

48249 48249 48249 48249 48249 48249 48249 48241

*01104 *01130 *01153 *01176 *01202 *01285 *1363 48249

48240 48240 48240 48240 48240 48240 48240 *48240

48241 48241 48241 48241 48241 48241 48241 01100

48249 48249 48249 48249 48249 48249 48249 01101

*01105 *01131 *01154 *01180 *01203 *01286 *3373 01102

48240 48240 48240 48240 48240 48240 3350 01103

48241 48241 48241 48241 48241 48241 33510 01104

48249 48249 48249 48249 48249 48249 33511 01105

*01106 *01132 *01155 *01181 *01204 *01790 33519 01106

48240 48240 48240 48240 48240 48240 33520 01110

48241 48241 48241 48241 48241 48241 33521 01111

48249 48249 48249 48249 48249 48249 33522 01112

*01110 *01133 *01156 *01182 *01205 *01791 33523 01113

48240 48240 48240 48240 48240 48240 33524 01114

48241 48241 48241 48241 48241 48241 33529 01115

48249 48249 48249 48249 48249 48249 3358 01116

*01111 *01134 *01160 *01183 *01206 *01792 3359 01120

48240 48240 48240 48240 48240 48240 *4800 01121

48241 48241 48241 48241 48241 48241 48240 01122

48249 48249 48249 48249 48249 48249 48241 01123

*01112 *01135 *01161 *01184 *01210 *01793 48249 01124

48240 48240 48240 48240 48240 48240 *4801 01125

48241 48241 48241 48241 48241 48241 48240 01126

48249 48249 48249 48249 48249 48249 48241 01130

*01113 *01136 *01162 *01185 *01211 *01794 48249 01131

48240 48240 48240 48240 48240 48240 *4802 01132

48241 48241 48241 48241 48241 48241 48240 01133

48249 48249 48249 48249 48249 48249 48241 01134

*01114 *01140 *01163 *01186 *01212 *01795 48249 01135

48240 48240 48240 48240 48240 48240 *4808 01136

48241 48241 48241 48241 48241 48241 48240 01140

48249 48249 48249 48249 48249 48249 48241 01141

*01115 *01141 *01164 *01190 *01213 *01796 48249 01142

48240 48240 48240 48240 48240 48240 *4809 01143

48241 48241 48241 48241 48241 48241 48240 01144

48249 48249 48249 48249 48249 48249 48241 01145

*01116 *01142 *01165 *01191 *01214 *0212 48249 01146

48240 48240 48240 48240 48240 48240 *481 01150

48241 48241 48241 48241 48241 48241 48240 01151

48249 48249 48249 48249 48249 48249 48241 01152

*01120 *01143 *01166 *01192 *01215 *0310 48249 01153

48240 48240 48240 48240 48240 48240 *4820 01154

48241 48241 48241 48241 48241 48241 48240 01155

48249 48249 48249 48249 48249 48249 48241 01156

*01121 *01144 *01170 *01193 *01216 *0391 48249 01160

48240 48240 48240 48240 48240 48240 *4821 01161

48241 48241 48241 48241 48241 48241 48240 01162

48249 48249 48249 48249 48249 48249 48241 01163

*01122 *01145 *01171 *01194 *01280 *11505 48249 01164

48240 48240 48240 48240 48240 48240 *4822 01165

48241 48241 48241 48241 48241 48241 48240 01166

48249 48249 48249 48249 48249 48249 48241 01170
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25661

PAGE 2 OF 3 PAGES

01171 4955 01183 5078 01195 48240 48241 48249

01172 4956 01184 5080 01196 48241 48249 *5061

01173 4957 01185 5081 01200 48249 *4950 48240

01174 4958 01186 5171 01201 *48283 48240 48241

01175 4959 01190 *48249 01202 48240 48241 48249

01176 5060 01191 01100 01203 48241 48249 *5062

01180 5061 01192 01101 01204 48249 *4951 48240

01181 5070 01193 01102 01205 *48284 48240 48241

01182 5071 01194 01103 01206 48240 48241 48249

01183 5078 01195 01104 01210 48241 48249 *5063

01184 5080 01196 01105 01211 48249 *4952 48240

01185 5081 01200 01106 01212 *48289 48240 48241

01186 5171 01201 01110 01213 48240 48241 48249

01190 *48241 01202 01111 01214 48241 48249 *5064

01191 01100 01203 01112 01215 48249 *4953 48240

01192 01101 01204 01113 01216 *4829 48240 48241

01193 01102 01205 01114 0310 48240 48241 48249

01194 01103 01206 01115 11505 48241 48249 *5069

01195 01104 01210 01116 11515 48249 *4954 48240

01196 01105 01211 01120 1304 *4830 48240 48241

01200 01106 01212 01121 1363 48240 48241 48249

01201 01110 01213 01122 481 48241 48249 *5070

01202 01111 01214 01123 4820 48249 *4955 48240

01203 01112 01215 01124 4821 *4831 48240 48241

01204 01113 01216 01125 4822 48240 48241 48249

01205 01114 0310 01126 48230 48241 48249 *5071

01206 01115 11505 01130 48231 48249 *4956 48240

01210 01116 11515 01131 48232 *4838 48240 48241

01211 01120 1304 01132 48239 48240 48241 48249

01212 01121 1363 01133 48240 48241 48249 *5078

01213 01122 481 01134 48241 48249 *4957 48240

01214 01123 4820 01135 48249 *4841 48240 48241

01215 01124 4821 01136 48281 48240 48241 48249

01216 01125 4822 01140 48282 48241 48249 *5080

0310 01126 48230 01141 48283 48249 *4958 48240

11505 01130 48231 01142 48284 *4843 48240 48241

11515 01131 48232 01143 48289 48240 48241 48249

1304 01132 48239 01144 4829 48241 48249 *5081

1363 01133 48240 01145 4830 48249 *4959 48240

481 01134 48241 01146 4831 *4845 48240 48241

4820 01135 48249 01150 4838 48240 48241 48249

4821 01136 48281 01151 4841 48241 48249 *5088

4822 01140 48282 01152 4843 48249 *496 48240

48230 01141 48283 01153 4845 *4846 48240 48241

48231 01142 48284 01154 4846 48240 48241 48249

48232 01143 48289 01155 4847 48241 48249 *5089

48239 01144 4829 01156 4848 48249 *500 48240

48240 01145 4830 01160 485 *4847 48240 48241

48241 01146 4831 01161 486 48240 48241 48249

48249 01150 4838 01162 4870 48241 48249 *5171

48281 01151 4841 01163 4950 48249 *501 48240

48282 01152 4843 01164 4951 *4848 48240 48241

48283 01153 4845 01165 4952 48240 48241 48249

48284 01154 4846 01166 4953 48241 48249 *5178

48289 01155 4847 01170 4954 48249 *502 48240

4829 01156 4848 01171 4955 *485 48240 48241

4830 01160 485 01172 4956 48240 48241 48249

4831 01161 486 01173 4957 48241 48249 *51881

4838 01162 4870 01174 4958 48249 *503 51883

4841 01163 4950 01175 4959 *486 48240 51884

4843 01164 4951 01176 5060 48240 48241 78603

4845 01165 4952 01180 5061 48241 48249 78604

4846 01166 4953 01181 5070 48249 *504 *51882

4847 01170 4954 01182 5071 *4870 48240 51883

4848 01171 4955 01183 5078 48240 48241 51884

485 01172 4956 01184 5080 48241 48249 78603

486 01173 4957 01185 5081 48249 *505 78604

4870 01174 4958 01186 5171 *4871 48240 *51883

4950 01175 4959 01190 *48281 48240 48241 51881

4951 01176 5060 01191 48240 48241 48249 51882

4952 01180 5061 01192 48241 48249 *5060 51883

4953 01181 5070 01193 48249 *494 48240 51884

4954 01182 5071 01194 *48282 48240 48241 78603
25662 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

PAGE 3 OF 3 PAGES

78604 53642 *99656 56962 V2384 V2384

7991 53649 99655 *99791 V2389 V2389

*51884 56962 99656 53640 *V230 V239

51881 9974 99659 53641 V2381 *V2389

51882 *53642 99660 53642 V2382 V237

51883 53640 99661 53649 V2383 V2381

51884 53641 99662 56962 V2384 V2382

78603 53642 99663 99586 V2389 V2383

78604 53649 99664 99655 *V231 V2384

7991 56962 99665 99656 V2381 V2389

*51889 9974 99666 99668 V2382 V239

48240 *53649 99667 *99799 V2383 *V239

48241 53640 99668 53640 V2384 V2381

48249 53641 99669 53641 V2389 V2382

*51900 53642 99670 53642 *V232 V2383

51900 53649 99671 53649 V2381 V2384

51901 56962 99672 56962 V2382 V2389

51902 9974 99673 99586 V2383

51909 *56960 99674 99655 V2384

*51901 56962 99675 99656 V2389

51900 *56961 99676 99668 *V233

51901 56962 99677 *9980 V2381

51902 *56962 99678 99586 V2382

51909 56960 99679 *99811 V2383

*51902 56961 *99659 99586 V2384

51900 56962 99655 *99812 V2389

51901 56969 99656 99586 *V234

51902 *56969 99668 *99813 V2381

51909 56962 *99660 99586 V2382

*51909 *74861 99655 *99881 V2383

51900 48240 99656 53640 V2384

51901 48241 99668 53641 V2389

51902 48249 *99668 53642 *V235

51909 *78603 99655 53649 V2381

*5191 78603 99656 56962 V2382

51900 78604 99659 99586 V2383

51901 *78604 99660 *99883 V2384

51902 78603 99661 53640 V2389

51909 78604 99662 53641 *V237

*5198 *7991 99663 53642 V2381

48240 51883 99664 53649 V2382

48241 51884 99665 56962 V2383

48249 78603 99666 99586 V2384

51883 78604 99667 *99889 V2389

51884 *9584 99668 53640 *V2381

51900 99586 99669 53641 V237

51901 *9954 99670 53642 V2381

51902 99586 99671 53649 V2382

51909 *99586 99672 56962 V2383

78603 99586 99673 99586 V2384

78604 *99652 99674 *9989 V2389

*5199 99655 99675 53640 V239

48240 *99655 99676 53641 *V2382

48241 99652 99677 53642 V237

48249 99655 99678 53649 V2381

51883 99660 99679 56962 V2382

51884 99661 *99669 99586 V2383

51900 99662 99655 *V220 V2384

51901 99663 99656 V2381 V2389

51902 99665 99668 V2382 V239

51909 99666 *99670 V2383 *V2383

78603 99667 99655 V2384 V237

78604 99669 99656 V2389 V2381

*53640 99670 99668 *V221 V2382

53640 99671 *99679 V2381 V2383

53641 99672 99655 V2382 V2384

53642 99673 99656 V2383 V2389

53649 99674 99668 V2384 V239

56962 99675 *9974 V2389 *V2384

9974 99676 53640 *V222 V237

*53641 99677 53641 V2381 V2381

53640 99678 53642 V2382 V2382

53641 99679 53649 V2383 V2383
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25663

TABLE 6G.—DELETIONS TO THE CC EXCLUSIONS LIST

[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.]

*01100 *01146 *01195 *11515 01143 48282 4824 4824

4824 4824 4824 4824 01144 48283 *4870 *5178

*01101 *01150 *01196 *11595 01145 48284 4824 4824

4824 4824 4824 4824 01146 48289 *4871 *51889

*01102 *01151 *01200 *1221 01150 4829 4824 4824

4824 4824 4824 4824 01151 4830 *494 *5190

*01103 *01152 *01201 *1304 01152 4831 4824 5190

4824 4824 4824 4824 01153 4838 *4950 *5191

*01104 *01153 *01202 *1363 01154 4841 4824 5190

4824 4824 4824 4824 01155 4843 *4951 *5198

*01105 *01154 *01203 *4800 01156 4845 4824 4824

4824 4824 4824 4824 01160 4846 *4952 5190

*01106 *01155 *01204 *4801 01161 4847 4824 *5199

4824 4824 4824 4824 01162 4848 *4953 4824

*01110 *01156 *01205 *4802 01163 485 4824 5190

4824 4824 4824 4824 01164 486 *4954 *74861

*01111 *01160 *01206 *4808 01165 4870 4824 4824

4824 4824 4824 4824 01166 4950 *4955 *V220

*01112 *01161 *01210 *4809 01170 4951 4824 V238

4824 4824 4824 4824 01171 4952 *4956 *V221

*01113 *01162 *01211 *481 01172 4953 4824 V238

4824 4824 4824 4824 01173 4954 *4957 *V222

*01114 *01163 *01212 *4820 01174 4955 4824 V238

4824 4824 4824 4824 01175 4956 *4958 *V230

*01115 *01164 *01213 *4821 01176 4957 4824 V238

4824 4824 4824 4824 01180 4958 *4959 *V231

*01116 *01165 *01214 *4822 01181 4959 4824 V238

4824 4824 4824 4824 01182 5060 *496 *V232

*01120 *01166 *01215 *48230 01183 5061 4824 V238

4824 4824 4824 4824 01184 5070 *500 *V233

*01121 *01170 *01216 *48231 01185 5071 4824 V238

4824 4824 4824 4824 01186 5078 *501 *V234

*01122 *01171 *01280 *48232 01190 5080 4824 V238

4824 4824 4824 4824 01191 5081 *502 *V235

*01123 *01172 *01281 *48239 01192 5171 4824 V238

4824 4824 4824 4824 01193 *48281 *503 *V237

*01124 *01173 *01282 *4824 01194 4824 4824 V238

4824 4824 4824 01100 01195 *48282 *504 *V238

*01125 *01174 *01283 01101 01196 4824 4824 V237

4824 4824 4824 01102 01200 *48283 *505 V238

*01126 *01175 *01284 01103 01201 4824 4824 V239

4824 4824 4824 01104 01202 *48284 *5060 *V239

*01130 *01176 *01285 01105 01203 4824 4824 V238

4824 4824 4824 01106 01204 *48289 *5061

*01131 *01180 *01286 01110 01205 4824 4824

4824 4824 4824 01111 01206 *4829 *5062

*01132 *01181 *01790 01112 01210 4824 4824

4824 4824 4824 01113 01211 *4830 *5063

*01133 *01182 *01791 01114 01212 4824 4824

4824 4824 4824 01115 01213 *4831 *5064

*01134 *01183 *01792 01116 01214 4824 4824

4824 4824 4824 01120 01215 *4838 *5069

*01135 *01184 *01793 01121 01216 4824 4824

4824 4824 4824 01122 0310 *4841 *5070

*01136 *01185 *01794 01123 11505 4824 4824

4824 4824 4824 01124 11515 *4843 *5071

*01140 *01186 *01795 01125 1304 4824 4824

4824 4824 4824 01126 1363 *4845 *5078

*01141 *01190 *01796 01130 481 4824 4824

4824 4824 4824 01131 4820 *4846 *5080

*01142 *01191 *0212 01132 4821 4824 4824

4824 4824 4824 01133 4822 *4847 *5081

*01143 *01192 *0310 01134 48230 4824 4824

4824 4824 4824 01135 48231 *4848 *5088

*01144 *01193 *0391 01136 48232 4824 4824

4824 4824 4824 01140 48239 *485 *5089

*01145 *01194 *11505 01141 4824 4824 4824

4824 4824 4824 01142 48281 *486 *5171
25664 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM; SELECTED PERCENTILE LENGTHS OF STAY

[FY97 MEDPAR Update 12/97 Grouper V15.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

1 .................................... 36587 9.6084 2 4 7 12 20

2 .................................... 6967 10.0350 3 5 8 13 20

3 .................................... 3 9.3333 7 7 9 12 12

4 .................................... 6322 7.7259 1 3 5 9 17

5 .................................... 101105 3.6387 1 2 2 4 8

6 .................................... 355 3.0225 1 1 2 4 7

7 .................................... 12601 10.0945 2 4 7 12 20

8 .................................... 3030 3.1845 1 1 2 4 7

9 .................................... 1692 6.4923 1 3 5 8 13

10 .................................. 19727 6.8631 2 3 5 8 14

11 .................................. 2960 4.1365 1 2 3 5 8

12 .................................. 38339 6.6619 2 3 5 8 12

13 .................................. 6315 5.4716 2 3 4 6 9

14 .................................. 372136 6.2938 2 3 5 8 12

15 .................................. 145631 3.8599 1 2 3 5 7

16 .................................. 13905 5.9283 2 3 4 7 11

17 .................................. 3212 3.4315 1 2 3 4 7

18 .................................. 27489 5.5809 2 3 4 7 10

19 .................................. 7294 3.8174 1 2 3 5 7

20 .................................. 6590 10.1862 2 5 8 13 19

21 .................................. 1369 6.8152 2 3 5 8 14

22 .................................. 2789 4.6587 2 2 4 6 9

23 .................................. 6884 4.2594 1 2 3 5 8

24 .................................. 57890 5.0641 1 2 4 6 10

25 .................................. 22696 3.4294 1 2 3 4 7

26 .................................. 34 3.1176 1 1 2 4 6

27 .................................. 4153 5.4211 1 1 3 7 12

28 .................................. 13896 5.9431 1 2 4 7 12

29 .................................. 4266 3.5375 1 1 3 4 7

31 .................................. 3075 4.4062 1 2 3 5 8

32 .................................. 1343 2.9717 1 1 2 3 6

34 .................................. 20072 5.4331 1 3 4 7 11

35 .................................. 4264 3.5561 1 2 3 4 7

36 .................................. 5393 1.5366 1 1 1 1 2

37 .................................. 1685 3.7187 1 1 2 4 8

38 .................................. 116 2.5948 1 1 2 3 5

39 .................................. 1898 2.0327 1 1 1 2 4

40 .................................. 2281 3.1806 1 1 2 4 7

42 .................................. 4026 2.0904 1 1 1 2 4

43 .................................. 120 3.4250 1 2 3 5 7

44 .................................. 1343 5.0551 2 3 4 6 9

45 .................................. 2414 3.4731 1 2 3 4 6

46 .................................. 3148 4.6436 1 2 4 6 9

47 .................................. 1220 3.2975 1 1 3 4 7

48 .................................. 2 4.5000 4 4 5 5 5

49 .................................. 2277 5.0097 1 2 4 6 9

50 .................................. 3004 1.9767 1 1 2 2 3

51 .................................. 299 2.8194 1 1 1 3 6

52 .................................. 89 2.7528 1 1 2 3 7

53 .................................. 2989 3.6554 1 1 2 4 8

54 .................................. 2 6.0000 5 5 7 7 7

55 .................................. 1686 2.9543 1 1 2 3 6

56 .................................. 684 2.8436 1 1 2 3 6

57 .................................. 608 3.7237 1 1 3 4 7

59 .................................. 120 2.4333 1 1 2 3 5

60 .................................. 1 4.0000 4 4 4 4 4

61 .................................. 278 4.5144 1 1 2 5 10

62 .................................. 4 1.2500 1 1 1 1 2

63 .................................. 3676 4.4502 1 2 3 5 9

64 .................................. 3408 6.7183 1 2 5 8 14

65 .................................. 29086 2.9715 1 2 2 4 5

66 .................................. 6812 3.2606 1 2 3 4 6

67 .................................. 489 3.7996 1 2 3 4 7

68 .................................. 11522 4.1519 1 2 3 5 7

69 .................................. 3450 3.3183 1 2 3 4 6

70 .................................. 37 2.5405 1 1 2 3 4

71 .................................. 99 3.9394 1 2 3 6 7

72 .................................. 817 3.7931 1 2 3 5 7

73 .................................. 6282 4.4062 1 2 3 6 8

74 .................................. 2 2.5000 2 2 3 3 3
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25665

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM; SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY97 MEDPAR Update 12/97 Grouper V15.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

75 .................................. 40757 10.2370 4 5 8 13 20

76 .................................. 41668 11.3195 3 5 9 14 21

77 .................................. 2040 4.8819 1 2 4 7 10

78 .................................. 30845 7.3107 3 5 7 9 12

79 .................................. 247000 8.4030 3 4 7 10 15

80 .................................. 8299 5.8754 2 3 5 7 10

81 .................................. 6 12.6667 2 3 6 8 8

82 .................................. 71035 7.1298 2 3 6 9 14

83 .................................. 7249 5.5655 2 3 4 7 10

84 .................................. 1290 3.3256 1 2 3 4 6

85 .................................. 22415 6.6640 2 3 5 8 13

86 .................................. 1501 3.8741 1 2 3 5 7

87 .................................. 73076 6.3172 1 3 5 8 12

88 .................................. 388565 5.4142 2 3 4 7 10

89 .................................. 469073 6.2791 2 4 5 8 11

90 .................................. 38989 4.4632 2 3 4 6 8

91 .................................. 48 3.9375 1 2 3 5 7

92 .................................. 14464 6.3794 2 3 5 8 12

93 .................................. 1314 4.3653 1 2 4 6 8

94 .................................. 13391 6.4833 2 3 5 8 12

95 .................................. 1388 3.8739 1 2 3 5 7

96 .................................. 61778 4.8513 2 3 4 6 9

97 .................................. 25587 3.8266 1 2 3 5 7

98 .................................. 28 4.9286 1 2 3 5 13

99 .................................. 26442 3.0393 1 1 2 4 6

100 ................................ 10283 2.1219 1 1 2 3 4

101 ................................ 20140 4.4383 1 2 3 5 9

102 ................................ 4520 2.7914 1 1 2 3 5

103 ................................ 490 48.0898 9 14 29 67 115

104 ................................ 29151 12.4470 4 7 10 16 23

105 ................................ 25542 9.6459 4 6 8 11 17

106 ................................ 106585 10.6917 6 7 9 12 17

107 ................................ 68972 7.9520 4 5 7 9 13

108 ................................ 8075 11.7282 4 6 9 14 22

110 ................................ 62245 9.6084 2 5 8 12 18

111 ................................ 5581 5.8094 2 4 6 7 9

112 ................................ 118470 3.9277 1 1 3 5 8

113 ................................ 46689 12.2570 4 6 9 15 24

114 ................................ 8489 8.3873 2 4 7 11 16

115 ................................ 15007 8.7475 2 4 7 11 17

116 ................................ 208927 4.1747 1 2 3 5 8

117 ................................ 3726 3.9847 1 1 2 5 9

118 ................................ 6481 2.9303 1 1 2 3 6

119 ................................ 1629 5.3640 1 1 3 7 13

120 ................................ 37814 8.1649 1 2 5 10 18

121 ................................ 170012 6.6480 2 4 6 8 12

122 ................................ 83182 4.2023 1 2 4 6 7

123 ................................ 43363 4.4029 1 1 2 5 10

124 ................................ 154194 4.4587 1 2 4 6 9

125 ................................ 62627 2.8721 1 1 2 4 6

126 ................................ 5399 12.4253 4 6 9 15 25

127 ................................ 719871 5.5133 2 3 4 7 10

128 ................................ 16049 6.0323 3 4 5 7 9

129 ................................ 4455 2.9495 1 1 1 3 7

130 ................................ 98047 5.9926 2 3 5 7 10

131 ................................ 24574 4.6703 1 3 4 6 8

132 ................................ 174092 3.1532 1 2 3 4 6

133 ................................ 6631 2.4803 1 1 2 3 5

134 ................................ 30358 3.4496 1 2 3 4 6

135 ................................ 8217 4.3269 1 2 3 5 8

136 ................................ 1113 2.9695 1 1 2 4 5

138 ................................ 209079 4.0464 1 2 3 5 8

139 ................................ 67303 2.5774 1 1 2 3 5

140 ................................ 107658 2.9719 1 1 2 4 5

141 ................................ 81733 3.8534 1 2 3 5 7

142 ................................ 36613 2.7911 1 1 2 3 5

143 ................................ 143826 2.2585 1 1 2 3 4

144 ................................ 78710 5.2279 1 2 4 7 10

145 ................................ 6350 2.8698 1 1 2 4 6

146 ................................ 10372 10.2717 5 7 9 12 17
25666 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM; SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY97 MEDPAR Update 12/97 Grouper V15.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

147 ................................ 1779 6.7482 4 5 7 8 10

148 ................................ 146892 12.2593 5 7 10 15 22

149 ................................ 14387 6.8504 4 5 6 8 10

150 ................................ 23756 10.8870 4 6 9 13 19

151 ................................ 4149 5.8894 2 3 5 8 10

152 ................................ 4713 8.3393 4 5 7 10 14

153 ................................ 1604 5.6359 3 4 5 7 8

154 ................................ 34348 13.3603 4 7 10 16 25

155 ................................ 4743 4.6884 1 2 4 6 9

156 ................................ 2 18.0000 6 6 30 30 30

157 ................................ 9287 5.3854 1 2 4 7 11

158 ................................ 4110 2.6190 1 1 2 3 5

159 ................................ 18320 4.9678 1 2 4 6 9

160 ................................ 9765 2.6768 1 1 2 3 5

161 ................................ 14601 4.0877 1 2 3 5 9

162 ................................ 7065 2.0350 1 1 1 2 4

163 ................................ 5 11.8000 4 4 11 13 22

164 ................................ 5272 8.5277 4 5 7 10 15

165 ................................ 1639 4.9555 2 3 5 6 8

166 ................................ 3542 5.1256 2 3 4 6 9

167 ................................ 2325 2.8456 1 2 2 4 5

168 ................................ 1700 4.5476 1 2 3 6 9

169 ................................ 843 2.5326 1 1 2 3 5

170 ................................ 12774 11.2370 2 5 8 14 23

171 ................................ 1004 4.8337 1 2 4 6 9

172 ................................ 32993 7.1114 2 3 5 9 14

173 ................................ 2135 3.9611 1 1 3 5 8

174 ................................ 248770 4.9263 2 3 4 6 9

175 ................................ 21672 3.0085 1 2 3 4 5

176 ................................ 18343 5.4925 2 3 4 7 10

177 ................................ 11138 4.5572 2 2 4 6 8

178 ................................ 3486 3.2114 1 2 3 4 6

179 ................................ 12485 6.4200 2 3 5 8 12

180 ................................ 93327 5.4284 2 3 4 7 10

181 ................................ 21330 3.5057 1 2 3 4 6

182 ................................ 234973 4.3571 1 2 3 5 8

183 ................................ 69893 3.0179 1 1 2 4 6

184 ................................ 91 3.1648 1 2 2 4 7

185 ................................ 4046 4.4881 1 2 3 6 9

187 ................................ 870 3.9908 1 2 3 5 8

188 ................................ 75257 5.5524 1 2 4 7 11

189 ................................ 8618 3.2060 1 1 2 4 6

190 ................................ 59 5.2712 1 2 4 7 11

191 ................................ 10625 14.5648 4 7 11 18 29

192 ................................ 831 6.7088 2 4 6 8 12

193 ................................ 7334 12.5020 5 7 10 15 22

194 ................................ 773 6.9288 3 4 6 9 12

195 ................................ 7094 9.8105 4 6 8 12 17

196 ................................ 1260 5.7254 2 4 5 7 10

197 ................................ 25012 8.6285 3 5 7 10 15

198 ................................ 6357 4.5945 2 3 4 6 8

199 ................................ 2037 10.1733 3 5 8 14 20

200 ................................ 1339 11.4593 2 4 8 14 23

201 ................................ 1651 14.2938 4 6 11 18 29

202 ................................ 28649 6.7440 2 3 5 8 13

203 ................................ 29508 6.8400 2 3 5 9 14

204 ................................ 53140 6.0853 2 3 5 7 11

205 ................................ 22927 6.5500 2 3 5 8 13

206 ................................ 1614 4.0694 1 2 3 5 8

207 ................................ 35502 5.1397 1 2 4 6 10

208 ................................ 9472 2.8992 1 1 2 4 6

209 ................................ 362634 5.4336 3 4 5 6 8

210 ................................ 141586 7.0191 3 4 6 8 12

211 ................................ 26005 5.1476 3 4 5 6 8

212 ................................ 13 3.7692 1 2 4 5 6

213 ................................ 7496 8.4066 2 4 6 11 16

216 ................................ 6117 9.8190 2 4 7 12 19

217 ................................ 20587 12.9505 3 5 9 16 27

218 ................................ 23700 5.3217 2 3 4 6 10

219 ................................ 18252 3.2882 1 2 3 4 5
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25667

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM; SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY97 MEDPAR Update 12/97 Grouper V15.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

220 ................................ 5 3.2000 1 1 3 4 7

223 ................................ 18540 2.6177 1 1 2 3 5

224 ................................ 7682 2.0607 1 1 2 3 4

225 ................................ 5644 4.3556 1 2 3 5 9

226 ................................ 5540 5.9224 1 2 4 7 12

227 ................................ 4597 2.7261 1 1 2 3 5

228 ................................ 2757 3.4345 1 1 2 4 8

229 ................................ 1100 2.3827 1 1 2 3 5

230 ................................ 2386 4.5306 1 2 3 5 9

231 ................................ 10685 4.5647 1 2 3 5 9

232 ................................ 496 3.8327 1 1 2 4 9

233 ................................ 4903 7.6490 2 3 5 9 16

234 ................................ 2258 3.6151 1 2 3 5 7

235 ................................ 5348 5.3113 1 2 4 6 10

236 ................................ 39380 5.1518 1 3 4 6 9

237 ................................ 1593 3.6353 1 2 3 5 7

238 ................................ 7851 8.8615 3 4 7 11 17

239 ................................ 59615 6.4289 2 3 5 8 12

240 ................................ 13635 6.6882 2 3 5 8 13

241 ................................ 2905 3.9983 1 2 3 5 7

242 ................................ 2634 6.7358 2 3 5 8 13

243 ................................ 81633 4.8627 2 3 4 6 9

244 ................................ 12420 4.9928 2 3 4 6 9

245 ................................ 4361 3.7420 1 2 3 5 7

246 ................................ 1273 3.9309 1 2 3 5 7

247 ................................ 12240 3.4938 1 2 3 4 7

248 ................................ 8122 4.6959 1 2 4 6 9

249 ................................ 10840 3.6358 1 1 3 4 7

250 ................................ 3561 4.2263 1 2 3 5 8

251 ................................ 2210 2.9570 1 1 2 4 5

252 ................................ 1 1.0000 1 1 1 1 1

253 ................................ 19384 4.8629 1 3 4 6 9

254 ................................ 9275 3.3439 1 2 3 4 6

255 ................................ 2 3.5000 1 1 6 6 6

256 ................................ 5517 5.1064 1 2 4 6 10

257 ................................ 21137 2.9877 1 2 2 3 5

258 ................................ 16396 2.1344 1 1 2 3 3

259 ................................ 3772 3.0803 1 1 2 3 7

260 ................................ 4464 1.5383 1 1 1 2 2

261 ................................ 1967 2.2466 1 1 2 3 4

262 ................................ 659 4.2231 1 1 3 6 9

263 ................................ 27474 11.3931 3 5 8 14 22

264 ................................ 3318 7.0530 2 3 5 8 14

265 ................................ 4309 6.5331 1 2 4 8 13

266 ................................ 2464 3.4054 1 1 2 4 7

267 ................................ 250 4.6400 1 2 3 5 9

268 ................................ 875 3.5783 1 1 2 4 7

269 ................................ 9415 7.8786 2 3 6 10 16

270 ................................ 2662 3.1480 1 1 2 4 7

271 ................................ 22961 7.1545 3 4 6 9 13

272 ................................ 5940 6.4330 2 3 5 8 12

273 ................................ 1307 4.7980 1 2 4 6 8

274 ................................ 2409 6.7430 1 3 5 8 14

275 ................................ 210 3.5143 1 1 2 4 7

276 ................................ 932 4.4678 1 2 4 6 8

277 ................................ 81663 5.9066 2 3 5 7 10

278 ................................ 24598 4.4950 2 3 4 6 8

279 ................................ 12 5.0000 2 2 4 7 9

280 ................................ 14156 4.3177 1 2 3 5 8

281 ................................ 5945 3.1527 1 1 3 4 6

282 ................................ 2 2.0000 2 2 2 2 2

283 ................................ 5201 4.8029 1 2 4 6 9

284 ................................ 1656 3.3255 1 2 3 4 6

285 ................................ 5534 11.0193 3 5 8 13 21

286 ................................ 2141 6.9650 3 4 5 8 13

287 ................................ 6161 11.2446 3 5 8 13 22

288 ................................ 1478 5.9303 2 3 5 6 9

289 ................................ 5457 3.2448 1 1 2 3 7

290 ................................ 8922 2.5158 1 1 2 3 4

291 ................................ 66 1.7576 1 1 1 2 3
25668 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM; SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY97 MEDPAR Update 12/97 Grouper V15.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

292 ................................ 5029 10.7174 2 4 8 14 21

293 ................................ 347 5.5476 1 2 4 7 12

294 ................................ 82039 4.9200 1 2 4 6 9

295 ................................ 3593 3.9585 1 2 3 5 7

296 ................................ 235524 5.3934 2 3 4 7 10

297 ................................ 32715 3.6521 1 2 3 4 7

298 ................................ 91 3.7253 1 1 2 4 8

299 ................................ 968 5.3657 1 2 4 7 10

300 ................................ 16820 6.2855 2 3 5 8 12

301 ................................ 2395 3.8113 1 2 3 5 7

302 ................................ 7784 10.1382 5 6 8 12 18

303 ................................ 19638 9.2247 4 5 7 10 16

304 ................................ 12813 8.9904 2 4 7 11 18

305 ................................ 2552 3.8985 1 2 3 5 7

306 ................................ 10658 5.5019 1 2 3 7 12

307 ................................ 2355 2.3996 1 1 2 3 4

308 ................................ 9167 6.0165 1 2 4 8 13

309 ................................ 3541 2.5945 1 1 2 3 5

310 ................................ 26694 4.2835 1 2 3 5 9

311 ................................ 7805 1.9543 1 1 1 2 4

312 ................................ 1731 4.3437 1 1 3 6 9

313 ................................ 587 2.3799 1 1 2 3 5

314 ................................ 1 10.0000 10 10 10 10 10

315 ................................ 28283 8.0413 1 2 5 10 18

316 ................................ 93071 6.8024 2 3 5 9 14

317 ................................ 787 2.8666 1 1 2 3 6

318 ................................ 6194 6.1022 1 3 5 8 12

319 ................................ 407 2.9902 1 1 2 4 6

320 ................................ 177474 5.5698 2 3 4 7 10

321 ................................ 23679 4.0416 2 2 3 5 7

322 ................................ 82 4.1098 2 2 3 4 7

323 ................................ 16931 3.2166 1 1 2 4 6

324 ................................ 7513 1.9385 1 1 1 2 4

325 ................................ 7409 3.9591 1 2 3 5 8

326 ................................ 2192 2.7199 1 1 2 3 5

327 ................................ 9 2.8889 1 1 2 3 4

328 ................................ 759 3.7167 1 2 3 5 7

329 ................................ 87 2.2644 1 1 1 3 4

331 ................................ 43598 5.5769 1 3 4 7 11

332 ................................ 4517 3.5603 1 1 3 5 7

333 ................................ 306 4.9477 1 2 4 6 11

334 ................................ 18572 4.9690 3 3 4 6 8

335 ................................ 10338 3.7163 2 3 3 4 5

336 ................................ 54082 3.6046 1 2 3 4 7

337 ................................ 31770 2.2858 1 1 2 3 4

338 ................................ 2767 4.7879 1 2 3 6 10

339 ................................ 1987 4.1726 1 1 3 5 9

340 ................................ 2 1.0000 1 1 1 1 1

341 ................................ 4909 2.9589 1 1 2 3 6

342 ................................ 1007 3.4518 1 2 2 4 7

344 ................................ 3882 2.6285 1 1 1 3 5

345 ................................ 1343 3.6389 1 1 2 4 8

346 ................................ 4844 5.8179 1 3 4 7 11

347 ................................ 365 3.1370 1 1 2 4 6

348 ................................ 3181 4.2521 1 2 3 5 8

349 ................................ 632 2.7658 1 1 2 4 5

350 ................................ 6114 4.3999 2 2 4 5 8

352 ................................ 638 3.6160 1 2 3 4 7

353 ................................ 2816 6.9457 3 4 5 8 12

354 ................................ 9926 5.7743 3 3 4 6 10

355 ................................ 5640 3.4624 2 3 3 4 5

356 ................................ 28862 2.6478 1 2 2 3 4

357 ................................ 6330 9.0289 3 5 7 11 17

358 ................................ 27373 4.3708 2 3 3 5 7

359 ................................ 27990 2.9775 2 2 3 3 4

360 ................................ 17843 3.1581 1 2 3 4 5

361 ................................ 540 3.3259 1 1 2 3 7

363 ................................ 3943 3.3109 1 2 2 3 6

364 ................................ 1828 3.5656 1 1 2 5 8

365 ................................ 2298 6.8903 1 2 5 9 14
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25669

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM; SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY97 MEDPAR Update 12/97 Grouper V15.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

366 ................................ 4368 6.8116 1 3 5 8 14

367 ................................ 506 2.8893 1 1 2 3 6

368 ................................ 2895 6.3530 2 3 5 8 12

369 ................................ 2588 3.0622 1 1 2 4 6

370 ................................ 1154 5.4610 2 3 4 5 9

371 ................................ 1157 3.4754 2 3 3 4 5

372 ................................ 975 3.1549 1 2 2 3 5

373 ................................ 3868 2.1171 1 1 2 2 3

374 ................................ 147 3.0340 1 2 2 3 3

375 ................................ 9 5.1111 2 2 3 9 10

376 ................................ 214 2.9252 1 2 2 3 6

377 ................................ 52 4.4808 1 2 3 6 9

378 ................................ 168 2.5952 1 1 2 3 4

379 ................................ 334 3.5868 1 1 2 3 7

380 ................................ 87 2.0345 1 1 2 2 3

381 ................................ 187 2.1283 1 1 1 2 4

382 ................................ 40 1.2750 1 1 1 1 2

383 ................................ 1460 3.7301 1 2 3 4 8

384 ................................ 123 2.6585 1 1 2 3 6

385 ................................ 1 2.0000 2 2 2 2 2

389 ................................ 9 8.6667 1 3 7 10 15

390 ................................ 13 6.0000 2 2 4 5 17

392 ................................ 2513 10.3828 4 5 7 12 21

394 ................................ 1805 7.0853 1 2 4 8 16

395 ................................ 70948 4.7241 1 2 3 6 9

396 ................................ 15 18.4667 1 2 5 11 15

397 ................................ 18814 5.5200 1 2 4 7 11

398 ................................ 18127 6.0414 2 3 5 7 11

399 ................................ 1322 3.7239 1 2 3 5 7

400 ................................ 7225 9.3664 2 3 6 12 20

401 ................................ 6653 11.0137 2 4 8 14 23

402 ................................ 1464 3.8907 1 1 3 5 9

403 ................................ 38919 8.1409 2 3 6 10 17

404 ................................ 3797 4.4464 1 2 3 6 9

406 ................................ 3308 9.5299 2 4 7 12 20

407 ................................ 634 4.3202 1 2 4 5 8

408 ................................ 2667 7.5047 1 2 5 9 16

409 ................................ 4644 5.8404 2 3 4 6 11

410 ................................ 59252 3.4182 1 2 3 4 6

411 ................................ 18 2.8889 1 1 2 2 6

412 ................................ 24 2.3333 1 1 2 3 4

413 ................................ 7781 7.4429 2 3 6 9 15

414 ................................ 676 4.2219 1 2 3 5 8

415 ................................ 45158 14.3432 4 7 11 18 28

416 ................................ 230365 7.3967 2 4 6 9 14

417 ................................ 41 5.9024 2 2 5 7 11

418 ................................ 21184 6.1906 2 3 5 8 11

419 ................................ 15269 5.0200 2 3 4 6 9

420 ................................ 2680 3.9474 1 2 3 5 7

421 ................................ 12113 3.9569 1 2 3 5 7

422 ................................ 86 3.3372 1 2 2 5 7

423 ................................ 10723 7.7520 2 3 6 9 15

424 ................................ 1621 14.2961 2 5 10 18 29

425 ................................ 15405 4.1352 1 2 3 5 8

426 ................................ 4449 4.9020 1 2 3 6 10

427 ................................ 1633 4.8010 1 2 3 6 10

428 ................................ 940 7.1755 1 2 4 8 14

429 ................................ 32769 7.1661 2 3 5 8 14

430 ................................ 56829 8.7198 2 4 7 11 17

431 ................................ 217 7.3088 1 3 5 9 13

432 ................................ 409 5.2152 1 2 3 6 12

433 ................................ 6811 3.2053 1 1 2 4 7

434 ................................ 21537 5.1804 2 3 4 6 9

435 ................................ 14552 4.4078 1 2 4 5 8

436 ................................ 3322 13.9618 4 7 13 21 28

437 ................................ 12779 9.2061 3 5 8 12 16

439 ................................ 1138 7.7065 1 3 5 9 16

440 ................................ 5155 8.9081 2 3 6 10 19

441 ................................ 570 3.4333 1 1 2 4 7

442 ................................ 16247 8.1177 1 3 6 10 17
25670 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM; SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY97 MEDPAR Update 12/97 Grouper V15.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

443 ................................ 3153 3.3321 1 1 2 4 7

444 ................................ 3425 4.5007 1 2 3 5 8

445 ................................ 1243 3.3628 1 2 3 4 6

446 ................................ 1 2.0000 2 2 2 2 2

447 ................................ 4257 2.5130 1 1 2 3 5

449 ................................ 27905 3.7822 1 1 3 5 8

450 ................................ 6171 2.0826 1 1 1 2 4

451 ................................ 9 2.7778 1 1 1 4 5

452 ................................ 22863 5.0341 1 2 4 6 10

453 ................................ 3796 2.9236 1 1 2 4 6

454 ................................ 3855 4.6905 1 2 3 6 9

455 ................................ 758 2.7401 1 1 2 3 5

456 ................................ 194 8.5670 1 1 3 9 21

457 ................................ 128 3.5859 1 1 1 3 9

458 ................................ 1526 15.0308 3 7 12 19 31

459 ................................ 480 8.9771 2 3 6 11 19

460 ................................ 2327 6.0812 1 3 4 7 12

461 ................................ 3047 4.4322 1 1 2 4 11

462 ................................ 10348 12.4504 4 6 10 16 23

463 ................................ 13983 4.4209 1 2 3 5 8

464 ................................ 3556 3.3751 1 2 3 4 6

465 ................................ 210 2.9095 1 1 1 3 5

466 ................................ 1748 4.0955 1 1 2 4 9

467 ................................ 1332 4.3949 1 1 2 4 7

468 ................................ 61704 13.4718 3 6 10 17 27

471 ................................ 12918 6.0694 3 4 5 7 10

472 ................................ 179 27.2179 1 8 19 37 55

473 ................................ 8429 12.7713 2 3 7 18 33

475 ................................ 109339 11.1900 2 5 9 15 22

476 ................................ 5924 11.9158 3 6 10 15 22

477 ................................ 28747 8.1623 1 3 6 11 17

478 ................................ 123286 7.4571 1 3 5 9 15

479 ................................ 18337 3.8430 1 2 3 5 7

480 ................................ 400 26.7550 8 11 20 32 53

481 ................................ 256 27.1133 16 20 24 32 43

482 ................................ 6596 12.7329 4 7 10 15 23

483 ................................ 41763 40.0560 14 21 33 50 73

484 ................................ 391 14.6931 2 6 11 18 27

485 ................................ 3471 9.5906 4 5 7 11 18

486 ................................ 2244 12.3382 1 5 10 16 25

487 ................................ 4210 7.3983 2 3 6 9 14

488 ................................ 865 17.0532 4 7 12 22 35

489 ................................ 14894 8.9049 2 4 6 11 19

490 ................................ 4863 5.4148 1 2 4 7 11

491 ................................ 11011 3.6593 2 2 3 4 6

492 ................................ 2334 17.1418 4 5 12 27 36

493 ................................ 56210 5.6284 1 2 5 7 11

494 ................................ 25155 2.4285 1 1 2 3 5

495 ................................ 125 16.9920 7 10 13 19 31

496 ................................ 895 10.5821 4 6 8 13 20

497 ................................ 21969 6.2886 2 3 5 7 11

498 ................................ 12500 3.5058 1 2 3 5 6

499 ................................ 36205 4.9604 2 2 4 6 9

500 ................................ 36448 2.8726 1 2 2 4 5

501 ................................ 1895 10.4391 4 6 8 12 19

502 ................................ 468 6.5876 3 4 6 8 10

503 ................................ 6317 4.2169 1 2 3 5 8

11244775

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM; SELECTED PERCENTILE LENGTHS OF STAY

[FY97 MEDPAR Update 12/97 Grouper V16.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

1 .................................... 36587 9.6084 2 4 7 12 20

2 .................................... 6967 10.0350 3 5 8 13 20

3 .................................... 3 9.3333 7 7 9 12 12
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25671

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM; SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY97 MEDPAR Update 12/97 Grouper V16.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

4 .................................... 6322 7.7259 1 3 5 9 17

5 .................................... 101105 3.6387 1 2 2 4 8

6 .................................... 355 3.0225 1 1 2 4 7

7 .................................... 12601 10.0945 2 4 7 12 20

8 .................................... 3030 3.1845 1 1 2 4 7

9 .................................... 1692 6.4923 1 3 5 8 13

10 .................................. 19727 6.8631 2 3 5 8 14

11 .................................. 2960 4.1365 1 2 3 5 8

12 .................................. 38339 6.6619 2 3 5 8 12

13 .................................. 6315 5.4716 2 3 4 6 9

14 .................................. 372136 6.2938 2 3 5 8 12

15 .................................. 145631 3.8599 1 2 3 5 7

16 .................................. 13905 5.9283 2 3 4 7 11

17 .................................. 3212 3.4315 1 2 3 4 7

18 .................................. 27489 5.5809 2 3 4 7 10

19 .................................. 7294 3.8174 1 2 3 5 7

20 .................................. 6590 10.1862 2 5 8 13 19

21 .................................. 1369 6.8152 2 3 5 8 14

22 .................................. 2789 4.6587 2 2 4 6 9

23 .................................. 6884 4.2594 1 2 3 5 8

24 .................................. 57890 5.0641 1 2 4 6 10

25 .................................. 22696 3.4294 1 2 3 4 7

26 .................................. 34 3.1176 1 1 2 4 6

27 .................................. 4153 5.4211 1 1 3 7 12

28 .................................. 13896 5.9431 1 2 4 7 12

29 .................................. 4266 3.5375 1 1 3 4 7

31 .................................. 3075 4.4062 1 2 3 5 8

32 .................................. 1343 2.9717 1 1 2 3 6

34 .................................. 20072 5.4331 1 3 4 7 11

35 .................................. 4264 3.5561 1 2 3 4 7

36 .................................. 5393 1.5366 1 1 1 1 2

37 .................................. 1685 3.7187 1 1 2 4 8

38 .................................. 116 2.5948 1 1 2 3 5

39 .................................. 1898 2.0327 1 1 1 2 4

40 .................................. 2281 3.1806 1 1 2 4 7

42 .................................. 4026 2.0904 1 1 1 2 4

43 .................................. 120 3.4250 1 2 3 5 7

44 .................................. 1343 5.0551 2 3 4 6 9

45 .................................. 2414 3.4731 1 2 3 4 6

46 .................................. 3148 4.6436 1 2 4 6 9

47 .................................. 1220 3.2975 1 1 3 4 7

48 .................................. 2 4.5000 4 4 5 5 5

49 .................................. 2277 5.0097 1 2 4 6 9

50 .................................. 3004 1.9767 1 1 2 2 3

51 .................................. 299 2.8194 1 1 1 3 6

52 .................................. 89 2.7528 1 1 2 3 7

53 .................................. 2989 3.6554 1 1 2 4 8

54 .................................. 2 6.0000 5 5 7 7 7

55 .................................. 1686 2.9543 1 1 2 3 6

56 .................................. 684 2.8436 1 1 2 3 6

57 .................................. 608 3.7237 1 1 3 4 7

59 .................................. 120 2.4333 1 1 2 3 5

60 .................................. 1 4.0000 4 4 4 4 4

61 .................................. 278 4.5144 1 1 2 5 10

62 .................................. 4 1.2500 1 1 1 1 2

63 .................................. 3676 4.4502 1 2 3 5 9

64 .................................. 3408 6.7183 1 2 5 8 14

65 .................................. 29086 2.9715 1 2 2 4 5

66 .................................. 6812 3.2606 1 2 3 4 6

67 .................................. 489 3.7996 1 2 3 4 7

68 .................................. 11522 4.1519 1 2 3 5 7

69 .................................. 3450 3.3183 1 2 3 4 6

70 .................................. 37 2.5405 1 1 2 3 4

71 .................................. 99 3.9394 1 2 3 6 7

72 .................................. 817 3.7931 1 2 3 5 7

73 .................................. 6282 4.4062 1 2 3 6 8

74 .................................. 2 2.5000 2 2 3 3 3

75 .................................. 40757 10.2370 4 5 8 13 20

76 .................................. 41668 11.3195 3 5 9 14 21

77 .................................. 2040 4.8819 1 2 4 7 10
25672 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM; SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY97 MEDPAR Update 12/97 Grouper V16.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

78 .................................. 30845 7.3107 3 5 7 9 12

79 .................................. 247000 8.4030 3 4 7 10 15

80 .................................. 8299 5.8754 2 3 5 7 10

81 .................................. 6 12.6667 2 3 6 8 8

82 .................................. 71035 7.1298 2 3 6 9 14

83 .................................. 7249 5.5655 2 3 4 7 10

84 .................................. 1290 3.3256 1 2 3 4 6

85 .................................. 22415 6.6640 2 3 5 8 13

86 .................................. 1501 3.8741 1 2 3 5 7

87 .................................. 73076 6.3172 1 3 5 8 12

88 .................................. 388565 5.4142 2 3 4 7 10

89 .................................. 469073 6.2791 2 4 5 8 11

90 .................................. 38989 4.4632 2 3 4 6 8

91 .................................. 48 3.9375 1 2 3 5 7

92 .................................. 14464 6.3794 2 3 5 8 12

93 .................................. 1314 4.3653 1 2 4 6 8

94 .................................. 13391 6.4833 2 3 5 8 12

95 .................................. 1388 3.8739 1 2 3 5 7

96 .................................. 61778 4.8513 2 3 4 6 9

97 .................................. 25587 3.8266 1 2 3 5 7

98 .................................. 28 4.9286 1 2 3 5 13

99 .................................. 26442 3.0393 1 1 2 4 6

100 ................................ 10283 2.1219 1 1 2 3 4

101 ................................ 20140 4.4383 1 2 3 5 9

102 ................................ 4520 2.7914 1 1 2 3 5

103 ................................ 490 48.0898 9 14 29 67 115

104 ................................ 29920 12.5288 4 7 10 16 23

105 ................................ 26799 9.7413 4 6 8 11 17

106 ................................ 4737 10.9261 5 7 9 13 19

107 ................................ 101848 10.6808 6 7 9 12 17

108 ................................ 6049 11.2420 4 6 9 14 21

109 ................................ 68972 7.9520 4 5 7 9 13

110 ................................ 62245 9.6084 2 5 8 12 18

111 ................................ 5581 5.8094 2 4 6 7 9

112 ................................ 118470 3.9277 1 1 3 5 8

113 ................................ 46689 12.2570 4 6 9 15 24

114 ................................ 8489 8.3873 2 4 7 11 16

115 ................................ 15007 8.7475 2 4 7 11 17

116 ................................ 208927 4.1747 1 2 3 5 8

117 ................................ 3726 3.9847 1 1 2 5 9

118 ................................ 6481 2.9303 1 1 2 3 6

119 ................................ 1629 5.3640 1 1 3 7 13

120 ................................ 37814 8.1649 1 2 5 10 18

121 ................................ 170012 6.6480 2 4 6 8 12

122 ................................ 83182 4.2023 1 2 4 6 7

123 ................................ 43363 4.4029 1 1 2 5 10

124 ................................ 154194 4.4587 1 2 4 6 9

125 ................................ 62627 2.8721 1 1 2 4 6

126 ................................ 5399 12.4253 4 6 9 15 25

127 ................................ 719871 5.5133 2 3 4 7 10

128 ................................ 16049 6.0323 3 4 5 7 9

129 ................................ 4455 2.9495 1 1 1 3 7

130 ................................ 98047 5.9926 2 3 5 7 10

131 ................................ 24574 4.6703 1 3 4 6 8

132 ................................ 174092 3.1532 1 2 3 4 6

133 ................................ 6631 2.4803 1 1 2 3 5

134 ................................ 30358 3.4496 1 2 3 4 6

135 ................................ 8217 4.3269 1 2 3 5 8

136 ................................ 1113 2.9695 1 1 2 4 5

138 ................................ 209079 4.0464 1 2 3 5 8

139 ................................ 67303 2.5774 1 1 2 3 5

140 ................................ 107658 2.9719 1 1 2 4 5

141 ................................ 81733 3.8534 1 2 3 5 7

142 ................................ 36613 2.7911 1 1 2 3 5

143 ................................ 143826 2.2585 1 1 2 3 4

144 ................................ 78710 5.2279 1 2 4 7 10

145 ................................ 6350 2.8698 1 1 2 4 6

146 ................................ 10372 10.2717 5 7 9 12 17

147 ................................ 1779 6.7482 4 5 7 8 10

148 ................................ 146892 12.2593 5 7 10 15 22
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25673

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM; SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY97 MEDPAR Update 12/97 Grouper V16.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

149 ................................ 14387 6.8504 4 5 6 8 10

150 ................................ 23756 10.8870 4 6 9 13 19

151 ................................ 4149 5.8894 2 3 5 8 10

152 ................................ 4713 8.3393 4 5 7 10 14

153 ................................ 1604 5.6359 3 4 5 7 8

154 ................................ 34348 13.3603 4 7 10 16 25

155 ................................ 4743 4.6884 1 2 4 6 9

156 ................................ 2 18.0000 6 6 30 30 30

157 ................................ 9287 5.3854 1 2 4 7 11

158 ................................ 4110 2.6190 1 1 2 3 5

159 ................................ 18320 4.9678 1 2 4 6 9

160 ................................ 9765 2.6768 1 1 2 3 5

161 ................................ 14601 4.0877 1 2 3 5 9

162 ................................ 7065 2.0350 1 1 1 2 4

163 ................................ 5 11.8000 4 4 11 13 22

164 ................................ 5272 8.5277 4 5 7 10 15

165 ................................ 1639 4.9555 2 3 5 6 8

166 ................................ 3542 5.1256 2 3 4 6 9

167 ................................ 2325 2.8456 1 2 2 4 5

168 ................................ 1700 4.5476 1 2 3 6 9

169 ................................ 843 2.5326 1 1 2 3 5

170 ................................ 12774 11.2370 2 5 8 14 23

171 ................................ 1004 4.8337 1 2 4 6 9

172 ................................ 32993 7.1114 2 3 5 9 14

173 ................................ 2135 3.9611 1 1 3 5 8

174 ................................ 248770 4.9263 2 3 4 6 9

175 ................................ 21672 3.0085 1 2 3 4 5

176 ................................ 18343 5.4925 2 3 4 7 10

177 ................................ 11138 4.5572 2 2 4 6 8

178 ................................ 3486 3.2114 1 2 3 4 6

179 ................................ 12485 6.4200 2 3 5 8 12

180 ................................ 93327 5.4284 2 3 4 7 10

181 ................................ 21330 3.5057 1 2 3 4 6

182 ................................ 234973 4.3571 1 2 3 5 8

183 ................................ 69893 3.0179 1 1 2 4 6

184 ................................ 91 3.1648 1 2 2 4 7

185 ................................ 4046 4.4881 1 2 3 6 9

187 ................................ 870 3.9908 1 2 3 5 8

188 ................................ 75257 5.5524 1 2 4 7 11

189 ................................ 8618 3.2060 1 1 2 4 6

190 ................................ 59 5.2712 1 2 4 7 11

191 ................................ 10625 14.5648 4 7 11 18 29

192 ................................ 831 6.7088 2 4 6 8 12

193 ................................ 7334 12.5020 5 7 10 15 22

194 ................................ 773 6.9288 3 4 6 9 12

195 ................................ 7094 9.8105 4 6 8 12 17

196 ................................ 1260 5.7254 2 4 5 7 10

197 ................................ 25012 8.6285 3 5 7 10 15

198 ................................ 6357 4.5945 2 3 4 6 8

199 ................................ 2037 10.1733 3 5 8 14 20

200 ................................ 1339 11.4593 2 4 8 14 23

201 ................................ 1651 14.2938 4 6 11 18 29

202 ................................ 28649 6.7440 2 3 5 8 13

203 ................................ 29508 6.8400 2 3 5 9 14

204 ................................ 53140 6.0853 2 3 5 7 11

205 ................................ 22927 6.5500 2 3 5 8 13

206 ................................ 1614 4.0694 1 2 3 5 8

207 ................................ 35502 5.1397 1 2 4 6 10

208 ................................ 9472 2.8992 1 1 2 4 6

209 ................................ 362634 5.4336 3 4 5 6 8

210 ................................ 141586 7.0191 3 4 6 8 12

211 ................................ 26005 5.1476 3 4 5 6 8

212 ................................ 13 3.7692 1 2 4 5 6

213 ................................ 7496 8.4066 2 4 6 11 16

216 ................................ 6117 9.8190 2 4 7 12 19

217 ................................ 20587 12.9505 3 5 9 16 27

218 ................................ 23700 5.3217 2 3 4 6 10

219 ................................ 18252 3.2882 1 2 3 4 5

220 ................................ 5 3.2000 1 1 3 4 7

223 ................................ 18540 2.6177 1 1 2 3 5
25674 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM; SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY97 MEDPAR Update 12/97 Grouper V16.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

224 ................................ 7682 2.0607 1 1 2 3 4

225 ................................ 5644 4.3556 1 2 3 5 9

226 ................................ 5540 5.9224 1 2 4 7 12

227 ................................ 4597 2.7261 1 1 2 3 5

228 ................................ 2757 3.4345 1 1 2 4 8

229 ................................ 1100 2.3827 1 1 2 3 5

230 ................................ 2386 4.5306 1 2 3 5 9

231 ................................ 10685 4.5647 1 2 3 5 9

232 ................................ 496 3.8327 1 1 2 4 9

233 ................................ 4903 7.6490 2 3 5 9 16

234 ................................ 2258 3.6151 1 2 3 5 7

235 ................................ 5348 5.3113 1 2 4 6 10

236 ................................ 39380 5.1518 1 3 4 6 9

237 ................................ 1593 3.6353 1 2 3 5 7

238 ................................ 7851 8.8615 3 4 7 11 17

239 ................................ 59615 6.4289 2 3 5 8 12

240 ................................ 13635 6.6882 2 3 5 8 13

241 ................................ 2905 3.9983 1 2 3 5 7

242 ................................ 2634 6.7358 2 3 5 8 13

243 ................................ 81633 4.8627 2 3 4 6 9

244 ................................ 12420 4.9928 2 3 4 6 9

245 ................................ 4361 3.7420 1 2 3 5 7

246 ................................ 1273 3.9309 1 2 3 5 7

247 ................................ 12240 3.4938 1 2 3 4 7

248 ................................ 8122 4.6959 1 2 4 6 9

249 ................................ 10840 3.6358 1 1 3 4 7

250 ................................ 3561 4.2263 1 2 3 5 8

251 ................................ 2210 2.9570 1 1 2 4 5

252 ................................ 1 1.0000 1 1 1 1 1

253 ................................ 19384 4.8629 1 3 4 6 9

254 ................................ 9275 3.3439 1 2 3 4 6

255 ................................ 2 3.5000 1 1 6 6 6

256 ................................ 5517 5.1064 1 2 4 6 10

257 ................................ 21137 2.9877 1 2 2 3 5

258 ................................ 16396 2.1344 1 1 2 3 3

259 ................................ 3772 3.0803 1 1 2 3 7

260 ................................ 4464 1.5383 1 1 1 2 2

261 ................................ 1967 2.2466 1 1 2 3 4

262 ................................ 659 4.2231 1 1 3 6 9

263 ................................ 27474 11.3931 3 5 8 14 22

264 ................................ 3318 7.0530 2 3 5 8 14

265 ................................ 4309 6.5331 1 2 4 8 13

266 ................................ 2464 3.4054 1 1 2 4 7

267 ................................ 250 4.6400 1 2 3 5 9

268 ................................ 875 3.5783 1 1 2 4 7

269 ................................ 9415 7.8786 2 3 6 10 16

270 ................................ 2662 3.1480 1 1 2 4 7

271 ................................ 22961 7.1545 3 4 6 9 13

272 ................................ 5940 6.4330 2 3 5 8 12

273 ................................ 1307 4.7980 1 2 4 6 8

274 ................................ 2409 6.7430 1 3 5 8 14

275 ................................ 210 3.5143 1 1 2 4 7

276 ................................ 932 4.4678 1 2 4 6 8

277 ................................ 81663 5.9066 2 3 5 7 10

278 ................................ 24598 4.4950 2 3 4 6 8

279 ................................ 12 5.0000 2 2 4 7 9

280 ................................ 14156 4.3177 1 2 3 5 8

281 ................................ 5945 3.1527 1 1 3 4 6

282 ................................ 2 2.0000 2 2 2 2 2

283 ................................ 5201 4.8029 1 2 4 6 9

284 ................................ 1656 3.3255 1 2 3 4 6

285 ................................ 5534 11.0193 3 5 8 13 21

286 ................................ 2141 6.9650 3 4 5 8 13

287 ................................ 6161 11.2446 3 5 8 13 22

288 ................................ 1478 5.9303 2 3 5 6 9

289 ................................ 5457 3.2448 1 1 2 3 7

290 ................................ 8922 2.5158 1 1 2 3 4

291 ................................ 66 1.7576 1 1 1 2 3

292 ................................ 5029 10.7174 2 4 8 14 21

293 ................................ 347 5.5476 1 2 4 7 12
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25675

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM; SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY97 MEDPAR Update 12/97 Grouper V16.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

294 ................................ 82039 4.9200 1 2 4 6 9

295 ................................ 3593 3.9585 1 2 3 5 7

296 ................................ 235524 5.3934 2 3 4 7 10

297 ................................ 32715 3.6521 1 2 3 4 7

298 ................................ 91 3.7253 1 1 2 4 8

299 ................................ 968 5.3657 1 2 4 7 10

300 ................................ 16820 6.2855 2 3 5 8 12

301 ................................ 2395 3.8113 1 2 3 5 7

302 ................................ 7784 10.1382 5 6 8 12 18

303 ................................ 19638 9.2247 4 5 7 10 16

304 ................................ 12813 8.9904 2 4 7 11 18

305 ................................ 2552 3.8985 1 2 3 5 7

306 ................................ 10658 5.5019 1 2 3 7 12

307 ................................ 2355 2.3996 1 1 2 3 4

308 ................................ 9167 6.0165 1 2 4 8 13

309 ................................ 3541 2.5945 1 1 2 3 5

310 ................................ 26694 4.2835 1 2 3 5 9

311 ................................ 7805 1.9543 1 1 1 2 4

312 ................................ 1731 4.3437 1 1 3 6 9

313 ................................ 587 2.3799 1 1 2 3 5

314 ................................ 1 10.0000 10 10 10 10 10

315 ................................ 28283 8.0413 1 2 5 10 18

316 ................................ 93071 6.8024 2 3 5 9 14

317 ................................ 787 2.8666 1 1 2 3 6

318 ................................ 6194 6.1022 1 3 5 8 12

319 ................................ 407 2.9902 1 1 2 4 6

320 ................................ 177474 5.5698 2 3 4 7 10

321 ................................ 23679 4.0416 2 2 3 5 7

322 ................................ 82 4.1098 2 2 3 4 7

323 ................................ 16931 3.2166 1 1 2 4 6

324 ................................ 7513 1.9385 1 1 1 2 4

325 ................................ 7409 3.9591 1 2 3 5 8

326 ................................ 2192 2.7199 1 1 2 3 5

327 ................................ 9 2.8889 1 1 2 3 4

328 ................................ 759 3.7167 1 2 3 5 7

329 ................................ 87 2.2644 1 1 1 3 4

331 ................................ 43598 5.5769 1 3 4 7 11

332 ................................ 4517 3.5603 1 1 3 5 7

333 ................................ 306 4.9477 1 2 4 6 11

334 ................................ 18572 4.9690 3 3 4 6 8

335 ................................ 10338 3.7163 2 3 3 4 5

336 ................................ 54082 3.6046 1 2 3 4 7

337 ................................ 31770 2.2858 1 1 2 3 4

338 ................................ 2767 4.7879 1 2 3 6 10

339 ................................ 1987 4.1726 1 1 3 5 9

340 ................................ 2 1.0000 1 1 1 1 1

341 ................................ 4909 2.9589 1 1 2 3 6

342 ................................ 1007 3.4518 1 2 2 4 7

344 ................................ 3882 2.6285 1 1 1 3 5

345 ................................ 1343 3.6389 1 1 2 4 8

346 ................................ 4844 5.8179 1 3 4 7 11

347 ................................ 365 3.1370 1 1 2 4 6

348 ................................ 3181 4.2521 1 2 3 5 8

349 ................................ 632 2.7658 1 1 2 4 5

350 ................................ 6114 4.3999 2 2 4 5 8

352 ................................ 638 3.6160 1 2 3 4 7

353 ................................ 2816 6.9457 3 4 5 8 12

354 ................................ 9926 5.7743 3 3 4 6 10

355 ................................ 5640 3.4624 2 3 3 4 5

356 ................................ 28862 2.6478 1 2 2 3 4

357 ................................ 6330 9.0289 3 5 7 11 17

358 ................................ 27373 4.3708 2 3 3 5 7

359 ................................ 27990 2.9775 2 2 3 3 4

360 ................................ 17843 3.1581 1 2 3 4 5

361 ................................ 540 3.3259 1 1 2 3 7

363 ................................ 3943 3.3109 1 2 2 3 6

364 ................................ 1828 3.5656 1 1 2 5 8

365 ................................ 2298 6.8903 1 2 5 9 14

366 ................................ 4368 6.8116 1 3 5 8 14

367 ................................ 506 2.8893 1 1 2 3 6
25676 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM; SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY97 MEDPAR Update 12/97 Grouper V16.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

368 ................................ 2895 6.3530 2 3 5 8 12

369 ................................ 2588 3.0622 1 1 2 4 6

370 ................................ 1154 5.4610 2 3 4 5 9

371 ................................ 1157 3.4754 2 3 3 4 5

372 ................................ 975 3.1549 1 2 2 3 5

373 ................................ 3868 2.1171 1 1 2 2 3

374 ................................ 147 3.0340 1 2 2 3 3

375 ................................ 9 5.1111 2 2 3 9 10

376 ................................ 214 2.9252 1 2 2 3 6

377 ................................ 52 4.4808 1 2 3 6 9

378 ................................ 168 2.5952 1 1 2 3 4

379 ................................ 334 3.5868 1 1 2 3 7

380 ................................ 87 2.0345 1 1 2 2 3

381 ................................ 187 2.1283 1 1 1 2 4

382 ................................ 40 1.2750 1 1 1 1 2

383 ................................ 1460 3.7301 1 2 3 4 8

384 ................................ 123 2.6585 1 1 2 3 6

385 ................................ 1 2.0000 2 2 2 2 2

389 ................................ 9 8.6667 1 3 7 10 15

390 ................................ 13 6.0000 2 2 4 5 17

392 ................................ 2513 10.3828 4 5 7 12 21

394 ................................ 1805 7.0853 1 2 4 8 16

395 ................................ 70948 4.7241 1 2 3 6 9

396 ................................ 15 18.4667 1 2 5 11 15

397 ................................ 18814 5.5200 1 2 4 7 11

398 ................................ 18127 6.0414 2 3 5 7 11

399 ................................ 1322 3.7239 1 2 3 5 7

400 ................................ 7225 9.3664 2 3 6 12 20

401 ................................ 6653 11.0137 2 4 8 14 23

402 ................................ 1464 3.8907 1 1 3 5 9

403 ................................ 38919 8.1409 2 3 6 10 17

404 ................................ 3797 4.4464 1 2 3 6 9

406 ................................ 3308 9.5299 2 4 7 12 20

407 ................................ 634 4.3202 1 2 4 5 8

408 ................................ 2667 7.5047 1 2 5 9 16

409 ................................ 4644 5.8404 2 3 4 6 11

410 ................................ 59252 3.4182 1 2 3 4 6

411 ................................ 18 2.8889 1 1 2 2 6

412 ................................ 24 2.3333 1 1 2 3 4

413 ................................ 7781 7.4429 2 3 6 9 15

414 ................................ 676 4.2219 1 2 3 5 8

415 ................................ 45158 14.3432 4 7 11 18 28

416 ................................ 230365 7.3967 2 4 6 9 14

417 ................................ 41 5.9024 2 2 5 7 11

418 ................................ 21184 6.1906 2 3 5 8 11

419 ................................ 15269 5.0200 2 3 4 6 9

420 ................................ 2680 3.9474 1 2 3 5 7

421 ................................ 12113 3.9569 1 2 3 5 7

422 ................................ 86 3.3372 1 2 2 5 7

423 ................................ 10723 7.7520 2 3 6 9 15

424 ................................ 1621 14.2961 2 5 10 18 29

425 ................................ 15405 4.1352 1 2 3 5 8

426 ................................ 4449 4.9020 1 2 3 6 10

427 ................................ 1633 4.8010 1 2 3 6 10

428 ................................ 940 7.1755 1 2 4 8 14

429 ................................ 32769 7.1661 2 3 5 8 14

430 ................................ 56829 8.7198 2 4 7 11 17

431 ................................ 217 7.3088 1 3 5 9 13

432 ................................ 409 5.2152 1 2 3 6 12

433 ................................ 6811 3.2053 1 1 2 4 7

434 ................................ 21537 5.1804 2 3 4 6 9

435 ................................ 14552 4.4078 1 2 4 5 8

436 ................................ 3322 13.9618 4 7 13 21 28

437 ................................ 12779 9.2061 3 5 8 12 16

439 ................................ 1138 7.7065 1 3 5 9 16

440 ................................ 5155 8.9081 2 3 6 10 19

441 ................................ 570 3.4333 1 1 2 4 7

442 ................................ 16247 8.1177 1 3 6 10 17

443 ................................ 3153 3.3321 1 1 2 4 7

444 ................................ 3425 4.5007 1 2 3 5 8
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25677

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM; SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY97 MEDPAR Update 12/97 Grouper V16.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

445 ................................ 1243 3.3628 1 2 3 4 6

446 ................................ 1 2.0000 2 2 2 2 2

447 ................................ 4257 2.5130 1 1 2 3 5

449 ................................ 27905 3.7822 1 1 3 5 8

450 ................................ 6171 2.0826 1 1 1 2 4

451 ................................ 9 2.7778 1 1 1 4 5

452 ................................ 22863 5.0341 1 2 4 6 10

453 ................................ 3796 2.9236 1 1 2 4 6

454 ................................ 3855 4.6905 1 2 3 6 9

455 ................................ 758 2.7401 1 1 2 3 5

461 ................................ 3047 4.4322 1 1 2 4 11

462 ................................ 10348 12.4504 4 6 10 16 23

463 ................................ 13983 4.4209 1 2 3 5 8

464 ................................ 3556 3.3751 1 2 3 4 6

465 ................................ 210 2.9095 1 1 1 3 5

466 ................................ 1748 4.0955 1 1 2 4 9

467 ................................ 1332 4.3949 1 1 2 4 7

468 ................................ 61704 13.4718 3 6 10 17 27

471 ................................ 12918 6.0694 3 4 5 7 10

473 ................................ 8429 12.7713 2 3 7 18 33

475 ................................ 109339 11.1900 2 5 9 15 22

476 ................................ 5924 11.9158 3 6 10 15 22

477 ................................ 28747 8.1623 1 3 6 11 17

478 ................................ 123286 7.4571 1 3 5 9 15

479 ................................ 18337 3.8430 1 2 3 5 7

480 ................................ 400 26.7550 8 11 20 32 53

481 ................................ 256 27.1133 16 20 24 32 43

482 ................................ 6596 12.7329 4 7 10 15 23

483 ................................ 41763 40.0560 14 21 33 50 73

484 ................................ 391 14.6931 2 6 11 18 27

485 ................................ 3471 9.5906 4 5 7 11 18

486 ................................ 2244 12.3382 1 5 10 16 25

487 ................................ 4210 7.3983 2 3 6 9 14

488 ................................ 865 17.0532 4 7 12 22 35

489 ................................ 14894 8.9049 2 4 6 11 19

490 ................................ 4863 5.4148 1 2 4 7 11

491 ................................ 11011 3.6593 2 2 3 4 6

492 ................................ 2334 17.1418 4 5 12 27 36

493 ................................ 56210 5.6284 1 2 5 7 11

494 ................................ 25155 2.4285 1 1 2 3 5

495 ................................ 125 16.9920 7 10 13 19 31

496 ................................ 895 10.5821 4 6 8 13 20

497 ................................ 21969 6.2886 2 3 5 7 11

498 ................................ 12500 3.5058 1 2 3 5 6

499 ................................ 36205 4.9604 2 2 4 6 9

500 ................................ 36448 2.8726 1 2 2 4 5

501 ................................ 1895 10.4391 4 6 8 12 19

502 ................................ 468 6.5876 3 4 6 8 10

503 ................................ 6317 4.2169 1 2 3 5 8

504 ................................ 157 31.5669 8 14 25 39 57

505 ................................ 171 5.8421 1 1 1 4 11

506 ................................ 1130 16.7522 4 8 13 21 34

507 ................................ 391 8.9668 2 4 7 12 17

508 ................................ 1206 7.7355 2 3 5 9 16

509 ................................ 462 4.8528 1 2 3 6 10

510 ................................ 1006 6.8897 2 3 5 8 13

511 ................................ 311 4.8135 1 2 3 6 9

11244775
25678 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE 8A.—STATEWIDE AVERAGE OPERATING COST-TO-CHARGE RATIOS

FOR URBAN AND RURAL HOSPITALS

(CASE WEIGHTED) MARCH 1998

State Urban Rural

ALABAMA ......................... 0.373 0.446

ALASKA ............................ 0.503 0.731

ARIZONA .......................... 0.375 0.540

ARKANSAS ....................... 0.515 0.457

CALIFORNIA ..................... 0.363 0.481

COLORADO ...................... 0.467 0.565

CONNECTICUT ................ 0.546 0.532

DELAWARE ...................... 0.506 0.488

DISTRICT OF COLUMBIA 0.521 ............

FLORIDA ........................... 0.384 0.389

GEORGIA ......................... 0.497 0.497

HAWAII ............................. 0.430 0.559

IDAHO ............................... 0.564 0.582

ILLINOIS ........................... 0.445 0.546

INDIANA ............................ 0.559 0.597

IOWA ................................. 0.513 0.640

KANSAS ............................ 0.429 0.644

KENTUCKY ....................... 0.496 0.519

LOUISIANA ....................... 0.442 0.496

MAINE ............................... 0.620 0.576

MARYLAND ...................... 0.765 0.818

MASSACHUSETTS .......... 0.540 0.571

MICHIGAN ........................ 0.467 0.580

MINNESOTA ..................... 0.532 0.611

MISSISSIPPI ..................... 0.478 0.499

MISSOURI ........................ 0.441 0.516

MONTANA ........................ 0.524 0.569

NEBRASKA ....................... 0.482 0.639

NEVADA ........................... 0.320 0.584

NEW HAMPSHIRE ........... 0.573 0.586

NEW JERSEY ................... 0.436 ............

NEW MEXICO .................. 0.466 0.510

NEW YORK ...................... 0.553 0.633

NORTH CAROLINA .......... 0.523 0.461

NORTH DAKOTA ............. 0.620 0.666

OHIO ................................. 0.533 0.576

OKLAHOMA ...................... 0.460 0.529

OREGON .......................... 0.546 0.624

PENNSYLVANIA ............... 0.407 0.527

PUERTO RICO ................. 0.481 0.569

RHODE ISLAND ............... 0.571 ............

SOUTH CAROLINA .......... 0.472 0.494

SOUTH DAKOTA .............. 0.537 0.620

TENNESSEE .................... 0.481 0.508

TEXAS .............................. 0.427 0.536

UTAH ................................ 0.538 0.635

VERMONT ........................ 0.615 0.577

VIRGINIA .......................... 0.476 0.499

WASHINGTON ................. 0.599 0.662

WEST VIRGINIA ............... 0.592 0.573

WISCONSIN ..................... 0.568 0.641

WYOMING ........................ 0.495 0.694

TABLE 8B.—STATEWIDE AVERAGE

CAPITAL COST-TO-CHARGE RATIOS

(CASE WEIGHTED) MARCH 1998

State Ratio

ALABAMA ......................................... 0.047

ALASKA ............................................ 0.066

ARIZONA .......................................... 0.043

ARKANSAS ...................................... 0.054

CALIFORNIA .................................... 0.038

COLORADO ..................................... 0.052

CONNECTICUT ................................ 0.042

DELAWARE ...................................... 0.058

TABLE 8B.—STATEWIDE AVERAGE

CAPITAL COST-TO-CHARGE RATIOS

(CASE WEIGHTED) MARCH 1998—

Continued

State Ratio

DISTRICT OF COLUMBIA ............... 0.040

FLORIDA .......................................... 0.046

GEORGIA ......................................... 0.049

HAWAII ............................................. 0.045

IDAHO ............................................... 0.054

ILLINOIS ........................................... 0.042

INDIANA ........................................... 0.059

IOWA ................................................ 0.054

KANSAS ........................................... 0.052

KENTUCKY ...................................... 0.051

LOUISIANA ....................................... 0.067

MAINE ............................................... 0.040

MARYLAND ...................................... 0.013

MASSACHUSETTS .......................... 0.056

MICHIGAN ........................................ 0.046

MINNESOTA ..................................... 0.056

MISSISSIPPI ..................................... 0.054

MISSOURI ........................................ 0.049

MONTANA ........................................ 0.052

NEBRASKA ...................................... 0.057

NEVADA ........................................... 0.068

NEW HAMPSHIRE ........................... 0.066

NEW JERSEY .................................. 0.039

NEW MEXICO .................................. 0.047

NEW YORK ...................................... 0.053

NORTH CAROLINA .......................... 0.047

NORTH DAKOTA ............................. 0.075

OHIO ................................................. 0.053

OKLAHOMA ...................................... 0.054

OREGON .......................................... 0.055

PENNSYLVANIA .............................. 0.043

PUERTO RICO ................................. 0.054

RHODE ISLAND ............................... 0.033

SOUTH CAROLINA .......................... 0.053

SOUTH DAKOTA ............................. 0.061

TENNESSEE .................................... 0.056

TEXAS .............................................. 0.052

UTAH ................................................ 0.056

VERMONT ........................................ 0.047

VIRGINIA .......................................... 0.058

WASHINGTON ................................. 0.066

WEST VIRGINIA ............................... 0.056

WISCONSIN ..................................... 0.052

WYOMING ........................................ 0.056

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 1999, 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. GME Payment to Nonhospital Providers

In the past, Medicare only paid hospitals

for GME costs. Therefore, FQHCs, RHCs and

Medicare+Choice organizations may have

been reluctant to train many residents since

they would incur costs in training the

residents but would not be reimbursed for

those costs by Medicare. Under this proposed

regulation, where the non-hospital site incurs

all or substantially all of the costs of the

training at that site, Medicare will reimburse
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25679

the provider for Medicare’s share of the

reasonable costs of the training. The proposal

to allow for payments directly to these nonhospital sites for the costs of training

residents in approved programs will facilitate

more training of residents in settings that will

be similar to the settings that many of those

residents will ultimately practice after their

training is completed. Additionally, this

could result in an increase in the number of

physicians practicing in underserved areas.

In addition, hospitals are currently allowed

to count residents, working in nonhospital

sites in their count of residents and the

hospital would be paid GME payments, if it

paid for all or substantially all of the costs

of the program at the non-hospital site.

Previously the regulation defined the

statutory requirement of ‘‘all or substantially

all’’ to mean at least the residents’’ salaries

and fringe benefits. Under the proposal we

would redefine ‘‘all or substantially all’’ of

the costs of the program at the nonhospital

site to also include the GME portion of the

teaching physicians’ salaries and fringe

benefits. This will require hospitals to incur

more of the costs of the training at the

nonhospital site in order to receive both

direct and indirect GME payments for those

residents.

Section 4625 of the Balanced Budget Act,

which provides for direct graduate medical

education payments to nonhospital

providers, would have minimal impact in the

context of total graduate medical education

costs. We believe that the most significant

impact resulting from section 4625 will be

the movement of resident training from the

inpatient setting to the nonhospital setting.

We expect that such a shift in the site where

resident training occurs will result in little if

any additional cost to Medicare. In addition

to the expected shift in training from the

inpatient setting to the nonhospital setting, in

relatively few cases, section 4625 could

result in additional resident training being

paid by Medicare. However, Medicare’s share

of costs incurred in those nonhospital sites

based on Medicare utilization is often

generally low, so we expect the impact of the

cost of training of any additional residents to

be negliglible.

V. Hospitals Included In and Excluded From

the Prospective Payment System

The prospective payment systems for

hospital inpatient operating and capitalrelated 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 March 1998, we have included 4,956

hospitals in our analysis. This represents

about 82 percent of all Medicareparticipating 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.

VI. Impact on Excluded Hospitals and Units

As of March 1998, there were 1,082

specialty hospitals excluded from the

prospective payment system and instead paid

on a reasonable cost basis subject to the rateof-increase ceiling under § 413.40. In

addition, there were 2,393 psychiatric and

rehabilitation units in hospitals otherwise

subject to the prospective payment system.

These excluded units are also paid in

accordance with § 413.40.

As required by section 1886(b)(3)(B) of the

Act, the update factor applicable to the rateof-increase limit for excluded hospitals and

units for FY 1999 would be between 0 and

2.5 percent, depending on the hospital’s costs

in relation to its limit.

The impact on excluded hospitals and

units of the proposed update in the rate-ofincrease 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-ofincrease limits, the major effect will be the

amount of excess costs that would not be

reimbursed.

We note that, under § 413.40(d)(3), an

excluded hospital or unit whose costs exceed

110 percent of its rate-of-increase limit

receives its rate-of-increase limit plus 50

percent of the difference between its

reasonable costs and 110 percent of the limit,

not to exceed 110 percent of its limit. In

addition, under the various provisions set

forth in § 413.40, certain excluded hospitals

and units can obtain payment adjustments

for justifiable increases in operating costs

that exceed the limit. At the same time,

however, by generally limiting payment

increases, we continue to provide an

incentive for excluded hospitals and units to

restrain the growth in their spending for

patient services.

VII. Quantitative Impact Analysis of the

Proposed Policy Changes Under the

Prospective Payment System for Operating

Costs

A. Basis and Methodology of Estimates

In this proposed rule, we are announcing

policy changes and payment rate updates for

the prospective payment systems for

operating and capital-related costs. We

estimate the total payment impact of these

changes on FY 1999 payments compared to

FY 1998 payments, to be approximately a

$400 million reduction. We have prepared

separate impact analyses of the proposed

changes to each system. This section deals

with changes to the operating prospective

payment system.

The data used in developing the

quantitative analyses presented below are

taken from the FY 1997 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 categorize hospitals. Our analysis has

several qualifications. First, we do not make

adjustments for behavioral changes that

hospitals may adopt in response to these

proposed policy changes. Second, due to the

interdependent nature of the prospective

payment system, it is very difficult to

precisely quantify the impact associated with

each proposed change. Third, we draw upon

various sources for the data used to

categorize hospitals in the tables. In some

cases, particularly the number of beds, there

is a fair degree of variation in the data from

different sources. We have attempted to

construct these variables with the best

available source overall. For individual

hospitals, however, some miscategorizations

are possible.

Using cases in the FY 1997 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 1999 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 implementing the

expanded transfer definition enacted by

section 4407 of the BBA, which counts as a

transfer any discharge from one of 10 DRGs

if upon discharge the patient is admitted to

an excluded hospital or distinct part unit or

a skilled nursing facility, or is provided home

health care that is related to the

hospitalization within 3 days of the date of

discharge.

• 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 1995 data).

• The effects of two proposed changes to

the wage index: (1) including the costs

associated with Part A physician costs under

contract; and (2) removing the overhead costs

related to departments excluded from the

wage data used to calculate the wage index

(for example, skilled nursing facilities and

distinct part units).

• The effects of geographic

reclassifications by the Medicare Geographic

Classification Review Board (MGCRB) that

will be effective in FY 1999.
25680 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

• The total change in payments based on

FY 1999 policies relative to payments based

on FY 1998 policies.

To illustrate the impacts of the FY 1999

proposed changes, our analysis begins with

a FY 1999 baseline simulation model using:

The FY 1998 GROUPER (version 15.0); the

FY 1998 wage index; the transfer definition

prior to implementation of section 4407 of

the BBA; 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 1999 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

1998 to FY 1999. Four 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 1999 using the most recently

forecasted hospital market basket increase for

FY 1999 of 2.6 percent minus 1.9 percentage

points. Similarly, section 1886(b)(3)(C)(ii) of

the Act provides that the update factor

applicable to the hospital-specific rates for

sole community hospitals (SCHs), essential

access community hospitals (EACHs) (which

are treated as SCHs for payment purposes),

and Medicare-dependent, small rural

hospitals (MDHs) is equal to the market

basket increase of 2.6 percent minus 1.9

percentage points (for an update of 0.7

percent).

A second significant factor impacting

changes in hospitals’ payments per case from

FY 1998 to FY 1999 is a change in MGCRB

reclassification status from one year to the

next. That is, hospitals reclassified in FY

1998 that are no longer reclassified in FY

1999 may have a negative payment impact

going from FY 1998 to FY 1999; conversely,

hospitals not reclassified in FY 1998 that are

reclassified in FY 1999 may have a positive

impact. In some cases, these impacts can be

quite substantial, so if a relatively small

number of hospitals in a particular category

lose their reclassification status, the

percentage increase in payments for the

category may be below the national mean.

A third significant factor is that we

currently estimate that actual outlier

payments during FY 1998 will be 5.4 percent

of actual total DRG payments. When the FY

1998 final rule was published, we projected

FY 1998 outlier payments would be 5.1

percent of total DRG payments, and the

standardized amounts were reduced

correspondingly. The effects of the slightly

higher than expected outlier payments

during FY 1998 (as discussed in the

Addendum to this proposed rule) are

reflected in the analyses below comparing

our current estimates of FY 1998 payments

per case to estimated FY 1999 payments per

case.

Fourth, payments per case in FY 1999 are

reduced from FY 1998 for hospitals that

receive the indirect medical education (IME)

or the disproportionate share (DSH)

adjustments. Section 1886(d)(5)(B)(ii) of the

Act provides that the IME adjustment is

reduced from approximately a 7.0 percent

increase for every 10 percent increase in a

hospital’s resident-to-bed ratio in FY 1998, to

a 6.5 percent increase in FY 1999. Similarly,

in accordance with section 1886(d)(5)(F)(ix)

of the Act, the DSH adjustment for FY 1999

is reduced by 2 percent from what would

otherwise have been paid, compared to a 1

percent reduction for FY 1998.

Table I demonstrates the results of our

analysis. The table categorizes hospitals by

various geographic and special payment

consideration groups to illustrate the varying

impacts on different types of hospitals. The

top row of the table shows the overall impact

on the 4,956 hospitals included in the

analysis. This is 132 fewer hospitals than

were included in the impact analysis in the

FY 1998 final rule with comment period (62

FR 46119).

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 2,792 hospitals

located in urban areas (MSAs or NECMAs)

included in our analysis. Among these, there

are 1,588 hospitals located in large urban

areas (populations over 1 million), and 1,204

hospitals in other urban areas (populations of

1 million or fewer). In addition, there are

2,164 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 1999 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 paid based on these

categorizations (after consideration of

geographic reclassifications) are 2,877, 1,681,

1,196, and 2,079, 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 3,875 nonteaching

hospitals in our analysis, 841 teaching

hospitals with fewer than 100 residents, and

240 teaching hospitals with 100 or more

residents.

In the DSH categories, hospitals are

grouped according to their DSH payment

status, and whether they are considered

urban or rural after MGCRB reclassifications.

Hospitals in the rural DSH categories,

therefore, represent hospitals that were not

reclassified for purposes of the standardized

amount or for purposes of the DSH

adjustment. (They may, however, have been

reclassified for purposes of the wage index.)

The next category groups hospitals

considered urban after geographic

reclassification, in terms of whether they

receive the IME adjustment, the DSH

adjustment, both, or neither.

The next row separately examines

hospitals that available data show may

qualify under section 4401(b) of the BBA for

the special temporary relief provision, which

grants an additional 0.3 percent update to the

standardized amounts (in addition to the 0.7

percent update other hospitals would receive

during FY 1999), resulting in a 1.0 percent

update for this category of hospitals. To be

eligible, a hospital must not be an MDH, nor

may it receive either IME or DSH payments.

It must also experience a negative margin on

its operating prospective payments during FY

1999. We estimated eligible hospitals based

on whether they had a negative operating

margin on their FY 1995 cost report (latest

available data). Finally, to qualify, a hospital

must be located in a State where the

aggregate FY 1995 operating prospective

payments were less than the aggregate

associated costs for all of the non-IME, nonDSH, non-MDH hospitals in the State. There

are 356 hospitals in this row.

The next four rows examine the impacts of

the proposed changes on rural hospitals by

special payment groups (SCHs, rural referral

centers (RRCs), MDHs, and EACHs), as well

as rural hospitals not receiving a special

payment designation. The RRCs (137), SCH/

EACHs (633), MDHs (351), and SCH/EACH

and RRCs (54) shown here were not

reclassified for purposes of the standardized

amount. There is one SCH that will be

reclassified for the standardized amount in

FY 1999 that, therefore, is not included in

these rows. There are six EACHs included in

our analysis and three 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 95 hospitals. For the

most part, these are new hospitals.

The next series of groupings concern the

geographic reclassification status of

hospitals. The first three groupings display

hospitals that were reclassified by the

MGCRB for both FY 1998 and FY 1999, or

for either of those 2 years, by urban/rural

status. The next rows illustrate the overall

number of FY 1999 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.
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25681

TABLE I.—IMPACT ANALYSIS OF CHANGES FOR FY 1999 OPERATING PROSPECTIVE PAYMENT SYSTEM

[Percent changes in payments per case]

Number of

hosps.1

PAC tran.

provision 2

DRG recalib. 3New wage

data 4

Contract

phys. pt a

costs 5

Allocated

overhead

costs 6

DRG & WI

changes 7

MGCRB

recl- assification 8

All FY 99

changes 9

(0) (1) (2) (3) (4) (5) (6) (7) (8)

(BY GEOGRAPHIC

LOCATION):

ALL HOSPITALS .. 4,956 ¥0.6 0.1 0.1 0.0 ¥0.1 0.0 0.0 ¥0.7

URBAN HOSPITALS .............. 2,792 ¥0.7 0.1 0.0 0.0 ¥0.2 ¥0.2 ¥0.4 ¥1.1

LARGE

URBAN ...... 1,588 ¥0.7 0.1 ¥0.3 0.0 ¥0.2 ¥0.5 ¥0.4 ¥1.4

OTHER

URBAN ...... 1,204 ¥0.6 0.1 0.4 0.0 ¥0.2 0.2 ¥0.3 ¥0.5

RURAL HOSPITALS .............. 2,164 ¥0.4 0.1 0.9 ¥0.1 0.3 1.3 2.4 1.5

BED SIZE

(URBAN):

0–99 BEDS .... 690 ¥0.8 0.2 ¥0.3 0.0 ¥0.1 ¥0.3 ¥0.5 ¥0.7

100–199

BEDS ......... 936 ¥0.8 0.2 ¥0.2 0.0 ¥0.1 ¥0.3 ¥0.4 ¥1.0

200–299

BEDS ......... 566 ¥0.7 0.1 ¥0.1 0.0 ¥0.1 ¥0.3 ¥0.3 ¥0.9

300–499

BEDS ......... 448 ¥0.6 0.1 0.0 0.0 ¥0.2 ¥0.3 ¥0.5 ¥1.2

500 OR

MORE

BEDS ......... 152 ¥0.5 0.1 0.3 0.0 ¥0.3 0.1 ¥0.2 ¥1.2

BED SIZE

(RURAL):

0–49 BEDS .... 1,135 ¥0.3 0.1 0.9 ¥0.1 0.5 1.3 ¥0.1 1.3

50–99 BEDS .. 635 ¥0.4 0.1 0.8 ¥0.1 0.3 1.1 0.9 1.1

100–149

BEDS ......... 229 ¥0.5 0.1 0.8 ¥0.1 0.4 1.3 3.3 1.3

150–199

BEDS ......... 91 ¥0.5 0.1 1.0 ¥0.1 0.3 1.5 3.9 2.7

200 OR

MORE

BEDS ......... 74 ¥0.4 0.1 1.0 0.0 0.2 1.4 4.6 1.6

URBAN BY CENSUS DIVISION:

NEW ENGLAND ......... 152 ¥0.7 0.1 ¥2.4 ¥0.1 0.1 ¥2.7 0.1 ¥3.5

MIDDLE ATLANTIC ...... 425 ¥0.4 0.2 0.4 0.3 ¥0.2 0.6 ¥0.5 ¥0.5

SOUTH ATLANTIC ...... 413 ¥0.6 0.1 0.8 ¥0.1 ¥0.2 0.6 ¥0.6 ¥0.3

EAST NORTH

CENTRAL .. 475 ¥0.8 0.1 0.0 ¥0.1 ¥0.4 ¥0.6 ¥0.3 ¥1.5

EAST SOUTH

CENTRAL .. 159 ¥0.6 0.1 0.5 ¥0.1 ¥0.4 0.0 ¥0.5 ¥0.7

WEST

NORTH

CENTRAL .. 186 ¥0.7 0.0 0.9 0.0 0.1 1.0 ¥0.6 0.1

WEST SOUTH

CENTRAL .. 350 ¥0.9 0.1 ¥1.1 0.1 ¥0.2 ¥1.4 ¥0.1 ¥2.0

MOUNTAIN ... 126 ¥0.8 0.1 0.4 0.2 ¥0.2 0.5 ¥0.6 ¥0.3

PACIFIC ........ 458 ¥0.8 0.1 ¥0.5 ¥0.1 0.0 ¥0.7 ¥0.3 ¥1.4

PUERTO

RICO .......... 48 ¥0.2 0.3 0.8 ¥0.3 ¥0.3 0.3 ¥0.5 0.3

RURAL BY CENSUS DIVISION:

NEW ENGLAND ......... 53 ¥0.4 0.0 1.3 0.1 0.0 1.4 0.6 ¥0.4

MIDDLE ATLANTIC ...... 80 ¥0.3 0.1 0.9 0.1 0.0 1.2 1.2 1.1

SOUTH ATLANTIC ...... 286 ¥0.4 0.2 0.8 ¥0.1 0.3 1.1 3.3 2.0

EAST NORTH

CENTRAL .. 284 ¥0.5 0.1 1.0 ¥0.3 0.3 1.2 1.9 1.5

EAST SOUTH

CENTRAL .. 269 ¥0.4 0.1 1.5 ¥0.1 0.3 1.9 2.5 2.0
25682 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE I.—IMPACT ANALYSIS OF CHANGES FOR FY 1999 OPERATING PROSPECTIVE PAYMENT SYSTEM—Continued

[Percent changes in payments per case]

Number of

hosps.1

PAC tran.

provision 2

DRG recalib. 3New wage

data 4

Contract

phys. pt a

costs 5

Allocated

overhead

costs 6

DRG & WI

changes 7

MGCRB

recl- assification 8

All FY 99

changes 9

(0) (1) (2) (3) (4) (5) (6) (7) (8)

WEST

NORTH

CENTRAL .. 499 ¥0.4 0.0 1.1 0.0 0.7 1.9 2.1 1.8

WEST SOUTH

CENTRAL .. 341 ¥0.5 0.1 0.3 ¥0.1 0.5 0.8 3.1 0.7

MOUNTAIN ... 206 ¥0.3 0.0 0.3 ¥0.1 0.5 0.8 1.6 1.2

PACIFIC ........ 141 ¥0.6 0.1 0.4 ¥0.1 0.4 1.0 2.3 1.1

PUERTO

RICO .......... 5 ¥0.4 0.1 2.3 0.1 ¥0.3 2.2 1.9 0.8

(BY PAYMENT CATEGORIES):

URBAN HOSPITALS .............. 2,877 ¥0.7 0.1 0.0 0.0 ¥0.2 ¥0.2 ¥0.3 ¥1.0

LARGE

URBAN ...... 1,681 ¥0.7 0.1 ¥0.3 0.0 ¥0.2 ¥0.4 ¥0.3 ¥1.3

OTHER

URBAN ...... 1,196 ¥0.6 0.1 0.4 0.0 ¥0.2 0.2 ¥0.4 ¥0.5

RURAL HOSPITALS .............. 2,079 ¥0.4 0.1 0.9 ¥0.1 0.4 1.3 2.0 1.4

TEACHING STATUS:

NON-TEACHING ............. 3,875 ¥0.7 0.1 0.2 ¥0.1 0.0 0.2 0.3 ¥0.1

LESS THAN

100 RES. ... 841 ¥0.7 0.1 0.0 0.0 ¥0.2 ¥0.2 ¥0.3 ¥0.9

100+ RESIDENTS ....... 240 ¥0.6 0.1 0.0 0.1 ¥0.2 ¥0.1 ¥0.3 ¥1.7

DISPROPORTIONATE SHARE

HOSPITALS

(DSH):

NON-DSH ...... 3,074 ¥0.6 0.1 0.1 0.0 ¥0.1 0.1 0.3 ¥0.4

URBAN DSH:

100 BEDS

OR

MORE 1,402 ¥0.7 0.1 0.0 0.0 ¥0.2 ¥0.2 ¥0.3 ¥1.1

FEWER

THAN

100

BEDS .. 93 ¥0.7 0.2 ¥0.2 ¥0.1 ¥0.1 ¥0.3 ¥0.5 ¥0.7

RURAL DSH:

SOLE

COMMUNITY

(SCH) .. 156 ¥0.2 0.1 0.8 ¥0.1 0.2 1.1 ¥0.1 1.3

REFERRAL

CENTERS

(RRC) .. 47 ¥0.5 0.2 1.3 ¥0.1 0.3 1.9 4.8 2.9

OTHER

RURAL

DSH

HOSP.:

100 BEDS

OR

MORE 64 ¥0.6 0.2 1.2 ¥0.1 0.4 1.8 1.3 0.8

FEWER

THAN

100

BEDS .. 120 ¥0.3 0.1 1.4 ¥0.1 0.4 1.8 0.0 1.7

URBAN TEACHING AND DSH:
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25683

TABLE I.—IMPACT ANALYSIS OF CHANGES FOR FY 1999 OPERATING PROSPECTIVE PAYMENT SYSTEM—Continued

[Percent changes in payments per case]

Number of

hosps.1

PAC tran.

provision 2

DRG recalib. 3New wage

data 4

Contract

phys. pt a

costs 5

Allocated

overhead

costs 6

DRG & WI

changes 7

MGCRB

recl- assification 8

All FY 99

changes 9

(0) (1) (2) (3) (4) (5) (6) (7) (8)

BOTH

TEACHING

AND DSH ... 700 ¥0.7 0.1 0.0 0.0 ¥0.2 ¥0.2 ¥0.4 ¥1.4

TEACHING

AND NO

DSH ........... 328 ¥0.6 0.0 0.0 0.0 ¥0.3 ¥0.2 ¥0.1 ¥1.0

NO TEACHING AND

DSH ........... 795 ¥0.8 0.2 0.0 ¥0.1 ¥0.1 ¥0.1 ¥0.2 ¥0.6

NO TEACHING AND

NO DSH ..... 1,054 ¥0.7 0.1 ¥0.2 0.0 ¥0.1 ¥0.3 ¥0.3 ¥0.6

SPECIAL UPDATE

HOSPITALS

(UNDER SEC.

4401(b) OF

PUBLIC LAW

105–33) ............. 356 ¥0.6 0.2 0.1 ¥0.1 ¥0.1 0.1 0.3 ¥0.3

RURAL HOSPITAL

TYPES:

NONSPECIAL

STATUS

HOSPITALS 904 ¥0.5 0.2 1.1 ¥0.1 0.5 1.6 1.1 1.0

RRC ............... 137 ¥0.6 0.1 1.2 0.0 0.4 1.8 5.6 2.5

SCH/EACH .... 633 ¥0.2 0.0 0.4 0.0 0.2 0.6 0.1 0.8

MDH .............. 351 ¥0.3 0.1 1.1 ¥0.1 0.5 1.5 0.4 1.3

SCH/EACH

AND RRC .. 54 ¥0.2 0.0 0.3 0.0 0.1 0.4 1.5 1.3

TYPE OF OWNERSHIP:

VOLUNTARY 2,859 ¥0.6 0.1 0.1 0.0 ¥0.1 ¥0.1 ¥0.1 ¥0.8

PROPRIETARY ....... 671 ¥0.9 0.2 0.1 ¥0.1 ¥0.1 ¥0.1 0.1 ¥0.9

GOVERNMENT ......... 1,331 ¥0.5 0.1 0.3 ¥0.1 0.0 0.3 0.3 ¥0.3

UNKNOWN .... 95 ¥0.7 0.2 0.3 ¥0.1 ¥0.1 0.2 ¥0.2 ¥0.7

MEDICARE UTILIZATION AS A

PERCENT OF

INPATIENT

DAYS:

0–25 ............... 249 ¥0.7 0.2 ¥0.7 ¥0.1 ¥0.1 ¥1.0 0.1 ¥1.6

25–50 ............. 1,267 ¥0.7 0.1 0.0 0.0 ¥0.1 ¥0.2 ¥0.2 ¥1.2

50–65 ............. 1,975 ¥0.6 0.1 0.2 0.0 ¥0.1 0.1 0.1 ¥0.4

OVER 65 ....... 1,370 ¥0.6 0.1 0.3 0.0 0.0 0.4 0.0 0.0

UNKNOWN .... 95 ¥0.7 0.2 0.3 ¥0.1 ¥0.1 0.2 ¥0.2 ¥0.7

HOSPITALS RECLASSIFIED BY THE

MEDICARE GEOGRAPHIC REVIEW

BOARD:

RECLASSIFICATION STATUS

DURING FY 98

AND FY 99:

RECLASSIFIED DURING BOTH

FY98 AND

FY99 .......... 311 ¥0.5 0.1 0.6 ¥0.1 0.1 0.8 6.6 ¥0.1

URBAN ... 70 ¥0.5 0.1 0.2 ¥0.1 ¥0.3 ¥0.1 5.4 ¥0.5

RURAL ... 241 ¥0.5 0.1 1.0 ¥0.1 0.4 1.5 7.5 0.2

RECLASSIFIED DURING FY99

ONLY ......... 178 ¥0.5 0.1 0.8 ¥0.1 0.2 1.0 4.0 4.7
25684 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE I.—IMPACT ANALYSIS OF CHANGES FOR FY 1999 OPERATING PROSPECTIVE PAYMENT SYSTEM—Continued

[Percent changes in payments per case]

Number of

hosps.1

PAC tran.

provision 2

DRG recalib. 3New wage

data 4

Contract

phys. pt a

costs 5

Allocated

overhead

costs 6

DRG & WI

changes 7

MGCRB

recl- assification 8

All FY 99

changes 9

(0) (1) (2) (3) (4) (5) (6) (7) (8)

URBAN ... 25 ¥0.5 0.1 0.4 ¥0.1 0.0 0.4 3.1 1.9

RURAL ... 153 ¥0.5 0.1 1.0 ¥0.1 0.3 1.3 4.4 6.1

RECLASSIFIED DURING FY98

ONLY ......... 111 ¥0.7 0.1 0.6 0.0 ¥0.2 0.5 ¥0.5 ¥3.1

URBAN ... 38 ¥0.7 0.1 0.5 0.1 ¥0.3 0.2 ¥0.6 ¥2.2

RURAL ... 73 ¥0.4 0.1 0.9 ¥0.1 0.4 1.3 ¥0.5 ¥6.1

FY 99 RECLASSIFICATIONS:

ALL RECLASSIFIED

HOSP. ........ 489 ¥0.5 0.1 0.7 ¥0.1 0.1 0.9 5.7 1.6

STAND.

AMOUNT

ONLY .. 94 ¥0.6 0.1 0.6 0.1 ¥0.3 0.5 1.0 ¥0.3

WAGE

INDEX

ONLY .. 281 ¥0.5 0.1 0.5 ¥0.1 0.3 0.8 6.6 ¥0.9

BOTH ..... 47 ¥0.6 0.2 0.9 ¥0.1 ¥0.4 0.6 3.8 ¥1.6

NONRECLASSIFIED 4,507 ¥0.7 0.1 0.1 0.0 ¥0.1 ¥0.1 ¥0.4 ¥0.7

ALL URBAN

RECLASS. 95 ¥0.5 0.1 0.3 ¥0.1 ¥0.2 0.0 4.7 0.2

STAND.

AMOUNT

ONLY .. 25 ¥0.4 0.2 0.9 0.1 ¥0.4 0.7 0.7 0.0

WAGE

INDEX

ONLY .. 45 ¥0.5 0.1 0.0 ¥0.1 0.1 ¥0.1 6.5 0.6

BOTH ..... 25 ¥0.5 0.1 0.6 ¥0.2 ¥0.6 ¥0.1 2.9 ¥0.5

NONRECLASSIFIED 2,670 ¥0.7 0.1 0.0 0.0 ¥0.2 ¥0.2 ¥0.6 ¥1.1

ALL RURAL

RECLASS. 394 ¥0.5 0.1 1.0 ¥0.1 0.4 1.4 6.3 2.5

STAND.

AMOUNT

ONLY .. 57 ¥0.5 0.1 1.1 ¥0.2 0.3 1.5 5.1 2.4

WAGE

INDEX

ONLY .. 309 ¥0.5 0.1 0.9 ¥0.1 0.4 1.4 6.1 2.3

BOTH ..... 28 ¥0.6 0.1 1.1 ¥0.1 0.3 1.6 9.2 3.8

NONRECLASSIFIED 1,770 ¥0.3 0.1 0.9 ¥0.1 0.3 1.2 ¥0.5 0.8

OTHER RECLASSIFIED HOSPITALS (SECTION

1886(d)(8)(B)) ... 27 ¥0.5 0.1 ¥0.9 0.2 ¥0.3 ¥0.9 0.7 ¥0.6

...................................... .................. .................. .................. .................. .................. .................. .................. .................. ..................

1Because 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 1997, and hospital cost report data are from reporting periods beginning in FY 1994 and FY 1995. 2This column displays the impact of the change enacted by section 4407 of the BBA, which defines discharges from 1 of 10 DRGs to

postacute care as transfers. Under our proposed policy, 3 of the 10 DRGs would be paid under an alternative methodology where they would receive 50 percent of the full DRG amount on the first day and 50 percent of the current per diem transfer payment amount for each remaining day

of the stay. The remaining seven DRGs would be paid using our current transfer payment methodology. 3This column displays the payment impact of the recalibration of the DRG weights based on FY 1997 MedPAR data and the DRG classification changes, in accordance with section 1886(d)(4)(C) of the Act.
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25685

4This column shows the payment effects of updating the data used to calculate the wage index with data from the FY 1995 cost reports.

5This column displays the impact of adding contract Part A physician costs to the wage data.

6This column illustrates the payment impact of removing the overhead costs allocated to departments where the directly assigned costs are already excluded from the wage index calculation (for example, SNFs and distinct part units). 7This column displays the combined impact of the reclassification and recalibration of the DRGs, the updated and revised wage data used to

calculate the wage index, and the budget neutrality adjustment factor for these two changes, in accordance with sections 1886(d)(4)(C)(iii) and

1886(d)(3)(E) of the Act. Thus, it represents the combined impacts shown in columns 2, 3, 4, and 5, and the FY 1999 budget neutrality factor of

0.999227. 8Shown here are the effects of geographic reclassifications by the Medicare Geographic Classification Review Board (MGCRB). The effects

shown here demonstrate the FY 1999 payment impact of going from no reclassifications to the reclassifications scheduled to be in effect for FY

1999. Reclassification for prior years has no bearing on the payment impacts shown here. 9This column shows changes in payments from FY 1998 to FY 1999. It incorporates all of the changes displayed in columns 1, 6, and 7 (the

changes displayed in columns 2, 3, 4 and 5 are included in column 6). It also displays the impact of the FY 1999 update, changes in hospitals’

reclassification status in FY 1999 compared to FY 1998, the difference in outlier payments from FY 1998 to FY 1999, and the reductions to payments through the IME and DSH adjustments taking effect during FY 1999. The sum of these columns may be different from the percentage

changes shown here due to rounding and interactive effects.

B. Impact of the Proposed Implementation of

the Expanded Transfer Definition (Column 1)

Section 1886(d)(5)(J) of the Act (added by

section 4407 of the BBA) requires the

Secretary to select 10 DRGs for which

discharges (from any one of these DRGs) to

a postacute care provider will be treated as

a transfer beginning with discharges on or

after October 1, 1998. Column 1 shows the

impact of this provision.

Although the expanded definition

encompasses only 10 DRGs, they were

selected, in accordance with the statute,

based upon their large and disproportionate

volume of cases receiving postacute care. We

estimate that approximately 25 percent of all

cases receiving follow-up postacute care

come from these 10 DRGs. Therefore, the

overall payment impact of this change is

significant (a 0.6 percent decrease in

payments per case).

The 10 DRGs that we are proposing to

include under this provision are identified in

section V.A. of the preamble to this proposed

rule. In addition to selecting 10 DRGs, the

statute authorizes the Secretary to develop an

alternative transfer payment methodology for

DRGs where a substantial portion of the costs

of the cases occur very early in the stay. This

is particularly likely to happen in some

surgical DRGs because of the high cost of the

surgical procedure. Based on our analysis

comparing the costs per case for these cases

with payments under our current transfer

payment methodology, we are proposing to

pay the current transfer per diem for all DRGs

except DRGs 209, 210, and 211. For those

three DRGs, the alternative payment

methodology we are proposing is 50 percent

of the full DRG payment amount for the first

day of the stay, plus 50 percent of the current

per diem transfer payment for each

remaining day, up to the full DRG payment.

To simulate the impact of these proposed

policies, we adjusted hospitals’ transferadjusted discharges and case-mix index

values (using version 15 of the GROUPER) to

reflect the impact of this expansion in the

transfer definition. The transfer-adjusted

discharge amount is calculated one of two

ways, depending on the transfer payment

methodology. Under our current transfer

payment methodology, and for all but the

three DRGs receiving special payment

consideration, this adjustment is made

simply by adding one to the length of stay

and dividing that amount by the geometric

mean length of stay for the DRG (not to

exceed 1.0). For example, a transfer after 3

days from a DRG with a geometric mean

length of stay of 6 days would have a

transfer-adjusted discharge weight of 0.667

((3+1)/6).

For transfers from any one of the three

DRGs receiving the alternative payment

methodology, the transfer-adjusted discharge

amount is 0.5 (to reflect that these cases

receive half the full DRG amount the first

day), plus one-half of the result of dividing

one plus the length of stay prior to transfer

by the geometric mean length of stay for the

DRG. As with the above adjustment, the

result is equal to the lesser of the transferadjusted DRG or 1.

The transfer-adjusted case-mix index

values are calculated by summing the

transfer-adjusted DRG weights and dividing

by the transfer-adjusted discharges. The

transfer-adjusted DRG weights are calculated

by multiplying the DRG weight by the lesser

of 1 or the transfer-adjusted discharge for the

case, divided by the geometric mean length

of stay for the DRG. In this way, simulated

payments per case can be compared before

and after the change to the transfer policy.

This change has the greatest impact among

urban hospitals (0.7 percent decrease).

Among urban hospitals, smaller hospitals

(under 200 beds) are most affected, with a 0.8

percent reduction in payments. For urban

hospitals grouped by census division, Puerto

Rico and the Middle Atlantic division have

the smallest negative impacts, 0.2 and 0.4

percent decreases, respectively. The Middle

Atlantic division has traditionally had the

longest average lengths of stay, therefore, it

is not surprising that the impact is smallest

here. Transfer cases with a length of stay

more than the (geometric) mean length of

stay minus one day do not experience any

payment impact under this provision. (Full

payment is reached one day prior to the

mean length of stay due to the double per

diem paid for the first day under our current

transfer payment methodology.) The small

impact in Puerto Rico would indicate that

these hospitals also are not discharging

patients to postacute care early in the stay.

Rural hospitals experience a smaller

payment impact overall, especially the

smallest rural hospitals: Those with fewer

than 50 beds (a 0.3 percent decrease). The

smallest impacts among rural census

divisions are in the Middle Atlantic and the

Mountain. The largest rural impact is in the

Pacific division, with a 0.6 percent decrease.

This change is consistent with the shorter

lengths of stay in this geographic region.

The largest negative impact is a 0.9 percent

decrease in payments, observed among urban

West South Central hospitals, and

proprietary hospitals. The smallest negative

impact besides urban Puerto Rico hospitals

occurs in SCHs (0.2 percent decrease). Those

SCHs paid based on their hospital-specific

amount would see no impact related to this

change, since there is no transfer adjustment

made to the hospital-specific amount.

C. Impact of the Proposed Changes to the

DRG Classifications and Relative Weights

(Column 2)

In column 2 of Table I, we present the

combined effects of the DRG reclassifications

and recalibration, as discussed in section II

of the preamble to this proposed rule. Section

1886(d)(4)(C)(I) of the Act requires us to

annually make appropriate classification

changes and to recalibrate the DRG weights

in order to reflect changes in treatment

patterns, technology, and any other factors

that may change the relative use of hospital

resources.

We compared aggregate payments using

the FY 1998 DRG relative weights (GROUPER

version 15) to aggregate payments using the

proposed FY 1999 DRG relative weights

(GROUPER version 16). 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 6).

Consistent with the minor changes we are

proposing for the FY 1999 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,

as well as for rural hospitals). Within

hospital categories, the net effects for urban

hospitals are small positive changes for all

hospitals (a 0.2 percent increase for hospitals

with fewer than 200 beds and a 0.1 percent

increase for larger hospitals). Among rural

hospitals, all hospital categories experience

an increase of 0.1 percent.

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 Puerto Rico. For rural hospitals, there is

no impact (that is, a 0.0 percent change) for

hospitals in the New England, West North

Central, and Mountain census divisions. All

other divisions experience a 0.1 percent

increase.

This pattern of small increases or no

change applies to all other hospital

categories. Overall, we attribute this change

to the increasing severity of illness of
25686 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

hospital inpatients. That is, as greater

numbers of less acutely ill patients are

treated outside the inpatient setting, the

acuity of the remaining hospital inpatients

increases. Although, in the past, this effect

was seen more clearly in large urban and

very large rural hospitals, which often had

more outpatient settings available for patient

treatment, hospitals in all areas now appear

to be able to take advantage of this practice.

Of course, in general, these positive impacts

are very minor, with virtually no hospital

group experiencing more than a 0.2 percent

increase.

D. Impact of Updating the Wage Data

(Column 3)

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

1999 is based on data submitted for hospital

cost reporting periods beginning on or after

October 1, 1994 and before October 1, 1995.

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 3 shows the percentage changes in

payments when going from a model using the

FY 1998 wage index based on FY 1994 wage

data before geographic reclassifications to a

model using the FY 1999 prereclassification

wage index based on FY 1995 wage data.

The wage data collected on the FY 1995

cost reports includes, for the first time,

contract labor costs and hours for top

management positions as allowable in the

wage index calculation. In addition, the

changes to wage-related costs associated with

hospital and home office salaries that were

discussed in the September 1, 1994 final rule

(59 FR 45355) are reflected in the FY 1995

data. These changes are reflected in column

3, as well as other year-to-year changes in

hospitals’ labor costs.

The results indicate that the new wage data

have an overall impact of a 0.1 percent

increase in hospital payments (prior to

applying the budget neutrality factor, see

column 6). Rural hospitals especially appear

to benefit from the update. Their payments

increase by 0.9 percent. These increases are

attributable to relatively large increases in the

wage index values for the rural areas of

particular States; South Dakota, Hawaii,

Mississippi, Wyoming, New Hampshire, and

Iowa all had increases greater than 6 percent

in their prereclassification wage index

values.

Urban hospitals as a group are not

significantly affected by the updated wage

data. The gains of hospitals in other urban

areas (0.4 percent increase) are offset by

decreases among hospitals in large urban

areas (0.3 percent decrease). The negative

impact among large urban areas appears to be

largely due to a 5.8 percent decrease in the

wage index values for the Boston MSA. This

impact is especially evident in the 2.4

percent decrease for urban New England

hospitals. Urban West South Central

hospitals experience a 1.1 percent decrease,

largely due to 11 Texas MSAs with FY 1999

wage indexes that fall by more than 7

percent. These appear to be primarily related

to large changes in the average hourly wages

of individual hospitals in MSAs with only a

few hospitals. We would point out that the

wage data used for the proposed wage index

is not final, and we understand that many

hospitals have submitted revision requests.

To the extent these requests are granted by

hospitals’ fiscal intermediaries, these

revisions are likely to affect the impacts

shown in the final rule. In addition, we

continue to verify the accuracy of the data for

hospitals with extraordinary changes in their

data from the prior year. We anticipate that

all these verifications will be completed

when we calculate the final FY 1999 wage

index.

The largest increases are seen in the rural

census divisions. Rural Puerto Rico

experiences the greatest positive impact, 2.3

percent. Hospitals in three other census

divisions receive positive impacts over 1.0

percent; East South Central at 1.5 percent,

New England at 1.3 percent, and West North

Central at 1.1 percent. We believe these

positive impacts of the new wage data for

rural hospitals stem from the expansion of

the contract labor definition, specifically to

include certain management categories. On

average, the hourly cost of contract labor

increased for rural hospitals by 5.9 percent.

Among urban hospitals, the increase was 4.2

percent.

E. Impact of Including Contract Physician

Part A Costs (Column 4)

As discussed in section III.C.1 of the

preamble, we began collecting separate wage

data for both direct and contract physician

Part A services on the FY 1995 cost report.

This change was made in order to address

any potential inequity of including only

salaried Part A physician costs in the wage

index while some States had laws prohibiting

their hospitals from employing physicians

directly (forcing hospitals to contract with

physicians for administrative services). Based

on our analysis, we are proposing to include

contract physician Part A costs in the wage

index calculation.

Column 4 shows the payment impacts of

including these data. Although only two

States currently maintain the prohibition

against hospitals directly employing

physicians (Texas and California), many

hospitals in other States reported these costs

as well. Thus, the impacts of this proposed

change extend well beyond Texas and

California. In fact, the urban Middle Atlantic

census division shows the largest positive

impact from this change (0.3 percent).

In general, hospitals in other areas

experience either no changes due to this

proposed policy, or small (0.1 percent)

increases or decreases. However, urban

hospitals in Puerto Rico and rural hospitals

in the East North Central census division

experience 0.3 percent decreases. The

negative rural East North Central impact is

largely due to a negative impact of this

change on the rural Wisconsin wage index.

As noted above, the data used to prepare

the proposed FY 1999 wage index are subject

to revision, and we understand that many

hospitals requested changes to their contract

physician Part A costs prior to the March 9

deadline for all requests for wage data

changes to be submitted to the fiscal

intermediaries. The extent of these requests

and the number which are approved by the

fiscal intermediaries may change the impacts

in the final rule.

F. Impact of Removing Overhead Costs of

Excluded Areas (Column 5)

Prior years’ wage index calculations have

removed the direct wages and hours

associated with certain subprovider

components excluded from the prospective

payment system; however, the overhead costs

associated with these excluded components

have not been removed. We revised the FY

1995 cost report to allow hospitals to report

separately overhead salaries and hours, and

we are proposing to remove the overhead

costs and hours allocated to areas of the

hospital excluded from the wage index

calculation.

Column 5 displays the impacts on FY 1999

payments per case of implementing this

change. The overall impact is a 0.1 percent

decline in payments; however, once again (as

with the impacts of the FY 1995 data), the

impact diverges along urban and rural lines.

Urban hospitals lose 0.2 percent as a result

of removing these overhead costs, while rural

hospitals gain 0.3 percent. Among rural

hospitals by bed size, the smallest rural

hospitals benefit the most, with a 0.5 percent

increase for rural hospitals with fewer than

50 beds.

Hospitals in the rural West North Central

census division experience the largest

percentage increase (0.7 percent). The largest

negative impacts are in Puerto Rico (urban

and rural), and urban East North Central and

urban East South Central.

The combined wage index changes in

Table I are determined by summing the

individual impacts in columns 3, 4, and 5.

For example, the rural West North Central

census division gains 1.1 percent from the

new wage data, and 0.7 percent from

removing the overhead costs allocated to

excluded areas. Therefore, the combined

impact of the FY 1999 wage index for these

hospitals is a 1.8 percent increase.

The following chart compares the shifts in

wage index values for labor market areas for

FY 1999 relative to FY 1998. This chart

demonstrates the impact of the proposed

changes for the FY 1999 wage index relative

to the FY 1998 wage index. The majority of

labor market areas (282) experience less than

a 5 percent change. A total of 54 labor market

areas experience an increase of more than 5

percent with 13 having an increase greater

than 10 percent. A total of 34 areas

experience decreases of more than 5 percent

(all urban). Of those, 6 decline by 10 percent

or more.

Percentage change in

area wage index values

Number of labor

market areas

FY 1998 FY 1999

Increase more than

10 percent ............. 2 13

Increase more than 5

percent and less

than 10 percent ..... 24 41

Increase or decrease

less than 5 percent 334 282
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25687

Percentage change in

area wage index values

Number of labor

market areas

FY 1998 FY 1999

Decrease more than

5 percent and less

than 10 percent ..... 9 28

Decrease more than

10 percent ............. 1 6

Among urban hospitals, 164 would

experience an increase of more than 5

percent and 29 more than 10 percent. More

rural hospitals have increases greater than 5

percent (360), but none greater than 10

percent. On the negative side, 268 urban

hospitals but no rural hospitals have

decreases in their wage index values of at

least 5 percent (30 of the urban hospitals

have decreases greater than 10 percent). The

following chart shows the projected impact

for urban and rural hospitals.

Percentage change in

area wage index values

Number of hospitals

Urban Rural

Increase more than

10 percent ............. 29 0

Increase more than 5

percent and less

than 10 percent ..... 164 360

Increase or decrease

less than 5 percent 2440 1924

Decrease more than

5 percent and less

than 10 percent ..... 238 0

Decrease more than

10 percent ............. 30 0

G. Combined Impact of DRG and Wage Index

Changes—Including Budget Neutrality

Adjustment (Column 6)

The impact of DRG reclassifications and

recalibration on aggregate payments is

required by section 1886(d)(4)(C)(iii) of the

Act to be budget neutral. In addition, section

1886(d)(3)(E) of the Act specifies that any

updates or adjustments to the wage index are

to be budget neutral. As noted in the

Addendum to this proposed rule, we

compared aggregate payments using the FY

1998 DRG relative weights and wage index to

aggregate payments using the FY 1999 DRG

relative weights and wage index. Based on

this comparison, we computed a wage and

recalibration budget neutrality factor of

0.999227. 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 6.

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 2, 3, 4, and 5, minus approximately

0.1 percent attributable to the budget

neutrality factor. There may, of course, be

some variation of plus or minus 0.1 percent

due to rounding.

H. Impact of MGCRB Reclassifications

(Column 7)

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 7 reflect the per case payment

impact of moving from this baseline to a

simulation incorporating the MGCRB

decisions for FY 1999. As noted below, these

decisions affect hospitals’ standardized

amount and wage index area assignments. In

addition, rural hospitals reclassified for

purposes of the standardized amount qualify

to be treated as urban for purposes of the

DSH adjustment.

Beginning in 1998, by February 28 of each

year, the MGCRB makes reclassification

determinations that will be effective for the

next fiscal year, which begins on October 1.

(In previous years, these determinations were

made by March 30.) The MGCRB may

approve a hospital’s reclassification request

for the purpose of using the other area’s

standardized amount, wage index value, or

both or for FYS 1999–2001 for purposes of

qualifying for a DSH adjustment or to receive

a higher DSH payment.

The proposed FY 1999 wage index values

incorporate all of the MGCRB’s

reclassification decisions for FY 1999. The

wage index values also reflect any decisions

made by the HCFA Administrator through

the appeals and review process for MGCRB

decisions as of February 27, 1998. 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 1999.

The overall effect of geographic

reclassification is required by section

1886(d)(8)(D) of the Act to be budget neutral.

Therefore, we applied an adjustment of

0.994019 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 2.4 percent, while payments to urban

hospitals decline 0.4 percent. Hospitals in

other urban areas see a decrease in payments

of 0.3 percent, while large urban hospitals

lose 0.4 percent. Among urban hospital

groups (that is, bed size, census division, and

special payment status), payments generally

decline.

A positive impact is evident among all

rural hospital groups except the smallest

hospitals (under 50 beds), which experience

a slight decrease of 0.1 percent. The smallest

increase among the rural census divisions is

0.6 percent for New England. The largest

increase is in rural South Atlantic, with an

increase of 3.3 percent.

Among rural hospitals designated as RRCs,

108 hospitals are reclassified for purposes of

the wage index only, leading to the 5.6

percent increase in payments among RRCs

overall. This positive impact on RRCs is also

reflected in the category of rural hospitals

with 200 or more beds, which has a 4.6

percent increase in payments.

Rural hospitals reclassified for FY 1998

and FY 1999 experience a 6.6 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 1999 only

experience a 4.4 percent increase in

payments, while rural hospitals reclassified

for FY 1998 only experience a 0.5 percent

decrease in payments. Urban hospitals

reclassified for FY 1998 but not FY 1999

experience a 0.6 percent decline in payments

overall. Urban hospitals reclassified for FY

1999 but not for FY 1998 experience a 3.1

percent increase in payments.

The FY 1999 Reclassification rows of Table

I show the changes in payments per case for

all FY 1999 reclassified and nonreclassified

hospitals in urban and rural locations for

each of the three reclassification categories

(standardized amount only, wage index only,

or both). The table illustrates that the largest

impact for reclassified rural hospitals is for

those hospitals reclassified for both the

standardized amount and the wage index.

These hospitals receive a 9.2 percent increase

in payments. In addition, rural hospitals

reclassified just for the wage index receive a

6.1 percent payment increase. The overall

impact on reclassified hospitals is to increase

their payments per case by an average of 5.7

percent for FY 1999.

Among the 27 rural hospitals deemed to be

urban under section 1886(d)(8)(B) of the Act,

payments increase 0.7 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

1999, 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 0.4 percent. Rural

nonreclassified hospitals decrease slightly

more, experiencing a 0.5 percent decrease,

and urban nonreclassified hospitals lose 0.6

percent (the amount of the budget neutrality

offset).

The number of reclassifications for

purposes of the standardized amount, or for

both the standardized amount and the wage

index, has increased from 149 in FY 1998 to

162 in FY 1999. The number of wage index

only reclassifications increased from 284 in

FY 1998 to 358 in FY 1999. These increases

are mainly attributable to two changes made

by the BBA. Section 4202 of the BBA

amended section 1886(d)(10)(D) of the Act to

allow RRCs to reclassify for wage index

purposes based only on comparison of the

RRC’s average hourly wage to the average

hourly wage of the area to which it applies

to be reclassified. In addition, section 4203

provides that for FYs 1999–2001, a rural
25688 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

hospital may be reclassified to an other urban

area for the sole purpose of receiving a higher

DSH payment.

The foregoing analysis was based on

MGCRB and HCFA Administrator decisions

made by February 27 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.

I. All Changes (Column 8)

Column 8 compares our estimate of

payments per case, incorporating all changes

reflected in this proposed rule for FY 1999

(including statutory changes), to our estimate

of payments per case in FY 1998. It includes

the effects of the 0.7 percent update to the

standardized amounts and the hospitalspecific rates for SCHs, EACHs, and MDHs.

It also reflects the 0.3 percentage point

difference between the projected outlier

payments in FY 1999 (5.1 percent of total

DRG payments) and the current estimate of

the percentage of actual outlier payments in

FY 1998 (5.4 percent), as described in the

introduction to this Appendix and the

Addendum to this proposed rule.

Additional changes affecting the difference

between FY 1998 and FY 1999 payments are

the reductions to the IME and DSH

adjustments enacted by the BBA. These

changes initially went into effect during FY

1998 and include additional decreases in

payment for each of several succeeding years.

As noted in the introduction to this impact

analysis, for FY 1999, IME is reduced to

approximately a 6.5 percent rate of increase,

and DSH is reduced by 2 percent from what

hospitals otherwise would receive. We

estimate the overall effect of these statutory

changes to be a 0.4 percent reduction in FY

1999 payments. For hospitals receiving both

IME and DSH, the impact is estimated to be

a 0.9 percent reduction in payments per case.

We also note that column 8 includes the

impacts of FY 1999 MGCRB reclassifications

compared to the payment impacts of FY 1998

reclassifications. Therefore, when comparing

FY 1999 payments to FY 1998, the percent

changes due to FY 1999 reclassifications

shown in column 7 need to be offset by the

effects of reclassification on hospitals’ FY

1998 payments (column 7 of Table 1, August

29, 1997 final rule with comment period; 62

FR 46119). For example, the impact of

MGCRB reclassifications on rural hospitals’

FY 1998 payments was approximately a 2.2

percent increase, offsetting much of the 2.4

percent increase in column 7 for FY 1999.

Therefore, the net change in FY 1999

payments due to reclassification for rural

hospitals is actually closer to an increase of

0.2 percent relative to FY 1998. 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 8 may not equal the sum of the

changes in columns 1, 6, and 7, plus the

other impacts that we are able to identify.

The overall payment change from FY 1998

to FY 1999 for all hospitals is a 0.7 percent

decrease. This reflects the 0.6 percent net

change in total payments due to the

postacute transfer change for FY 1999 shown

in column 1; the 0.7 percent update for FY

1999, the 0.3 percent lower outlier payments

in FY 1999 compared to FY 1998 (5.1 percent

compared to 5.4 percent); and the 0.4 percent

reduction due to lower IME and DSH

payments.

Hospitals in urban areas experience a 1.1

percent drop in payments per case compared

to FY 1998. Urban hospitals lose 0.9 percent

due to the expanded transfer definition and

the DRG and wage index changes combined.

The 0.4 percent negative impact due to

reclassification is offset by an identical

negative impact for FY 1998. The impact of

reducing IME and DSH is a 0.6 percent

reduction in FY 1999 payments per case.

Most of this negative impact is incurred by

hospitals in large urban areas, where

payments are expected to fall 1.4 percent per

case compared to 0.5 percent per case for

hospitals in other urban areas.

Hospitals in rural areas, meanwhile,

experience a 1.5 percent payment increase.

As discussed previously, this is primarily

due to a smaller negative impact due to the

expanded transfer definition (0.4 percent

decrease compared to 0.6 percent nationally)

and the positive effect due to the wage index

and DRG changes (1.3 percent increase).

Among census divisions, urban New

England displays the largest negative

impact, 3.5 percent. This outcome is

primarily related to the 2.4 percent

decrease due to the new wage data.

Similarly, urban West South Central

experiences a 2.0 percent drop in

payments per case, due to a 1.1 percent

drop due to the new wage data. The

urban East North Central and the urban

Pacific also experience overall payment

declines of more than 1.0 percent, with

1.5 and 1.4 percent decreases,

respectively. The West North Central is

the only urban census category to

experience a rise in payments,

stemming primarily from a 0.9 percent

increase due to the new wage data.

Hospitals in this census division also

are less reliant on IME and DSH

funding, and are therefore, impacted

less by these reductions.

The only rural census division to

experience a negative payment impact is

New England (0.4 percent fall). This

appears to result from a much smaller

reclassification effect for rural New

England hospitals in FY 1999. For FY

1998, the impact of MGCRB

reclassification for these hospitals was a

2.1 percent increase (see 62 FR 46119).

For FY 1999, the increase is only 0.6

percent. The largest increases by rural

census division are in the South

Atlantic and the East South Central,

both with 2.0 percent increases in their

FY 1999 payments per case. In the

South Atlantic, this is primarily due to

a larger FY 1999 benefit from MGCRB

reclassifications. For the East South

Central, it is largely due to a 1.5 percent

increase from the FY 1995 wage data.

Among special categories of rural

hospitals, RRCs have the largest

increase, 2.5 percent. This carries over

to other categories as well: rural

hospitals with between 150 and 200

beds have a 2.7 percent rise in payments

(there are 37 RRCs in this category); and

RRCs receiving DSH see a 2.9 percent

increase.

The largest negative payment impacts

from FY 1998 to FY 1999 are among

hospitals that were reclassified for FY

1998 and are not reclassified for FY

1999. Overall, these hospitals lose 3.1

percent. The urban hospitals in this

category lose 2.2 percent, while the

rural hospitals lose 6.1 percent. On the

other hand, hospitals reclassified for FY

1999 that were not reclassified for FY

1998 would experience the greatest

payment increases: 4.7 percent overall;

6.1 percent for 153 rural hospitals in

this category and 1.9 percent for 25

urban hospitals.

TABLE II.—IMPACT ANALYSIS OF CHANGES FOR FY 1999 OPERATING PROSPECTIVE PAYMENT SYSTEM

[Payments per case]

Number of

hospitals

Average FY

1998 payment per

case

Average FY

1999 payment per

case

All changes

(1) (2) 1 (3) 1 (4)

(BY GEOGRAPHIC LOCATION):

ALL HOSPITALS ....................................................................................................... 4,956 6,764 6,715 ¥0.7

URBAN HOSPITALS ................................................................................................. 2,792 7,332 7,255 ¥1.1

LARGE URBAN AREAS ........................................................................................... 1,588 7,891 7,782 ¥1.4
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25689

TABLE II.—IMPACT ANALYSIS OF CHANGES FOR FY 1999 OPERATING PROSPECTIVE PAYMENT SYSTEM—Continued

[Payments per case]

Number of

hospitals

Average FY

1998 payment per

case

Average FY

1999 payment per

case

All changes

(1) (2) 1 (3) 1 (4)

OTHER URBAN AREAS ........................................................................................... 1,204 6,584 6,549 ¥0.5

RURAL AREAS ......................................................................................................... 2,164 4,461 4,528 1.5

BED SIZE (URBAN):

0–99 BEDS ................................................................................................................ 690 4,922 4,890 ¥0.7

100–199 BEDS .......................................................................................................... 936 6,127 6,069 ¥1.0

200–299 BEDS .......................................................................................................... 566 6,921 6,860 ¥0.9

300–499 BEDS .......................................................................................................... 448 7,839 7,744 ¥1.2

500 OR MORE BEDS ............................................................................................... 152 9,724 9,607 ¥1.2

BED SIZE (RURAL):

0–49 BEDS ................................................................................................................ 1,135 3,663 3,712 1.3

50–99 BEDS .............................................................................................................. 635 4,173 4,218 1.1

100–149 BEDS .......................................................................................................... 229 4,609 4,669 1.3

150–199 BEDS .......................................................................................................... 91 4,799 4,927 2.7

200 OR MORE BEDS ............................................................................................... 74 5,603 5,692 1.6

URBAN BY CENSUS DIV.:

NEW ENGLAND ........................................................................................................ 152 7,873 7,597 ¥3.5

MIDDLE ATLANTIC .................................................................................................. 425 8,168 8,123 ¥0.5

SOUTH ATLANTIC ................................................................................................... 413 6,973 6,955 ¥0.3

EAST NORTH CENTRAL ......................................................................................... 475 7,016 6,909 ¥1.5

EAST SOUTH CENTRAL ......................................................................................... 159 6,558 6,511 ¥0.7

WEST NORTH CENTRAL ........................................................................................ 186 7,001 7,011 0.1

WEST SOUTH CENTRAL ........................................................................................ 350 6,807 6,672 ¥2.0

MOUNTAIN ............................................................................................................... 126 7,065 7,045 ¥0.3

PACIFIC .................................................................................................................... 458 8,403 8,289 ¥1.4

PUERTO RICO ......................................................................................................... 48 3,049 3,057 0.3

RURAL BY CENSUS DIV.:

NEW ENGLAND ........................................................................................................ 53 5,308 5,285 ¥0.4

MIDDLE ATLANTIC .................................................................................................. 80 4,802 4,857 1.1

SOUTH ATLANTIC ................................................................................................... 286 4,606 4,697 2.0

EAST NORTH CENTRAL ......................................................................................... 284 4,492 4,559 1.5

EAST SOUTH CENTRAL ......................................................................................... 269 4,160 4,242 2.0

WEST NORTH CENTRAL ........................................................................................ 499 4,174 4,250 1.8

WEST SOUTH CENTRAL ........................................................................................ 341 3,989 4,019 0.7

MOUNTAIN ............................................................................................................... 206 4,815 4,871 1.2

PACIFIC .................................................................................................................... 141 5,603 5,664 1.1

PUERTO RICO ......................................................................................................... 5 2,369 2,389 0.8

(BY PAYMENT CATEGORIES):

URBAN HOSPITALS ................................................................................................. 2,877 7,289 7,215 ¥1.0

LARGE URBAN AREAS ........................................................................................... 1,681 7,795 7,691 ¥1.3

OTHER URBAN AREAS ........................................................................................... 1,196 6,564 6,533 ¥0.5

RURAL AREAS ......................................................................................................... 2,079 4,440 4,501 1.4

TEACHING STATUS:

NON-TEACHING ....................................................................................................... 3,875 5,478 5,472 ¥0.1

FEWER THAN 100 RESIDENTS .............................................................................. 841 7,219 7,155 ¥0.9

100 OR MORE RESIDENTS .................................................................................... 240 10,987 10,796 ¥1.7

DISPROPORTIONATE SHARE HOSPITALS (DSH):

NON–DSH ................................................................................................................. 3,074 5,830 5,809 ¥0.4

URBAN DSH:

100 BEDS OR MORE ........................................................................................ 1,402 7,941 7,850 ¥1.1

FEWER THAN 100 BEDS ................................................................................. 93 5,024 4,990 ¥0.7

RURAL DSH:

SOLE COMMUNITY (SCH) ............................................................................... 156 4,255 4,310 1.3

REFERRAL CENTERS (RRC) .......................................................................... 47 5,293 5,446 2.9

OTHER RURAL DSH HOSP.:

100 BEDS OR MORE ........................................................................................ 64 4,196 4,229 0.8

FEWER THAN 100 BEDS ................................................................................. 120 3,572 3,633 1.7

URBAN TEACHING AND DSH:

BOTH TEACHING AND DSH ............................................................................ 700 8,961 8,837 ¥1.4

TEACHING AND NO DSH ................................................................................. 328 7,390 7,318 ¥1.0

NO TEACHING AND DSH ................................................................................. 795 6,342 6,303 ¥0.6

NO TEACHING AND NO DSH .......................................................................... 1,054 5,661 5,626 ¥0.6

SPECIAL UPDATE HOSPITALS (UNDER SEC. 4401(b) OF PUBLIC LAW 105–

33 ........................................................................................................................... 356 5,322 5,305 ¥0.3

RURAL HOSPITAL TYPES:

NONSPECIAL STATUS

HOSPITALS ....................................................................................................... 904 3,948 3,986 1.0
25690 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE II.—IMPACT ANALYSIS OF CHANGES FOR FY 1999 OPERATING PROSPECTIVE PAYMENT SYSTEM—Continued

[Payments per case]

Number of

hospitals

Average FY

1998 payment per

case

Average FY

1999 payment per

case

All changes

(1) (2) 1 (3) 1 (4)

RRC .................................................................................................................... 137 5,182 5,309 2.5

SCH/EACH ......................................................................................................... 633 4,490 4,525 0.8

MDH ................................................................................................................... 351 3,701 3,747 1.3

SCH/EACH AND RRC ....................................................................................... 54 5,363 5,433 1.3

TYPE OF OWNERSHIP:

VOLUNTARY ..................................................................................................... 2,859 6,949 6,894 ¥0.8

PROPRIETARY .................................................................................................. 671 6,148 6,092 ¥0.9

GOVERNMENT .................................................................................................. 1,331 6,233 6,215 ¥0.3

UNKNOWN ........................................................................................................ 95 7,984 7,928 ¥0.7

MEDICARE UTILIZATION AS A PERCENT OF INPATIENT DAYS:

0–25 ................................................................................................................... 249 8,884 8,740 ¥1.6

25–50 ................................................................................................................. 1,267 8,243 8,142 ¥1.2

50–65 ................................................................................................................. 1,975 6,168 6,143 ¥0.4

OVER 65 ............................................................................................................ 1,370 5,250 5,247 0.0

UNKNOWN ........................................................................................................ 95 7,984 7,928 ¥0.7

HOSPITALS RECLASSIFIED BY THE MEDICARE GEOGRAPHIC REVIEW BOARD:

RECLASSIFICATION STATUS DURING FY98 AND FY99:

RECLASSIFIED DURING BOTH FY98 AND FY99 .......................................... 311 5,995 5,989 ¥0.1

URBAN ........................................................................................................ 70 7,505 7,468 ¥0.5

RURAL ........................................................................................................ 241 5,250 5,258 0.2

RECLASSIFIED DURING FY99 ONLY ............................................................. 178 5,512 5,773 4.7

URBAN ........................................................................................................ 25 8,442 8,605 1.9

RURAL ........................................................................................................ 153 4,705 4,993 6.1

RECLASSIFIED DURING FY98 ONLY ............................................................. 111 6,192 6,000 ¥3.1

URBAN ........................................................................................................ 38 7,018 6,865 ¥2.2

RURAL ........................................................................................................ 73 4,458 4,185 ¥6.1

FY 99 RECLASSIFICATIONS:

ALL RECLASSIFIED HOSP. ............................................................................. 489 5,815 5,908 1.6

STAND. AMT. ONLY .................................................................................. 94 5,938 5,920 ¥0.3

WAGE INDEX ONLY .................................................................................. 281 5,994 5,940 ¥0.9

BOTH .......................................................................................................... 47 6,390 6,290 ¥1.6

NONRECLASS. .......................................................................................... 4,507 6,844 6,795 ¥0.7

ALL URBAN RECLASS. .................................................................................... 95 7,767 7,786 0.2

STAND. AMT. ONLY .................................................................................. 25 5,922 5,924 0.0

WAGE INDEX ONLY .................................................................................. 45 9,138 9,194 0.6

BOTH .......................................................................................................... 25 6,679 6,647 ¥0.5

NONRECLASS. .......................................................................................... 2,670 7,327 7,245 ¥1.1

ALL RURAL RECLASS. ..................................................................................... 394 5,026 5,149 2.5

STAND. AMT. ONLY .................................................................................. 57 4,516 4,626 2.4

WAGE INDEX ONLY .................................................................................. 309 5,086 5,204 2.3

BOTH .......................................................................................................... 28 5,038 5,230 3.8

NONRECLASS. .......................................................................................... 1,770 4,106 4,137 0.8

OTHER RECLASSIFIED HOSPITALS (SECTION 1886(d)(8)(B)) ........................... 27 4,725 4,695 ¥0.6

1These 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 1999 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 1999 with the average estimated per case

payments for FY 1998, 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 8 of Table I.

VIII. 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 available for the fourth

year of the capital prospective payment

system (cost reports beginning in FY 1995)

available through the December 1997 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.
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25691

• Moreover, our policy of recognizing

certain obligated capital as old capital makes

it difficult to project future capital-related

costs for individual hospitals. Under

§ 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 1999

capital cost projections. In Appendix B of

this proposed rule, we discuss the

assumptions and computations that we

employ to generate the amount of obligated

capital commitments for use in the FY 1999

capital cost projections.

In Table III of this section, we present the

redistributive effects that are expected to

occur between ‘‘hold-harmless’’ hospitals

and ‘‘fully prospective’’ hospitals in FY 1999.

In addition, we have integrated sufficient

hospital-specific information into our

actuarial model to project the impact of the

proposed FY 1999 capital payment policies

by the standard prospective payment system

hospital groupings. While we now have

actual information on the effects of the

transition payment methodology and interim

payments under the capital prospective

payment system and cost report data for most

hospitals, we still need to randomly generate

numbers for the change in old capital costs,

new capital costs for each year, and obligated

amounts that will be put in use for patient

care services and recognized as old capital

each year. We continue to be unable to

predict accurately FY 1999 capital costs for

individual hospitals, but with the most

recent data hospitals’ experience under the

capital prospective payment system, there is

adequate information to estimate the

aggregate impact on most hospital groupings.

B. Projected Impact Based on the Proposed

FY 1999 Actuarial Model

1. Assumptions. In this impact analysis, we

model dynamically the impact of the capital

prospective payment system from FY 1998 to

FY 1999 using a capital cost model. The FY

1999 model, as described in Appendix B of

this proposed rule, integrates actual data

from individual hospitals with randomly

generated capital cost amounts. We have

capital cost data from cost reports beginning

in FY 1989 through FY 1995 as reported on

the December 1997 update of HCRIS, interim

payment data for hospitals already receiving

capital prospective payments through

PRICER, and data reported by the

intermediaries that include the hospitalspecific rate determinations that have been

made through January 1, 1998 in the

provider-specific file. We used these data to

determine the proposed FY 1999 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 1995, and we age that

capital by a formula described in Appendix

B. Therefore, we need to randomly generate

only new capital acquisitions for any year

after FY 1995. All Federal rate payment

parameters are assigned to the applicable

hospital.

For purposes of this impact analysis, the

FY 1999 actuarial model includes the

following assumptions:

• Medicare inpatient capital costs per

discharge will change at the following rates

during these periods:

AVERAGE PERCENTAGE CHANGE IN

CAPITAL COSTS PER DISCHARGE

Fiscal Year Percentage

Change

1997 .......................................... ¥2.20

1998 .......................................... ¥0.44

1999 .......................................... 0.61

We have reduced our estimate of the growth

in Medicare costs per discharge from the

August 29, 1997 final rule with comment

period to this proposed rule based on later

cost data. We are now estimating a much

smaller increase in costs per discharge.

• The Medicare case-mix index will

increase by 1.0 percent in FY 1998 and FY

1999.

• The Federal capital rate and hospitalspecific 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 1999 update for

inflation is 0.20 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 1998 to FY

1999. Table III shows the effect of the capital

prospective payment system on low capital

cost hospitals and high capital cost hospitals.

We consider a hospital to be a low capital

cost hospital if, based on a comparison of its

initial hospital-specific rate and the

applicable Federal rate, it will be paid under

the fully prospective payment methodology.

A high capital cost hospital is a hospital that,

based on its initial hospital-specific rate and

the applicable Federal rate, will be paid

under the hold-harmless payment

methodology. Based on our actuarial model,

the breakdown of hospitals is as follows:

CAPITAL TRANSITION PAYMENT METHODOLOGY FOR FY 1999

Type of hospital Percent of

hospitals

Percent of

discharges

Percent of

capital costs

Percent of

capital payments

Low Cost Hospital ............................................................................................................ 67 62 53 58

High Cost Hospital ............................................................................................................ 33 38 47 42

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 § 412.302(e) for putting

obligated capital in to use for patient care).

If the redetermined hospital-specific rate is

greater than the adjusted Federal rate, these

hospitals will be paid under the holdharmless payment methodology. Regardless

of whether the hospital became a holdharmless payment hospital as a result of a

redetermination, we continue to show these

hospitals as low capital cost hospitals in

Table III.

Assuming no behavioral changes in

capital expenditures, Table III displays

the percentage change in payments from

FY 1998 to FY 1999 using the above

described actuarial model. With the

proposed Federal rate, we estimate

aggregate Medicare capital payments

will increase by 2.60 percent in FY

1999.
25692 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE III.—IMPACT OF PROPOSED CHANGES FOR FY 1999 ON PAYMENTS PER DISCHARGE

Number

of hospitalsDischarges

Adjusted

federal

payment

Average

federal

percent

Hospital

specific

payment

Hold

harmless

payment

Exceptions payment

Total

payment

Percent

change

over FY

1998

FY 1998 Payments per

Discharge:

Low Cost Hospitals .................. 3,260 6,746,172 $458.89 72.51 $86.07 $4.04 $8.87 $557.88 ................

Fully Prospective .............. 3,021 6,102,199 440.78 70.00 95.16 ................ 8.21 544.15 ................

100% Federal Rate .......... 208 567,402 661.26 100.00 ................ ................ 11.10 672.36 ................

Hold Harmless .................. 31 76,570 402.65 59.69 ................ 355.79 45.50 803.94 ................

High Cost Hospitals ................. 1,637 4,163,057 636.32 95.82 ................ 36.64 16.72 689.68 ................

100% Federal Rate .......... 1,398 3,701,256 667.50 100.00 ................ ................ 11.65 679.14 ................

Hold Harmless .................. 239 461,801 386.44 60.70 ................ 330.33 57.34 774.12 ................

Total Hospitals .............. 4,897 10,909,229 526.60 81.67 53.23 16.48 11.87 608.18 ................

FY 1999 Payments per

Discharge:

Low Cost Hospitals .................. 3,260 6,596,003 $529.51 81.61 $58.10 $3.38 $9.53 $597.52 7.11

Fully Prospective .............. 3,021 5,966,449 513.52 80.00 64.23 ................ 8.47 586.21 7.73

100% Federal Rate .......... 211 561,909 674.19 100.00 ................ ................ 10.98 685.17 1.91

Hold Harmless .................. 28 67,646 445.71 64.76 ................ 329.56 91.77 867.04 7.85

High Cost Hospitals ................. 1,637 4,068,306 655.17 97.22 ................ 25.50 23.85 704.52 2.15

100% Federal Rate .......... 1,417 3,678,286 681.02 100.00 ................ ................ 16.94 697.97 2.77

Hold Harmless .................. 220 390,020 411.40 67.81 ................ 265.94 88.99 766.33 ¥1.01

Total Hospitals .............. 4,897 10,664,309 575.59 87.73 35.93 11.82 15.00 638.34 4.96

We project that low capital cost hospitals

paid under the fully prospective payment

methodology will experience an average

increase in payments per case of 7.73

percent, and high capital cost hospitals will

experience an average increase of 2.15

percent.

For hospitals paid under the fully

prospective payment methodology, the

Federal rate payment percentage will

increase from 70 percent to 80 percent and

the hospital-specific rate payment percentage

will decrease from 30 to 20 percent in FY

1999. 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 60.70 percent to

67.81 percent. We estimate the percentage of

hold-harmless hospitals paid based on 100

percent of the Federal rate will increase from

85.6 percent to 86.8 percent. We estimate that

high cost hold-harmless hospitals will

experience a decrease in payments of 1.01

percent from FY 1998 to FY 1999. The

apparent decrease occurs because we

estimate that there will be 19 fewer high-cost

hold-harmless hospitals in FY 1999. These 19

hospitals may have higher payments than the

remaining hospitals, hence the apparent

decrease when they are removed from the

group. This decrease is partially offset by an

increase in the Federal portion of the

hospital’s payments and a projected increase

in exceptions payments.

We expect that the average hospitalspecific rate payment per discharge will

decrease from $95.16 in FY 1998 to $64.23

in FY 1999. This is partly due to the decrease

in the hospital-specific rate payment

percentage from 30 percent in FY 1998 to 20

percent in FY 1999.

We are proposing no changes in our

exceptions policies for FY 1999. 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 1.95 percent of total capital

payments in FY 1998 to 2.35 percent of

payments in FY 1999. Since the August 29,

1997 final rule with comment period, we

have reduced our estimates of capital cost per

case based on more recent data. Although we

still estimate that more hospitals will receive

exceptions payment in FY 1999 than in FY

1998 fewer hospitals will have costs over the

exceptions threshold then we previously

estimated. The projected distribution of the

exception payments is shown in the table

below:

Estimated FY 1999 Exceptions

Payments

Type of hospital Number of

hospitals

Percent of

exceptions

payments

Low Capital Cost 178 39

High Capital

Cost ............... 200 61

Total ........... 378 100

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

(1)

Total No. of

Hospitals

(2)

Hold-harmless (3)

Percentage

paid fully

prospective

rate

Percentage

paid holdharmless

(A)

Percentage

paid fully

federal

(B)

By Geographic Location:

All hospitals ............................................................................................................... 4,897 5.1 33.2 61.7

Large urban areas (populations over 1 million) ........................................................ 1,558 5.7 40.7 53.6
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25693

TABLE IV.—DISTRIBUTION BY METHOD OF PAYMENT (HOLD-HARMLESS/FULLY PROSPECTIVE) OF HOSPITALS RECEIVING

CAPITAL PAYMENTS—Continued

(1)

Total No. of

Hospitals

(2)

Hold-harmless (3)

Percentage

paid fully

prospective

rate

Percentage

paid holdharmless

(A)

Percentage

paid fully

federal

(B)

Other urban areas (populations of 1 million or fewer) .............................................. 1,188 6.2 40.8 52.9

Rural areas ................................................................................................................ 2,151 4.0 23.7 72.4

Urban hospitals ......................................................................................................... 2,746 5.9 40.8 53.3

0–99 beds .......................................................................................................... 653 5.8 33.8 60.3

100–199 beds .................................................................................................... 928 8.5 45.9 45.6

200–299 beds .................................................................................................... 565 5.8 40.9 53.3

300–499 beds .................................................................................................... 448 2.2 40.8 56.9

500 or more beds ............................................................................................... 152 2.0 38.2 59.9

Rural hospitals ........................................................................................................... 2,151 4.0 23.7 72.4

0–49 beds .......................................................................................................... 1,124 3.5 16.1 80.4

50–99 beds ........................................................................................................ 633 4.3 28.8 67.0

100–149 beds .................................................................................................... 229 4.8 38.0 57.2

150–199 beds .................................................................................................... 91 7.7 25.3 67.0

200 or more beds ............................................................................................... 74 1.4 48.6 50.0

By Region

Urban by Region ....................................................................................................... 2,746 5.9 40.8 53.3

New England ...................................................................................................... 151 0.0 27.8 72.2

Middle Atlantic .................................................................................................... 421 4.5 34.0 61.5

South Atlantic ..................................................................................................... 409 5.4 53.5 41.1

East North Central ............................................................................................. 472 5.5 30.5 64.0

East South Central ............................................................................................. 157 10.8 48.4 40.8

West North Central ............................................................................................ 183 6.0 36.6 57.4

West South Central ............................................................................................ 332 13.3 55.7 31.0

Mountain ............................................................................................................. 122 4.9 50.8 44.3

Pacific ................................................................................................................. 451 3.3 37.7 59.0

Puerto Rico ........................................................................................................ 48 6.3 22.9 70.8

Rural by Region ........................................................................................................ 2,151 4.0 23.7 72.4

New England ...................................................................................................... 53 0.0 22.6 77.4

Middle Atlantic .................................................................................................... 79 5.1 25.3 69.6

South Atlantic ..................................................................................................... 282 2.5 33.0 64.5

East North Central ............................................................................................. 283 3.2 19.1 77.7

East South Central ............................................................................................. 267 1.9 34.1 64.0

West North Central ............................................................................................ 498 3.6 16.1 80.3

West South Central ............................................................................................ 339 3.8 27.4 68.7

Mountain ............................................................................................................. 205 10.7 15.6 73.7

Pacific ................................................................................................................. 140 5.0 23.6 71.4

Large urban areas (populations over 1 million) ........................................................ 1,651 5.9 40.5 53.7

Other urban areas (populations of 1 million or fewer) .............................................. 1,180 5.8 41.1 53.1

Rural areas ................................................................................................................ 2,066 4.0 23.0 73.0

Teaching Status:

Non-teaching ............................................................................................................. 3,818 5.1 32.8 62.0

Fewer than 100 Residents ........................................................................................ 840 5.7 35.1 59.2

100 or more Residents .............................................................................................. 239 1.7 33.5 64.9

Disproportionate share hospitals (DSH):

Non-DSH ................................................................................................................... 3,029 5.3 28.9 65.8

Urban DSH:

100 or more beds ............................................................................................... 1,397 5.2 43.7 51.0

Less than 100 beds ........................................................................................... 87 1.1 29.9 69.0

Rural DSH:

Sole Community (SCH/EACH) ........................................................................... 156 5.1 22.4 72.4

Referral Center (RRC/EACH) ............................................................................ 47 2.1 53.2 44.7

Other Rural:

100 or more beds ....................................................................................... 64 4.7 37.5 57.8

Less than 100 beds .................................................................................... 117 0.9 28.2 70.9

Urban teaching and DSH:

Both teaching and DSH ............................................................................................ 699 4.0 36.6 59.4

Teaching and no DSH ............................................................................................... 327 6.7 31.5 61.8

No teaching and DSH ............................................................................................... 785 5.9 48.5 45.6

No teaching and no DSH .......................................................................................... 1,020 6.8 40.5 52.7

Rural Hospital Types:

Non special status hospitals ..................................................................................... 894 2.0 24.0 73.9

RRC/EACH ................................................................................................................ 137 2.2 40.1 57.7

SCH/EACH ................................................................................................................ 632 8.2 19.9 71.8

Medicare-dependent hospitals (MDH) ...................................................................... 349 1.1 17.5 81.4

SCH, RRC and EACH ............................................................................................... 54 11.1 33.3 55.6
25694 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE IV.—DISTRIBUTION BY METHOD OF PAYMENT (HOLD-HARMLESS/FULLY PROSPECTIVE) OF HOSPITALS RECEIVING

CAPITAL PAYMENTS—Continued

(1)

Total No. of

Hospitals

(2)

Hold-harmless (3)

Percentage

paid fully

prospective

rate

Percentage

paid holdharmless

(A)

Percentage

paid fully

federal

(B)

Type of Ownership:

Voluntary ................................................................................................................... 2,847 4.9 33.0 62.1

Proprietary ................................................................................................................. 656 10.1 58.2 31.7

Government ............................................................................................................... 1,329 3.2 21.1 75.7

Medicare Utilization as a Percent of Inpatient Days:

0–25 ........................................................................................................................... 238 4.2 30.7 65.1

25–50 ......................................................................................................................... 1,260 5.9 41.0 53.2

50–65 ......................................................................................................................... 1,970 5.6 33.0 61.4

Over 65 ...................................................................................................................... 1,364 3.8 26.6 69.6

As we explain in Appendix B, we were not

able to determine a hospital-specific rate for

59 of the 4,956 hospitals in our database.

Consequently, the payment methodology

distribution is based on 4,897 hospitals.

These data should be fully representative of

the payment methodologies that will be

applicable to hospitals.

The cross-sectional distribution of hospital

by payment methodology is presented by: (1)

Geographic location, (2) region, and (3)

payment classification. This provides an

indication of the percentage of hospitals

within a particular hospital grouping that

will be paid under the fully prospective

payment methodology and the hold-harmless

payment methodology.

The percentage of hospitals paid fully

Federal (100 percent of the Federal rate) as

hold-harmless hospitals is expected to

increase to 33.2 percent in FY 1999. We note

that the number of hospitals paid fully

Federal as hold-harmless hospitals has not

increased as quickly as we predicted in the

August 29, 1997 final rule with comment

period because of revised estimates.

Table IV indicates that 61.7 percent of

hospitals will be paid under the fully

prospective payment methodology. (This

figure, unlike the figure of 67 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 (73.0 percent and

75.7 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 31.7 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 1999 actuarial model to

estimate the potential impact of our proposed

changes for FY 1999 on total capital

payments per case, using a universe of 4,897

hospitals. The individual hospital payment

parameters are taken from the best available

data, including: The January 1, 1998 update

to the provider-specific file, cost report data,

and audit information supplied by

intermediaries. In Table V we present the

results of the cross-sectional analysis using

the results of our actuarial model and the

aggregate impact of the FY 1999 payment

policies. Columns 3 and 4 show estimates of

payments per case under our model for FY

1998 and FY 1999. Column 5 shows the total

percentage change in payments from FY 1998

to FY 1999. Column 6 presents the

percentage change in payments that can be

attributed to Federal rate changes alone.

Federal rate changes represented in

Column 6 include the 1.5 percent increase 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 5 includes the effects of

the Federal rate changes represented in

Column 6. Column 5 also reflects the effects

of all other changes, including: the change

from 70 percent to 80 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 5.0 percent in FY 1999.

The results show that the effect of the Federal

rate changes alone is to increase payments by

1.5 percent. In addition to the increase

attributable to the Federal rate changes, a 3.5

percent increase is attributable to the effects

of all other changes.

Our comparison by geographic location

shows that urban and rural hospitals will

experience slightly different rates of increase

in capital payments per case (4.8 percent and

6.3 percent, respectively). This difference is

due to the lower rate of increase for urban

hospitals relative to rural hospitals (1.3

percent and 3.2 percent, respectively) from

the Federal rate changes alone. Urban

hospitals will gain approximately the same as

rural hospitals (3.5 percent versus 3.1

percent) from the effects of all other changes.

All regions are estimated to receive

increases in total capital payments per case,

partly due to the increased share of payments

that are based on the Federal rate (from 70

to 80 percent). Changes by region vary from

a low of 3.6 percent increase (West South

Central urban region) to a high of 7.8 percent

increase (Pacific rural region).

By type of ownership, government

hospitals are projected to have the largest rate

of increase (6.2 percent, 1.9 percent due to

Federal rate changes and 4.3 percent from the

effects of all other changes). Payments to

voluntary hospitals will increase 5.1 percent

(a 1.5 percent increase due to Federal rate

changes and a 3.6 percent increase from the

effects of all other changes) and payments to

proprietary hospitals will increase 2.8

percent (a 1.1 percent increase due to Federal

rate changes and a 1.7 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

and for purposes of DSH, for FY 1999–2001.

Although the Federal capital rate is not

affected, a hospital’s geographic classification

for purposes of the operating standardized

amount does affect a hospital’s capital

payments as a result of the large urban

adjustment factor and the disproportionate

share adjustment for urban hospitals with

100 or more beds. Reclassification for wage

index purposes affects the geographic

adjustment factor since that factor is

constructed from the hospital wage index.

To present the effects of the hospitals being

reclassified for FY 1999 compared to the

effects of reclassification for FY 1998, we

show the average payment percentage

increase for hospitals reclassified in each
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25695

fiscal year and in total. For FY 1999

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 1999 as a

whole are projected to experience a 6.8

percent increase in payments (a 3.5 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 (5.1 percent) than reclassified

hospitals (6.8 percent) overall. Payments to

nonreclassified hospitals will increase less

than reclassified hospitals from the Federal

rate changes (1.5 percent compared to 3.5

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 1998 COMPARED TO FY 1999)

Number of

hospitals

Average FY

1998 payments/case

Average FY

1999 payments/caseAll changes

Portion attributable to

federal rate

change

By Geographic Location:

All hospitals ....................................................................................... 4,897 608 638 5.0 1.5

Large urban areas (populations over 1 million) ................................ 1,558 700 732 4.5 1.1

Other urban areas (populations of 1 million of fewer) ...................... 1,188 601 633 5.2 1.5

Rural areas ........................................................................................ 2,151 405 431 6.3 3.2

Urban hospitals .................................................................................. 2,746 658 689 4.8 1.3

0–99 beds ................................................................................... 653 482 502 4.1 1.2

100–199 beds ............................................................................. 928 584 605 3.6 1.1

200–299 beds ............................................................................. 565 628 661 5.4 1.3

300–499 beds ............................................................................. 448 686 720 4.9 1.2

500 or more beds ....................................................................... 152 824 866 5.1 1.4

Rural hospitals ................................................................................... 2,151 405 431 6.3 3.2

0–49 beds ................................................................................... 1,124 325 348 6.9 2.9

50–99 beds ................................................................................. 633 382 407 6.6 2.8

100–149 beds ............................................................................. 229 421 446 5.9 3.0

150–199 beds ............................................................................. 91 442 469 6.0 3.8

200 or more beds ....................................................................... 74 500 531 6.2 3.7

By Region:

Urban by Region ............................................................................... 2,746 658 689 4.8 1.3

New England .............................................................................. 151 659 685 4.0 ¥0.4

Middle Atlantic ............................................................................ 421 708 743 5.0 1.8

South Atlantic ............................................................................. 409 649 678 4.4 1.8

East North Central ...................................................................... 472 616 650 5.5 1.0

East South Central ..................................................................... 157 611 633 3.6 0.8

West North Central ..................................................................... 183 638 673 5.6 2.3

West South Central .................................................................... 332 664 688 3.6 0.5

Mountain ..................................................................................... 122 691 728 5.4 1.6

Pacific ......................................................................................... 451 719 755 5.1 1.0

Puerto Rico ................................................................................. 48 277 288 4.1 1.9

Rural by Region ................................................................................. 2,151 405 431 6.3 3.2

New England .............................................................................. 53 475 497 4.5 1.9

Middle Atlantic ............................................................................ 79 413 443 7.4 3.4

South Atlantic ............................................................................. 282 430 455 5.9 3.5

East North Central ...................................................................... 283 401 431 7.4 3.4

East South Central ..................................................................... 267 376 400 6.6 3.4

West North Central ..................................................................... 498 390 411 5.6 3.4

West South Central .................................................................... 339 370 390 5.5 2.5

Mountain ..................................................................................... 205 434 461 6.4 2.4

Pacific ......................................................................................... 140 478 515 7.8 2.8

By Payment Classification:

All hospitals ....................................................................................... 4,897 608 638 5.0 1.5

Large urban areas (populations over 1 million) ................................ 1,651 692 724 4.5 1.1

Other urban areas (populations of 1 million of fewer) ...................... 1,180 599 631 5.2 1.5

Rural areas ........................................................................................ 2,066 402 427 6.2 3.0

Teaching Status:

Non-teaching .............................................................................. 3,818 517 540 4.5 1.7

Fewer than 100 Residents ......................................................... 840 647 682 5.4 1.3

100 or more Residents ............................................................... 239 889 936 5.3 1.3

Urban DSH:

100 or more beds ................................................................ 1,397 693 727 4.9 1.3

Less than 100 beds ............................................................ 87 444 467 5.1 1.1

Rural DSH:

Sole Community (SCH/EACH) ............................................ 156 364 383 5.2 2.5

Referral Center (RRC/EACH) ............................................. 47 462 494 7.0 4.5

Other Rural:

100 or more beds ................................................................ 64 384 400 4.3 2.8

Less than 100 beds ............................................................ 117 320 340 6.3 3.3

Urban teaching and DSH:

Both teaching and DSH ............................................................. 699 761 801 5.3 1.2

Teaching and no DSH ................................................................ 327 659 696 5.5 1.3
25696 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

TABLE V.—COMPARISON OF TOTAL PAYMENTS PER CASE (FY 1998 COMPARED TO FY 1999)—Continued

Number of

hospitals

Average FY

1998 payments/case

Average FY

1999 payments/caseAll changes

Portion attributable to

federal rate

change

No teaching and DSH ................................................................ 785 585 610 4.3 1.3

No teaching and no DSH ........................................................... 1,020 558 579 3.7 1.3

Rural Hospital Types:

Non special status hospitals ...................................................... 894 367 389 6.0 2.6

RRC/EACH ................................................................................. 137 475 506 6.5 3.9

SCH/EACH ................................................................................. 632 391 416 6.2 2.4

Medicare-dependent hospitals (MDH) ....................................... 349 324 355 9.5 3.6

SCH, RRC and EACH ................................................................ 54 483 500 3.5 3.1

Hospitals Reclassified by the Medicare Geographic Classification

Review Board:

Reclassification Status During FY98 and FY99:

Reclassified During Both FY98 and FY99 .......................... 311 540 566 4.8 1.7

Reclassified During FY99 Only .................................................. 178 487 537 10.4 6.8

Reclassified During FY98 Only .................................................. 110 580 587 1.2 ¥1.4

FY99 Reclassifications:

All Reclassified Hospitals .................................................... 489 520 555 6.8 3.5

All Nonreclassified Hospitals ............................................... 4,449 614 646 5.1 1.5

All Urban Reclassified Hospitals ......................................... 95 663 708 6.8 2.3

Urban Nonreclassified Hospitals ......................................... 2,624 659 689 4.7 1.2

All Reclassified Rural Hospitals .......................................... 394 462 494 6.8 4.2

Rural Nonreclassified Hospitals .......................................... 1,757 369 391 6.0 2.4

Other Reclassified Hospitals (Section 1886 (D)(8)(B)) .............. 27 461 476 3.3 1.1

Type of Ownership:

Voluntary .................................................................................... 2,847 622 653 5.1 1.5

Proprietary .................................................................................. 656 617 634 2.8 1.1

Government ................................................................................ 1,329 530 563 6.2 1.9

Medicare Utilization as a Percent of Inpatient Days:

0–25 ............................................................................................ 238 685 725 5.8 1.1

25–50 .......................................................................................... 1,260 724 759 4.7 1.3

50–65 .......................................................................................... 1,970 565 594 5.2 1.6

Appendix B: Technical Appendix on the

Capital Cost Model and Required

Adjustments

Under section 1886(g)(1)(A) of the Act, we

set capital prospective payment rates for FY

1992 through FY 1995 so that aggregate

prospective payments for capital costs were

projected to be 10 percent lower than the

amount that would have been payable on a

reasonable cost basis for capital-related costs

in that year. To implement this requirement,

we developed the capital acquisition model

to determine the budget neutrality

adjustment factor. Even though the budget

neutrality requirement expired effective with

FY 1996, we must continue to determine the

recalibration and geographic reclassification

budget neutrality adjustment factor, and the

reduction in the Federal and hospital-specific

rates for exceptions payments. To determine

these factors, we must continue to project

capital costs and payments.

We 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. For FY 1998,

we developed a new capital cost model to

replace the capital acquisition model. This

revised model makes use of the data from

these cost reports.

The following cost reports are used in the

capital cost model for this proposed rule: The

December 31, 1997 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, 1998 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 through FY 1998

hospital-specific rates using the providerspecific 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 hospitalspecific 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:

Source Number of

hospitals

Provider-Specific File Only ....... 99

Provider-Specific and Audit File 4857

Total ................................... 4956

Eighty-six of the 4,956 hospitals had

unusable or missing data or had no cost

reports available. We determined from the

cost reports that 27 of the 86 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 27

hospitals in the analysis. We used the cost

report data of 4,897 hospitals for the analysis.

Fifty-nine hospitals could not be used in the

analysis because of insufficient information.

These hospitals account for approximately

0.3 percent of admissions, therefore, any

effects from the elimination of their cost

report data should be minimal.

We analyzed changes in capital-related

costs (depreciation, interest, rent, leases,

insurance, and taxes) reported in the cost

reports. We found a wide variance among

hospitals in the growth of these costs. For

hospitals with more than 100 beds, the

distribution and mean of these cost increases

were different for large changes in bed-size

(greater than ±20 percent). We also analyzed

changes in the growth in old capital and new

capital for cost reports that provided this

information. For old capital, we limited the

analysis to decreases in old capital. We did

this since the opportunity for most hospitals

to treat ‘‘obligated’’ capital put into service as
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25697

old capital has expired. Old capital costs

should, therefore, decrease as assets become

fully depreciated, and as interest costs

decrease as the loan is amortized.

The new capital cost model separates the

hospitals into three mutually exclusive

groups. Hold-harmless hospitals with data on

old capital were placed in the first group. Of

the remaining hospitals, those hospitals with

fewer than 100 beds comprise the second

group. The third group consists of all

hospitals that did not fit into either of the

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 as follows:

(1) For hold-harmless hospitals, old capital

cost changes were fitted to a truncated

gamma distribution, that is, a gamma

distribution covering only the distribution of

cost decreases. New capital costs changes

were fitted to the entire gamma distribution

allowing for both decreases and increases.

(2) For hospitals with fewer than 100 beds

(small), total capital cost changes were fitted

to the gamma distribution allowing for both

decreases and increases.

(3) Other (large) hospitals were further

separated into three groups:

• Bed-size decreases over 20 percent

(decrease).

• Bed-size increases over 20 percent

(increase).

• Other (no-change).

Capital cost changes for large hospitals

were fitted to gamma distributions for each

bed-size change group, allowing for both

decreases and increases in capital costs. We

analyzed the probability distribution of

increases and decreases in bed-size for large

hospitals. We found the probability

somewhat dependent on the prior year

change in bed-size and factored this

dependence into the analysis. Probabilities of

bed-size change were determined. Separate

sets of probability factors were calculated to

reflect the dependence on prior year change

in bed-size (increase, decrease, and no

change).

The gamma distributions were fitted to

changes in aggregate capital costs for the

entire hospital. We checked the relationship

between aggregate costs and Medicare per

discharge costs. For large hospitals, there was

a small variance, but the variance was larger

for small hospitals. Since costs are used only

for the hold-harmless methodology and to

determine exceptions, we decided to use the

gamma distributions fitted to aggregate cost

increases for estimating distributions of cost

per discharge increases.

Capital costs per discharge calculated from

the cost reports were increased by random

numbers drawn from the gamma distribution

to project costs in future years. Old and new

capital were projected separately for holdharmless hospitals. Aggregate capital per

discharge costs were projected for all other

hospitals. Because the distribution of

increases in capital costs varies with changes

in bed-size for large hospitals, we first

projected changes in bed-size for large

hospitals before drawing random numbers

from the gamma distribution. Bed-size

changes were drawn from the uniform

distribution with the probabilities dependent

on the previous year bed-size change. The

gamma distribution has a shape parameter

and a scaling parameter. (We used different

parameters for each hospital group, and for

old and new capital.)

We used discharge counts from the cost

reports to calculate capital cost per discharge.

To estimate total capital costs for FY 1997

(the MedPAR data year) and later, we use the

number of discharges from the MEDPAR

data. Some hospitals have considerably more

discharges in FY 1997 than in the years for

which we calculated cost per discharge from

the cost report data. Consequently, a hospital

with few cost report discharges would have

a high capital cost per discharge since fixed

costs would be allocated over only a few

discharges. If discharges increase

substantially, the cost per discharge would

decrease because fixed costs would be

allocated over more discharges. If the

projection of capital cost per discharge is not

adjusted for increases in discharges, the

projection of exceptions would be overstated.

We address this situation by recalculating the

cost per discharge with the MedPAR

discharges if the MedPAR discharges exceed

the cost report discharges by more than 20

percent. We do not adjust for increases of less

than 20 percent because we have not

received all of the FY 1997 discharges, and

we have removed some discharges from the

analysis because they are statistical outliers.

This adjustment reduces our estimate of

exceptions payments, and consequently, the

reduction to the Federal rate for exceptions

is smaller. We will continue to monitor our

modeling of exceptions payments and make

adjustments as needed.

The average national capital cost per

discharge generated by this model is the

combined average of many randomly

generated increases. This average must equal

the projected average national capital cost

per discharge, which we projected separately

(outside this model). We adjusted the shape

parameter of the gamma distributions so that

the modeled average capital cost per

discharge matches our projected capital cost

per discharge. The shape parameter for old

capital was not adjusted since we are

modeling the aging of ‘‘existing’’ assets. This

model provides a distribution of capital costs

among hospitals that is consistent with our

aggregate capital projections.

Once each hospital’s capital-related costs

are generated, the model projects capital

payments. We use the actual payment

parameters (for example, the case-mix index

and the geographic adjustment factor) that

are applicable to the specific hospital.

To project capital payments, the model

first assigns the applicable payment

methodology (fully prospective or holdharmless) 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 1997 MedPAR file using the FY

1998 DRG relative weights published in

section V. of the Addendum to this proposed

rule. The case-mix index is increased each

year after FY 1997 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 1.0

percent in FY 1998 and 1.0 percent in FY

1999. (Since we are using FY 1997 cases for

our analysis, the FY 1997 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 1998, the budget neutrality

adjustment factor was 1.00015.

Since we implemented a separate

geographic adjustment factor for Puerto Rico,

we propose to apply separate budget

neutrality adjustments for the national

geographic adjustment factor and the Puerto

Rico geographic adjustment factor. We

propose to apply the same budget neutrality

factor for DRG reclassifications and

recalibration nationally and for Puerto Rico.

Separate adjustments were unnecessary for

FY 1998 since the geographic adjustment

factor for Puerto Rico was implemented in

1998.

To determine the factors for FY 1999, we

first determined the portions of the Federal

national and Puerto Rico rates that would be

paid for each hospital in FY 1999 based on

its applicable payment methodology. Using

our model, we then compared, separately for

the national rate and the Puerto Rico rate,

estimated aggregate Federal rate payments

based on the FY 1998 DRG relative weights

and the FY 1998 geographic adjustment

factor to estimated aggregate Federal rate

payments based on the FY 1998 relative

weights and the FY 1999 geographic

adjustment factor. In making the comparison,

we held the FY 1999 Federal rate portion

constant and set the other budget neutrality

adjustment factor and the exceptions

reduction factor to 1.00. We determined that,

to achieve budget neutrality for the changes

in the national geographic adjustment factor,

an incremental budget neutrality adjustment

of 0.99995 for FY 1999 should be applied to

the previous cumulative FY 1998 adjustment

of 1.00015, yielding a cumulative adjustment

of 1.00010 through FY 1999. Since this is the

first adjustment for Puerto Rico, the

incremental and cumulative adjustment for

Puerto Rico would be 0.99887 through 1999.

We apply these new adjustments then

compare estimated aggregate Federal rate

payments based on the FY 1998 DRG relative

weights and the FY 1999 geographic

adjustment factors to estimated aggregate
25698 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

Federal rate payments based on the FY 1999

DRG relative weights and the FY 1999

geographic adjustment factors. The

incremental adjustment for DRG

classifications and changes in relative

weights would be 1.00328 nationally and for

Puerto Rico. The cumulative adjustments for

DRG classifications and changes in relative

weights and for changes in the geographic

adjustment factors through 1999 would be

1.00338 nationally, and 1.00215 for Puerto

Rico. The following table summarizes the

adjustment factors for each fiscal year:

BUDGET NEUTRALITY ADJUSTMENT FOR DRG RECLASSIFICATIONS AND RECALIBRATION AND THE GEOGRAPHIC

ADJUSTMENT FACTORS

Fiscal year

National Puerto Rico

Incremental Adjustment

Cumulative

Incremental Adjustment

Geographic Cumulative

Adjustment

Factor

DRG Reclassifications and

Recalibration

Combined

Geographic

Adjustment

Factor

DRG Reclassifications and

Recalibration

Combined

1992 ................................... .................... .................... .................... 1,000.00 .................... .................... .................... ....................

1993 ................................... .................... .................... 0.998.00 0.998.00 .................... .................... .................... ....................

1994 ................................... .................... .................... 1.00531 1.00330 .................... .................... .................... ....................

1995 ................................... .................... .................... 0.99980 1.00310 .................... .................... .................... ....................

1996 ................................... .................... .................... 0.99940 1.00250 .................... .................... .................... ....................

1997 ................................... .................... .................... 0.99873 1.00123 .................... .................... .................... ....................

1998 ................................... .................... .................... 0.99892 1.00015 .................... .................... .................... 1.00000

1999 ................................... 0.99995 1.00328 1.00323 1.00338 0.99887 1.00328 1.00215 1.00215

The methodology used to determine the

recalibration and geographic (DRG/GAF)

budget neutrality adjustment factor is similar

to that used in establishing budget neutrality

adjustments under the prospective payment

system for operating costs. One difference is

that, under the operating prospective

payment system, the budget neutrality

adjustments for the effect of geographic

reclassifications are determined separately

from the effects of other changes in the

hospital wage index and the DRG relative

weights. Under the capital prospective

payment system, there is a single DRG/GAF

budget neutrality adjustment factor (the

national rate and the Puerto Rico rate are

determined separately) for changes in the

geographic adjustment factor (including

geographic reclassification) and the DRG

relative weights. In addition, there is no

adjustment for the effects that geographic

reclassification has on the other payment

parameters, such as the payments for serving

low-income patients or the large urban addon 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 fiscal

years 1992 through 1998, the proposed

factors for fiscal year 1999, and the estimated

factors that would be applicable through FY

2003. We caution that these are estimates for

fiscal years 2000 and later, and are subject to

revisions resulting from continued

methodological refinements, receipt of

additional data, and changes in payment

policy changes. We note that in making these

projections, we have assumed that the

cumulative national DRG/GAF budget

neutrality adjustment factor will remain at

1.00338 (1.00215 for Puerto Rico) for FY 1999

and later because we do not have sufficient

information to estimate the change that will

occur in the factor for years after FY 1999.

The projections are as follows:
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25699

Fiscal year Update

factor

Exceptions

reduction

factor

Budget neutrality factorDRG/GAF adjustment factor 1

Outlier adjustment

factor

Federal rate

adjustment

Federal rate

(after outlier

reduction)

1992 .................................................. N/A 0.9813 0.9602 ............................ .9497 .................... 415.59

1993 .................................................. 6.07 .9756 .9162 .9980 .9496 .................... 417.29

1994 .................................................. 3.04 .9485 .8947 1.0053 .9454 2.9260 378.34

1995 .................................................. 3.44 .9734 .8432 .9998 .9414 .................... 376.83

1996 .................................................. 1.20 .9849 N/A .9994 .9536 3.9972 461.96

1997 .................................................. 0.70 .9358 N/A .9987 .9481 .................... 438.92

1998 .................................................. 0.90 .9659 N/A .9989 .9382 4.8222 371.51

1999 .................................................. 0.20 .9761 N/A 1.0032 .9378 .................... 377.25

2000 .................................................. 0.80 .9749 N/A 5 1.0000 5.9378 .................... 379.80

2001 .................................................. 0.80 .9720 N/A 1.0000 .9378 .................... 381.70

2002 .................................................. 0.90 6 1.0000 N/A 1.0000 .9378 .................... 396.23

2003 .................................................. 0.90 6 1.0000 N/A 1.0000 .9378 4 1.0255 410.01

1 Note: The incremental change over the previous year.

2 Note: OBRA 1993 adjustment.

3 Note: Adjustment for change in the transfer policy.

4 Note: Balanced Budget Act of 1997 adjustment.

5 Note: Future adjustments are, for purposes of this projection, assumed to remain at the same level.

6 Note: We are unable to estimate exceptions payments for the year under the special exceptions provision (§ 412.348(g) of the regulations)

because the regular exceptions provision (§ 412.348(e)) expires.

BILLING CODE 4120–03–U
25700 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25701
25702 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25703

BILLING CODE 4120–03–C
25704 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

Appendix D: Recommendation of Update

Factors for Operating Cost Rates of Payment

for Inpatient Hospital Services

I. Background

Several provisions of the Act address the

setting of update factors for inpatient services

furnished in FY 1999 by hospitals subject to

the prospective payment system and those

excluded from the prospective payment

system. Section 1886(b)(3)(B)(i)(XIV) of the

Act sets the FY 1999 percentage increase in

the operating cost standardized amounts

equal to the rate of increase in the hospital

market basket minus 1.9 percent for

prospective payment hospitals in all areas.

Section 1886(b)(3)(B)(iv) of the Act sets the

FY 1999 percentage increase in the hospitalspecific rates applicable to sole community

and Medicare-dependent, small rural

hospitals equal to the rate set forth in section

1886(b)(3)(B)(i) of the Act, that is, the same

update factor as all other hospitals subject to

the prospective payment system, or the rate

of increase in the market basket minus 1.9

percentage points. (We note that, as provided

in section 4401(b) of the Balanced Budget Act

of 1997, certain hospitals that do not receive

indirect medical education or

disproportionate share payments and are not

designated as Medicare-dependent, small

rural hospitals will receive an update that is

0.3 percent higher than the update for other

prospective payment hospitals. Section

1886(b)(3)(B)(ii) of the Act sets the FY 1999

percentage increase in the rate of increase

limits for hospitals excluded from the

prospective payment system equal to the rate

of increase in the excluded hospital market

basket minus a percentage between 0 and 2.5

percent percentage points, depending on the

hospital’s costs in relation to its limit.

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 fourth

quarter 1997 forecast of the FY 1999 market

basket increase of 2.6 percent for hospitals

subject to the prospective payment system,

the proposed updates to the standardized

amounts are 0.7 percent (that is, the market

basket rate of increase minus 1.9 percent) for

hospitals in both large urban and other areas.

The proposed update to the hospital-specific

rate applicable to sole community and

Medicare-dependent, small rural hospitals is

also 0.7 percent. The proposed update for

hospitals excluded from the prospective

payment system is the percentage increase in

the excluded hospital market basket

(currently estimated at 2.5 percent) less a

percentage between 0 and 2.5 percentage

points, or an update equal to between 0 and

2.5 percent.

Section 1886(e)(4) of the Act requires that

the Secretary, taking into consideration the

recommendations of the Medicare Payment

Advisory Commission (MedPAC),

recommend update factors for each fiscal

year that take into account the amounts

necessary for the efficient and effective

delivery of medically appropriate and

necessary care of high quality. Under section

1886(e)(5) of the Act, we are required to

publish the update factors recommended

under section 1886(e)(4) of the Act.

Accordingly, this appendix provides the

recommendations of appropriate update

factors, the analysis underlying our

recommendations, and our responses to the

MedPAC recommendations concerning the

update factors.

In its March 1, 1998 report, MedPAC stated

that the legislated update of market basket

increase minus 1.9 percentage points will

provide a reasonable level of payment to

hospitals. Although MedPAC suggests that a

somewhat lower update could be justified in

light of changes in the utilization and

provision of hospital inpatient care, the

Commission does not believe it is necessary

to recommend a lower update for FY 1999.

MedPAC did not make a separate

recommendation for the hospital-specific

rates applicable to sole community and

Medicare-dependent, small rural hospitals.

We discuss MedPAC’s recommendations

concerning the update factors and our

responses to these recommendations below.

II. Secretary’s Recommendations

Under section 1886(e)(4) of the Act, we are

recommending that an appropriate update

factor for the standardized amounts is 0.7

percent for hospitals located in large urban

and other areas. We are also recommending

an update of 0.7 percent to the hospitalspecific rate for sole community hospitals

and Medicare-dependent, small rural

hospitals. These figures are consistent with

the President’s FY 1999 budget

recommendations, which reflect the update

provided by section 4401(a) of the Balanced

Budget Act of 1997. We believe these

recommended update factors would ensure

that Medicare acts as a prudent purchaser

and provide incentives to hospitals for

increased efficiency, thereby contributing to

the solvency of the Medicare Part A Trust

Fund. When the President’s budget was

submitted, the market basket rate of increase

was projected at 2.7 percent. As noted above,

this proposed recommendation is based on

the most recent forecast of the market basket,

2.6 percent.

We recommend that hospitals excluded

from the prospective payment system receive

an update of between 0 and 2.5 percent. The

update for excluded hospitals and units is

equal to the increase in the excluded hospital

operating market basket, less a percentage

between 0 and 2.5 percentage points

depending on the hospital’s or unit’s costs in

relation to its rate-of-increase limit. The

market basket rate of increase is currently

forecast at 2.5 percentage points. This

recommendation is consistent with the

President’s FY 1999 budget, although we

note that the market basket rate of increase

was forecast at 2.7 percent when the budget

was submitted.

As required by section 1886(e)(4) of the

Act, we have taken into consideration the

recommendations of MedPAC in setting these

recommended update factors. Our responses

to the MedPAC recommendations concerning

the update factors are discussed below.

III. MedPAC Recommendation for Updating

the Prospective Payment System

Standardized Amounts

For FY 1999, MedPAC’s update framework

would support an update of the increase in

the hospital market basket minus a figure

between 4.4 percentage points and 1.1

percentage points. MedPAC notes that costs

per case have grown more slowly than

payments per case since 1992 and, as a

result, overall Medicare operating margins for

hospitals have been rising. MedPAC predicts

that Medicare operating margins will

continue to be quite favorable even with the

payment reductions enacted by the Balanced

Budget Act of 1997. MedPAC further notes

that Medicare payments are just one of many

factors that affect hospital margins. Thus,

while MedPAC agrees with the proposed

update of market basket increase minus 1.9

percentage points for 1999, that update is

closer to the higher end than the lower end

of MedPAC’s update framework. The

Commission 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. MedPAC’s estimate of the market

basket increase is 2.5 percent, which is 0.1

percentage points below HCFA’s current

estimate. MedPAC’s market basket estimate

focuses on employee compensation changes

in the hospital industry and the economy in

general, while HCFA’s market basket forecast

gives less weight to the projected changes in

the hospital industry’s wages. Thus,

MedPAC’s update framework reflects a 0.1

percent adjustment for this difference.

Response: We agree with MedPAC’s

recommendation of an update for FY 1999 for

prospective payment system hospitals of

market basket minus 1.9 percentage points.

Our recommendation is supported by the

following analyses that measure changes in

hospital productivity, scientific and

technological advances, practice pattern

changes, and changes in case mix:

a. Productivity

Service level productivity is defined as the

ratio of total service output to full-time

equivalent employees (FTEs). While we

recognize that productivity is a function of

many variables (for example, labor, nonlabor

material, and capital inputs), we use a labor

productivity measure since this update

framework applies to operating payment. To

recognize that we are apportioning the short

run output changes to the labor input and not

considering the nonlabor inputs, we weight

our productivity measure for operating costs

by the share of direct labor services in the

market basket rate of increase to determine

the expected effect on cost per case.

Our recommendation for the service

productivity component is based on

historical trends in productivity and total

output for both the hospital industry and the

general economy, and projected levels of

future hospital service output. MedPAC’s

predecessor, the Prospective Payment

Assessment Commission (ProPAC), estimated

cumulative service productivity growth to be

4.9 percent from 1985–1989, or 1.2 percent

annually. At the same time, MedPAC

estimated total output growth at 3.4 percent
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25705

annually, implying a ratio of service

productivity growth to output growth of 0.35.

Since it is not possible at this time to

develop a productivity measure specific to

Medicare patients, we examined productivity

(output per hour) and output (gross domestic

product) for the economy. Depending on the

exact time period, annual changes in

productivity range from 0.3 to 0.35 percent

of the change in output (that is, a 1.0 percent

increase in output would be correlated with

a 0.3 to 0.35 percent change in output per

hour).

Under our framework, the recommended

update is based in part on expected

productivity—that is, projected service

output during the year, multiplied by the

historical ratio of service productivity to total

service output, multiplied by the share of

labor in total operating inputs, as calculated

in the hospital market basket rate of increase.

This method estimates an expected labor

productivity improvement in the same

proportion to expected total service growth

that has occurred in the past and assumes

that, at a minimum, growth in FTEs changes

proportionally to the growth in total service

output. Thus, the recommendation allows for

unit productivity to be smaller than the

historical averages in years that output

growth is relatively low and larger in years

that output growth is higher than the

historical averages. Based on the above

estimates from both the hospital industry and

the economy, we have chosen to employ the

range of ratios of productivity change to

output change of 0.30 to 0.35.

The expected change in total hospital

service output is the product of projected

growth in total admissions (adjusted for

outpatient usage), projected real case-mix

growth, 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 (¥2.0 percent for FY 1999), and

projected real case-mix growth (0.8 percent),

or ¥1.2 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 (¥1.2 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 61.4,

provides our productivity standard of ¥0.2

to ¥0.3 percent.

MedPAC believes that the update should

also take into account the effects of product

change. MedPAC analysis indicates that

between 1992 and 1996, the decline in length

of stay and corresponding increase in the

intensity of services per day resulted in a net

reduction of about 11 percent for services

provided per hospital admission. In the past,

ProPAC 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, MedPAC believes a product

adjustment in the range of ¥3.0 to ¥1.0

percentage points is appropriate. In addition,

MedPAC’s update framework contains a

productivity adjustment of between ¥0.7 to

¥0.3 percent, which is slightly more

optimistic than our estimate.

b. Intensity

We base our intensity standard on the

combined effect of three separate factors:

Changes in the use of quality enhancing

services, changes in the use of services due

to shifts in within-DRG severity, and changes

in the use of services due to reductions of

cost-ineffective practices. For FY 1999, 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 qualityenhancing technology changes. A study

published in the Winter 1992 issue of the

Health Care Financing Review,

‘‘Contributions of case mix and intensity

change to hospital cost increases’’ (p. 151–

163), suggests that one-third of the intensity

change is attributable to high-cost

technology. The balance was unexplained

but the authors speculated that it is

attributable to fixed costs in service delivery.

Typically, a specific new technology

increases cost in some uses and decreases

cost in other uses. Concurrently, health status

is improved in some situations while in other

situations it may be unaffected or even

worsened using the same technology. It is

difficult to separate out the relative

significance of each of the cost increasing

effects for individual technologies and new

technologies.

All things being equal, per-discharge fixed

costs tend to fluctuate in inverse proportion

to changes in volume. Fixed costs exist

whether patients are treated or not. If volume

is declining, per-discharge fixed costs will

rise, but the reverse is true if volume is

increasing.

Following methods developed by HCFA’s

Office of the Actuary for deriving hospital

output estimates from total hospital charges,

we have developed Medicare-specific

intensity measures based on a 5-year average

using FY 1993–FY 1997 MedPAR billing

data. Case-mix constant intensity is

calculated as the change in total Medicare

charges per discharge adjusted for changes in

the average charge per unit of service as

measured by the Medical CPI hospital

component and changes in real case mix.

Thus, in order to measure changes in

intensity, one must measure changes in real

case mix.

For FY 1993–FY 1997, observed case mix

index change ranged from a low of 0.8

percent to a high of 1.7 percent, with a 5-year

average change of 1.3 percent. Based on

evidence from past studies of case-mix

change, we estimate that real case mix

change fluctuates between 1.0 and 1.4

percent and the observed values generally

fall in this range. The average percentage

change in charge per discharge was 3.4

percent and the average annual change in the

medical CPI was 5.7 percent. Dividing the

change in charge per discharge by the

quantity of the real case-mix index change

and the medical CPI, yields an average

annual change in intensity of ¥3.4 percent.

Assuming the technology/fixed cost ratio still

holds, technology would account for a ¥1.1

percent annual decline while fixed costs

would account for a ¥2.3 percent annual

decline. The decline in fixed costs per

discharge makes intuitive sense as volume,

measured by total discharges, as increased

during the period. Since we estimate that

intensity has declined during that period, we

are recommending a 0.0 percent intensity

adjustment for FY 1999.

c. Quality Enhancing New Science and

Technology

For FY 1999, MedPAC 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. As in past

recommendations, MedPAC has included an

adjustment ranging from 0.3 to 1.0 percentage

points. MedPAC believes that the costcompetitive environment now faced by

hospitals may dampen the adoption of new

technologies as they closely evaluate their

relative costs and benefits. Therefore,

MedPAC recommends an adjustment of 0.5

percentage points for the increase in

operating costs due to scientific and

technological advances.

d. 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 1999 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 higherweighted DRGs, but do not reflect greater

resource requirements. For FY 1999, 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. Thus, we are projecting an increase

of 0.8 percentage points for the real case-mix

index.

Unlike ProPAC’s case-mix

recommendation in previous years, MedPAC

did not make a specific percentage change

recommendation but rather estimated a range

from ¥0.2 to 0.2 percentage point change

based on changes in the 1998 case mix index.

e. Effect of FY 1997 DRG Reclassification and

Recalibration

We estimate that DRG reclassification and

recalibration for FY 1997 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. MedPAC does not make an

adjustment for DRG reclassification and

recalibration in its update recommendation.

f. Correction for Market Basket Forecast Error

The estimated market basket percentage

increase used to update the FY 1997 payment
25706 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules

rates was 2.5 percent. Our most recent data

indicate the actual FY 1997 increase was 2.1

percent. The resulting forecast error in the FY

1997 market basket rate of increase is 0.4

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 ¥0.4

percentage points to reflect this

overestimation of the FY 1997 market basket

rate of increase. The following is a summary

of the update ranges supported by our

analyses compared to MedPAC’s framework.

TABLE 1.—COMPARISON OF FY 1999 UPDATE RECOMMENDATIONS

HHS MedPAC

Market Basket .................................................................................................................. MB .................................... MB

Difference between HCFA & MedPAC Market Baskets .................................................. ........................................... ¥0.1

Subtotal ...................................................................................................... MB .................................... MB

Policy Adjustments Factors:

Productivity ............................................................................................................... ¥0.3 to ¥0.2 ................... ¥0.7 to ¥0.3

Product ...................................................................................................................... (3) ...................................... ¥3.0 to ¥1.0

Intensity ..................................................................................................................... 0.0.

Science & Technology ....................................................................................... ........................................... 0.0 to 0.5

Practice Patterns ............................................................................................... ........................................... (1)

Real Within DRG Change ................................................................................. ........................................... (2)

Subtotal ...................................................................................................... ¥0.3 to ¥0.2 ................... ¥3.7 to ¥0.8

Case-Mix Adjustment Factors:

Projected Case-Mix Change ..................................................................................... ¥1.0 .................................

Real Across DRG Change ....................................................................................... 0.8 .................................... ¥0.2 to 0.0

Real Within DRG Change ........................................................................................ (3) ...................................... 0.0 to 0.2

Subtotal ...................................................................................................... ¥0.2 ................................. ¥0.2 to 0.2

Effect of 1996 Reclassification & Recalibration ............................................................... 0.0 ....................................

Forecast Error Correction ................................................................................................ ¥0.4 ................................. ¥0.4

Total Recommended Update ..................................................................... MB ¥0.9 to MB ¥0.8 ...... MB ¥4.4 to MB ¥1.1

1 Included in MedPAC’s Productivity Measure.

2 Included in MedPAC’s Case-Mix Adjustment.

3 Included in HHS’ Intensity Factor.

Because we are not recommending a

negative adjustment for intensity (as our

methodology would suggest is appropriate),

the update suggested by our framework

appears to be more generous than the

recommendation of MedPAC. While the

above framework would support an update of

the market basket increase minus 0.9

percentage points, we are recommending an

update of the market basket increase minus

1.9 percentage points (0.7 percent). 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 MedPAC that a 0.7 percent update

for FY 1999 would not disadvantage the

hospital industry nor harm Medicare

beneficiaries. We also recommend that the

hospital-specific rates applicable to sole

community and Medicare-dependent, small

rural hospitals be increased by the same

update, 0.7 percentage points.

IV. MedPAC Recommendation for Updating

the Rate-of-Increase Limits for Excluded

Hospitals

MedPAC recommends an update factor

equal to a 2.1 percent average increase for

TEFRA target amounts for excluded hospitals

and units. The update formula enacted by

section 4411(a) of the Balanced Budget Act

is equal to the increase in the excluded

hospital market basket less a percentage

point between 0 and 2.5 percent, depending

on the hospital’s or unit’s costs in relation to

the target amount. MedPAC’s

recommendation reflects a reduction of 0.4

percentage points from HCFA’s market basket

increase forecast of 2.5 percent. The

reduction consists of an adjustment of -0.4

percentage points to account for the forecast

error in the FY 1997 market basket rate of

increase, and no allowance for new

technology.

Response: We recommend that hospitals

excluded from the prospective payment

system also receive a 2.5 percent increase in

the market basket used in the update formula

for TEFRA target amount 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.

BILLING CODE 4120–03–U
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25707
25708 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25709
25710 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25711
25712 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25713
25714 Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules
Federal Register / Vol. 63, No. 89 / Friday, May 8, 1998 / Proposed Rules 25715

[FR Doc. 98–12207 Filed 5–7–98; 8:45 am]

BILLING CODE 4120–03–C