27444 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Health Care Financing Administration

42 CFR Parts 412, 413, and 489

[BPD–847–P]

RIN 0938–AH34

Medicare Program; Changes to the

Hospital Inpatient Prospective

Payment Systems and Fiscal Year 1997

Rates

AGENCY: Health Care Financing

Administration (HCFA), HHS.

ACTION: Proposed rule.

SUMMARY: We are proposing to revise the

Medicare hospital inpatient prospective

payment systems for operating costs and

capital-related costs to implement

necessary changes arising from our

continuing experience with the systems.

In addition, in the addendum to this

proposed rule, we are describing

proposed changes in the amounts and

factors necessary to determine

prospective payment rates for Medicare

hospital inpatient services for operating

costs and capital-related costs. These

changes would be applicable to

discharges occurring on or after October

1, 1996. We are also setting forth

proposed rate-of-increase limits as well

as proposing changes for hospitals and

hospital units excluded from the

prospective payment systems.

DATES: Comments will be considered if

received at the appropriate address, as

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

July 31, 1996.

ADDRESSES: Mail written comments (an

original and 3 copies) to the following

address:

Health Care Financing Administration,

Department of Health and Human

Services, Attention: BPD–847–P, P.O.

Box 7517, Baltimore, MD 21207–0517.

If you prefer, you may deliver your

written comments (an original and 3

copies) to one of the following

addresses:

Room 309–G, Hubert H. Humphrey

Building, 200 Independence Avenue,

SW., Washington, DC 20201, or

Room C5–09–26, Central Building, 7500

Security Boulevard, Baltimore, MD

21244–1850.

Because of staffing and resource

limitations, we cannot accept comments

by facsimile (FAX) transmission. In

commenting, please refer to file code

BPD–847–P. Comments received timely

will be available for public inspection as

they are received, generally beginning

approximately 3 weeks after publication

of a document, in Room 309–G of the

Department’s offices at 200

Independence Avenue, SW.,

Washington, DC, on Monday through

Friday of each week from 8:30 a.m. to

5 p.m. (phone: (202) 690–7890).

For comments that relate to

information collection requirements,

mail a copy of comments to: Office of

Information and Regulatory Affairs,

Office of Management and Budget,

Room 10235, New Executive Office

Building, Washington, DC 20503, Attn:

Allison Herron Eydt, HCFA Desk

Officer.

Copies: To order copies of the Federal

Register containing this document, send

your request to: New Orders,

Superintendent of Documents, P.O. Box

371954, Pittsburgh, PA 15250–7954.

Specify the date of the issue requested

and enclose a check or money order

payable to the Superintendent of

Documents, or enclose your Visa or

Master Card number and expiration

date. Credit card orders can also be

placed by calling the order desk at (202)

512–1800 or by faxing to (202) 512–

2250. The cost for each copy is $8.00.

As an alternative, you can view and

photocopy the Federal Register

document at most libraries designated

as Federal Depository Libraries and at

many other public and academic

libraries throughout the country that

receive the Federal Register.

FOR FURTHER INFORMATION CONTACT:

Nancy Edwards (410) 786–4531,

Operating Prospective Payment, DRG,

Wage Index Issues.

Tzvi Hefter (410) 786–4529, Capital

Prospective Payment, Excluded

Hospitals.

SUPPLEMENTARY INFORMATION:

I. Background

A. Summary

Under section 1886(d) of the Social

Security Act (the Act), a system of

payment for the operating costs of acute

care hospital inpatient stays under

Medicare Part A (Hospital Insurance)

based on prospectively-set rates was

established effective with hospital cost

reporting periods beginning on or after

October 1, 1983. Under this system,

Medicare payment for hospital inpatient

operating costs is made at a

predetermined, specific rate for each

hospital discharge. All discharges are

classified according to a list of

diagnosis-related groups (DRGs). The

regulations governing the hospital

inpatient prospective payment system

are located in 42 CFR part 412. On

September 1, 1995, we published a final

rule with comment period (60 FR

45778) to implement changes to the

prospective payment system for hospital

operating costs beginning with Federal

fiscal year (FY) 1996.

For cost reporting periods beginning

before October 1, 1991, hospital

inpatient operating costs were the only

costs covered under the prospective

payment system. Payment for capitalrelated costs had been made on a

reasonable cost basis because, under

sections 1886(a)(4) and (d)(1)(A) of the

Act, those costs had been specifically

excluded from the definition of

inpatient operating costs. However,

section 4006(b) of the Omnibus Budget

Reconciliation Act of 1987 (Public Law

100–203) revised section 1886(g)(1) of

the Act to require that, for hospitals

paid under the prospective payment

system for operating costs, capitalrelated costs would also be paid under

a prospective payment system effective

with cost reporting periods beginning

on or after October 1, 1991. As required

by section 1886(g) of the Act, we

replaced the reasonable cost-based

payment methodology with a

prospective payment methodology for

hospital inpatient capital-related costs.

Under the new methodology, effective

for cost reporting periods beginning on

or after October 1, 1991, a

predetermined payment amount per

discharge is made for Medicare

inpatient capital-related costs. (See

subpart M of 42 CFR part 412, and the

August 30, 1991 final rule (56 FR 43358)

for a complete discussion of the

prospective payment system for hospital

inpatient capital-related costs.)

B. Major Contents of This Proposed Rule

In this proposed rule, we are setting

forth proposed changes to the Medicare

hospital inpatient prospective payment

systems for both operating costs and

capital-related costs. This proposed rule

would be effective for discharges

occurring on or after October 1, 1996.

Following is a summary of the major

changes that we are proposing to make:

1. Changes to the DRG Classifications

and Relative Weights

As required by section 1886(d)(4)(C)

of the Act, we must adjust the DRG

classifications and relative weights at

least annually. Our proposed changes

for FY 1997 are set forth in section II of

this preamble.

2. Changes to the Hospital Wage Index

In section III of this preamble, we

discuss revisions to the wage index and

the annual update of the wage data.

Specific issues addressed in this section

include:

• FY 1997 wage index update.
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27445

• Revisions to the wage index based

on hospital redesignations.

• Solicitation of public comment on

possible changes to the following:

—Contract labor—expansion of

allowable costs.

—Revision in Puerto Rico labor market

areas.

• Medicare Geographic Classification

Review Board—composition and

criteria.

3. Rebasing and Revision of the Hospital

Market Baskets

In section IV of this preamble, we

discuss our proposal to use a rebased

and revised hospital market basket in

developing the FY 1997 update factor

for the operating prospective payment

rates, the capital prospective payment

rates, and the excluded hospital rate-ofincrease limits.

4. Other Changes to the Prospective

Payment System for Inpatient Operating

Costs

In section V of this preamble, we

discuss several provisions of the

regulations in 42 CFR parts 412, 413,

and 489 and set forth certain proposed

changes concerning the following:

• Sole community hospitals.

• Rural referral centers.

• Disproportionate share adjustment.

• Direct graduate medical education

programs.

• Hospital distribution of ‘‘An

Important Message from Medicare.’’

5. Changes and Clarifications to the

Prospective Payment System for CapitalRelated Costs

In section VI of this preamble, we

discuss several provisions of the

regulations in 42 CFR part 412 and set

forth certain proposed changes

concerning the following:

• Use of simplified cost accounting.

• The capital Federal and hospitalspecific rates.

6. Changes for Hospitals and Hospital

Units Excluded From the Prospective

Payment Systems

In section VII of this preamble, we

discuss a clarification concerning the

calculation of payments to hospitals

excluded from the prospective payment

system.

7. Determining Prospective Payment

Operating and Capital Rates and Rate-ofIncrease Limits

In the addendum to this proposed

rule, we set forth proposed changes to

the amounts and factors for determining

the FY 1997 prospective payment rates

for operating costs and capital-related

costs. We are also proposing update

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

beginning in FY 1997 for hospitals and

hospital units excluded from the

prospective payment system. In

addition, we have included a detailed

discussion of our methodology for

setting thresholds for outlier cases. We

are inviting comments on our

methodology and any suggestions for

changes in that methodology that could

help us better predict outlier payments.

8. Impact Analysis

In Appendix A, we set forth an

analysis of the impact that the proposed

changes described in this rule would

have on affected entities.

9. Capital Acquisition Model

Appendix B contains the technical

appendix on the proposed FY 1997

capital acquisition model.

10. Rebased Market Basket Data Sources

Appendix C sets forth the data

sources used to determine the market

basket relative weights and choice of

price proxies.

11. Report to Congress on the Update

Factor for Prospective Payment

Hospitals and Hospitals Excluded From

the Prospective Payment System

Section 1886(e)(3)(B) of the Act

requires that the Secretary report to

Congress on our initial estimate of an

update factor for FY 1997 for both

hospitals included in and hospitals

excluded from the prospective payment

systems. This report is included as

Appendix D to this proposed rule.

12. Proposed Recommendation of

Update Factor for Hospital Inpatient

Operating Costs

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

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

our recommendation of the appropriate

percentage change for FY 1997 for the

following:

• Large urban area and other area

average standardized amounts (and

hospital-specific rates applicable to sole

community hospitals) for hospital

inpatient services paid for under the

prospective payment system for

operating costs.

• Target rate-of-increase limits to the

allowable operating costs of hospital

inpatient services furnished by hospitals

and hospital units excluded from the

prospective payment system.

13. Discussion of Prospective Payment

Assessment Commission

Recommendations

The Prospective Payment Assessment

Commission (ProPAC) is directed by

section 1886(e)(2)(A) of the Act to make

recommendations on the appropriate

percentage change factor to be used in

updating the average standardized

amounts. In addition, section

1886(e)(2)(B) of the Act directs ProPAC

to make recommendations regarding

changes in each of the Medicare

payment policies under which

payments to an institution are

prospectively determined. In particular,

the recommendations relating to the

hospital inpatient prospective payment

systems are to include

recommendations concerning the

number of DRGs used to classify

patients, adjustments to the DRGs to

reflect severity of illness, and changes in

the methods under which hospitals are

paid for capital-related costs. Under

section 1886(e)(3)(A) of the Act, the

recommendations required of ProPAC

under sections 1886(e)(2)(A) and (B) of

the Act are to be reported to Congress

not later than March 1 of each year.

We are printing ProPAC’s March 1,

1996 report, which includes its

recommendations, as Appendix F of this

document. The recommendations, and

the actions we are proposing to take

with regard to them (when an action is

recommended), are discussed in detail

in the appropriate sections of this

preamble, the addendum, or the

appendices to this proposed rule. See

section VIII of this preamble for specific

information concerning where

individual recommendations are

addressed. For a brief summary of the

ProPAC recommendations, we refer the

reader to the beginning of the ProPAC

report as set forth in Appendix F of this

proposed rule. For further information

relating specifically to the ProPAC

report, contact ProPAC at (202) 401–

8986.

II. Proposed Changes to DRG

Classifications and Relative Weights

A. Background

Under the prospective payment

system, we pay for inpatient hospital

services on the basis of a rate per

discharge that varies by the DRG to

which a beneficiary’s stay is assigned.

The formula used to calculate payment

for a specific case takes an individual

hospital’s payment rate per case and

multiplies it by the weight of the DRG

to which the case is assigned. Each DRG

weight represents the average resources

required to care for cases in that

particular DRG relative to the average

resources used to treat cases in all

DRGs.

Congress recognized that it would be

necessary to recalculate the DRG

relative weights periodically to account
27446 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

for changes in resource consumption.

Accordingly, section 1886(d)(4)(C) of

the Act requires that the Secretary

adjust the DRG classifications and

relative weights annually. These

adjustments are made to reflect changes

in treatment patterns, technology, and

any other factors that may change the

relative use of hospital resources. The

proposed changes to the DRG

classification system and the proposed

recalibration of the DRG weights for

discharges occurring on or after October

1, 1996 are discussed below.

B. DRG Reclassification

1. General

Cases are classified into DRGs for

payment under the prospective payment

system based on the principal diagnosis,

up to eight additional diagnoses, and up

to six procedures performed during the

stay, as well as age, sex, and discharge

status of the patient. The diagnosis and

procedure information is reported by

the hospital using codes from the

International Classification of Diseases,

Ninth Edition, Clinical Modification

(ICD–9–CM). The Medicare fiscal

intermediary enters the information into

its claims system and subjects it to a

series of automated screens called the

Medicare Code Editor (MCE). These

screens are designed to identify cases

that require further review before

classification into a DRG can be

accomplished.

After screening through the MCE and

any further development of the claims,

cases are classified by the GROUPER

software program into the appropriate

DRG. The GROUPER program was

developed as a means of classifying

each case into a DRG on the basis of the

diagnosis and procedure codes and

demographic information (that is, sex,

age, and discharge status). It is used

both to classify past cases in order to

measure relative hospital resource

consumption to establish the DRG

weights and to classify current cases for

purposes of determining payment. The

records for all Medicare hospital

inpatient discharges are maintained in

the Medicare Provider Analysis and

Review (MedPAR) file. The data in this

file are used to evaluate possible DRG

classification changes and to recalibrate

the DRG weights.

Currently, cases are assigned to one of

492 DRGs in 25 major diagnostic

categories (MDCs). Most MDCs are

based on a particular organ system of

the body (for example, MDC 6, Diseases

and Disorders of the Digestive System);

however, some MDCs are not

constructed on this basis since they

involve multiple organ systems (for

example, MDC 22, Burns).

In general, principal diagnosis

determines MDC assignment. However,

there are five DRGs to which cases are

assigned on the basis of procedure codes

rather than first assigning them to an

MDC based on the principal diagnosis.

These are the DRGs for liver, bone

marrow, and lung transplant (DRGs 480,

481, and 495, respectively) and the two

DRGs for tracheostomies (DRGs 482 and

483). Cases are assigned to these DRGs

before classification to an MDC.

Within most MDCs, cases are then

divided into surgical DRGs (based on a

surgical hierarchy that orders individual

procedures or groups of procedures by

resource intensity) and medical DRGs.

Medical DRGs generally are

differentiated on the basis of diagnosis

and age. Some surgical and medical

DRGs are further differentiated based on

the presence or absence of

complications or comorbidities

(hereafter CC).

Generally, GROUPER does not

consider other procedures; that is,

nonsurgical procedures or minor

surgical procedures generally not

performed in an operating room are not

listed as operating room (OR)

procedures in the GROUPER decision

tables. However, there are a few non-OR

procedures that do affect DRG

assignment for certain principal

diagnoses, such as extracorporeal shock

wave lithotripsy for patients with a

principal diagnosis of urinary stones.

The changes we are proposing to

make to the DRG classification system

for FY 1997 and other decisions

concerning DRGs are set forth below.

2. Pre-MDC DRGs

Effective October 1, 1994, ICD–9–CM

procedure code 41.04, Autologous

hematopoietic stem cell transplant, was

created to capture the transplantation of

stem cells obtained from bone marrow

or peripheral blood. At that time, we

designated the code as non-OR. This

transplant procedure was previously

assigned to procedure code 99.73,

Therapeutic erythrocytapheresis, which

is designated as a non-OR procedure.

When we created this code, we received

comments requesting that it be

designated as an OR procedure and

assigned to DRG 481 (Bone Marrow

Transplant) based on the resource use

associated with the type of transplant.

However, as we stated in the September

1, 1994 final rule (59 FR 45340), when

a new code is introduced, our

longstanding practice is to assign it to

the same DRG category as its

predecessor code. One compelling

reason for this practice is our inability

to move the cases associated with a new

code to a new DRG assignment as part

of DRG reclassification and

recalibration. Because we could not

separately identify the stem cell

transplant cases from the other cases

coded with 99.73 in order to reclassify

them and their charges to a new DRG,

we were unable to predict the new

weights of both the DRGs in which this

code currently is classified and the new

DRG to which it would be assigned.

Therefore, we were prevented from

redesignating code 41.04 as an OR

procedure or assigning it to a DRG.

However, we stated that we would

analyze the stem cell cases as soon as

the FY 1995 cases were available.

This year, the FY 1995 Medicare

Provider Analysis and Review

(MedPAR) file is available for use in

DRG analysis and weight setting for FY

1997. In the December 1995 update to

the FY 1995 MedPAR file, there are a

total of 178 cases reporting the

performance of a stem cell transplant.

Of that number, 13 cases also reported

the performance of a bone marrow

transplant. Those cases were removed

from our analysis because they are

already classified to DRG 481. Of the

remaining 165 cases, 100 cases did not

meet the coverage criteria for Medicare

payment. As set forth in the Medicare

Coverage Issues Manual at section 35–

30.1 (see Transmittal No. 84, April

1996), autologous stem cell transplants

are not covered when performed for the

following conditions:

• Acute leukemia not in remission

(diagnosis codes 204.00, 205.00, 206.00,

207.00, and 208.00).

• Chronic granulocytic leukemia

(diagnosis codes 205.10 and 205.11).

• Solid tumors (other than

neuroblastomas) (diagnosis codes 140.0

through 199.1)

• Multiple myeloma (diagnosis codes

203.00, 203.01 and 238.6).

After eliminating the noncovered

cases, 65 cases of stem cell transplant

remained. The average standardized

charge for these cases was

approximately $83,000. The average

standardized charge for bone marrow

transplant cases in the FY 1995

MedPAR file is approximately $98,000.

Thus, since the average resource use

associated with stem cell transplant is

similar to that associated with bone

marrow transplant, we are proposing to

assign procedure code 41.04 to DRG 481

effective with discharges occurring on

or after October 1, 1996. The overall

average charge for stem cell and bone

marrow combined is just under $93,000.

In addition, we propose to designate

stem cell transplant as an OR procedure.
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27447

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 of patients who are age 0–17.

Occasionally, a pair of DRGs is split on age>17 and

age 0–17.

3. MDC 1 (Diseases and Disorders of the

Nervous System)

a. Sleep Apnea

We have received correspondence

requesting that we review the DRG

assignment of cases in which surgery is

performed to correct obstructive sleep

apnea (diagnosis code 780.57). When

coded as a principal diagnosis, sleep

apnea is assigned to DRGs 34 and 35

(Other Disorders of the Nervous

System)1 in MDC 1.

Recently, new surgical interventions

to correct sleep apnea have been

introduced. The procedures most

frequently performed for this condition

are the following:

Code and Description

27.69 Other plastic repair of palate

29.4 Plastic operation on pharynx

29.59 Other repair of pharynx

Since none of these surgical

procedures is assigned to MDC 1, cases

of sleep apnea treated with one of these

surgeries are assigned to DRG 468

(Extensive OR Procedure Unrelated to

Principal Diagnosis) in the case of codes

25.59 and 78.49 or to DRG 477

(Nonextensive OR Procedure Unrelated

to Principal Diagnosis) in the case of

code 29.4.

We are proposing to address this

situation by assigning the three surgical

procedures to MDC 1. Based on the

charges associated with these cases and

the fact that they are not clinically

similar to the other surgical DRGs in

MDC 1, we are proposing to include

them in DRGs 7 and 8 (Peripheral and

Cranial Nerve and Other Nervous

System Procedures).

b. Guillain-Barre ́ Syndrome

Guillain-Barre ́ syndrome (diagnosis

code 357.0) is a post-infectious

polyneuropathy in which severely

affected patients may require ventilatory

assistance and long stays in intensive

care. In recognition of the high resource

consumption associated with this

diagnosis, effective with FY 1991, we

reassigned code 357.0 from DRGs 18

and 19 (Cranial and Peripheral Nerve

Disorders) to DRG 20 (Nervous System

Infection Except Viral Meningitis). (See

the September 4, 1990 final rule (55 FR

36024).) A commenter stated that

although DRG 20 would provide a

higher payment for these cases, it would

still be inadequate to cover the costs of

treating these patients, and we agreed

that we would monitor this issue.

We have recently received requests

that we again review this assignment.

These commenters stated that the

treatment for these cases remains very

costly and often entails long hospital

stays. Therefore, we conducted an

analysis of the cases assigned to DRG 20

using the 10 percent random sample of

the FY 1995 MedPAR file that we use

for analyzing possible classification

changes.

Cases coded with 357.0 comprise

approximately 20 percent of the cases

assigned to DRG 20. As the commenters

predicted, the average standardized

charges for these cases, approximately

$22,400, was higher than the average

charge for the DRG, approximately

$17,100. However, the length of stay

was only slightly higher, 9.1 days

compared to 8.4. We believe that DRG

20 is the appropriate assignment

clinically for Guillain-Barre ́ cases and

the average charge is well within the

variation in charges for this DRG. In

addition, DRG 20 is the most resourceintensive, and, thus, the highestweighted medical DRG in MDC 1.

However, in reviewing the other cases

assigned to DRG 20, we noted that the

average charges for two diagnoses were

significantly lower than the overall

average charge. These diagnoses, herpes

zoster of the nervous system (code

053.10) and herpes zoster of the nervous

system, NEC (code 053.19) had average

charges of only $7,700 and $7,100,

respectively. They also had significantly

lower average lengths of stay (4.4 and

4.2 days, respectively). Because these

two diagnoses also account for

approximately 20 percent of the cases in

DRG 20, their low average charge has

the effect of significantly lowering the

average charge for the DRG. Removing

these two codes from DRG 20 increases

the average charge to approximately

$20,000. After reviewing the remaining

medical DRGs in MDC 1, we believe that

reassigning codes 053.10 and 053.19 to

DRGs 18 and 19 is appropriate both

clinically and in terms of resource

consumption. In the 10 percent

MedPAR file, these DRGs had an

average charge of approximately $8,000

and $5,300, respectively. Therefore, we

are proposing to make this DRG

classification change effective for FY

1997. This change would significantly

increase the relative weight for DRG 20

and provide higher payment for the

Guillain-Barre ́ cases. The proposed

weight for DRG 20 is 2.4782, an increase

of 17 percent over the FY 1996 weight

of 2.1157.

4. MDC 5 (Diseases and Disorders of the

Circulatory System)

Effective for discharges occurring on

or after October 1, 1995, we created a

new code for insertion of a coronary

artery stent (procedure code 36.06).

Until creation of the new code, insertion

of coronary artery stent had been

included in the codes for percutaneous

transluminal coronary angioplasty

(PTCA) (procedure codes 36.01, 36.02,

and 36.05).

As discussed above in section II.B.2,

when a new code is introduced, our

longstanding practice is to assign it to

the same DRG category as its

predecessor code or codes. Therefore, in

the June 2, 1995 proposed rule, we

assigned procedure code 36.06 to DRG

112 (Percutaneous Cardiovascular

Procedures), the DRG to which PTCA is

assigned. In response to comments

received, in the September 1, 1995 final

rule, we explained our policy on DRG

assignment of new codes (60 FR 45785).

We also stated that the resource use and

other data associated with procedure

code 36.06 will be available in the FY

1996 Medicare cases which are used for

analysis as part of FY 1998 DRG

changes. We will evaluate the DRG

assignment of coronary artery stent

insertion at that time.

Since publication of the September 1,

1995 final rule, we have received data

on stent cases provided by the

manufacturer of one of the two stent

devices currently approved by the Food

and Drug Administration (FDA). In

addition, the manufacturer has provided

us with an analysis of the charges and

length of stay of approximately 7,500

Medicare patients who received stents

in FY 1995. Because there was no code

for the procedure during that year, the

manufacturer matched its list of stent

recipients with the FY 1995 MedPAR

file.

The manufacturer’s analysis found

that the FY 1995 average charge for

PTCA cases without stent is

approximately $15,700 and the average

charge for cases with stent is

approximately $21,000. However, our

analysis of the data shows that there is

wide variation in the hospital

standardized charges reported for cases

with implant of coronary artery stent.

Individual hospital average charges for

these cases range from about $9,000 to

over $45,000.

This inconsistency in the data

illustrates why our policy of not

reassigning new codes until we have

collected an entire year of coded

Medicare data for analysis is prudent.

The uncertainty associated with using

incomplete data collected outside the
27448 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

Medicare program that cannot be

verified remains a problem. Therefore,

we are not proposing any DRG

assignment change for implant of

coronary artery stent. As noted above, a

full year of coded FY 1996 Medicare

data will be available in early 1997 for

analysis. We will review the data at that

time, and any proposed DRG changes

will be announced in the FY 1998

proposed rule.

5. MDC 8 (Diseases and Disorders of the

Musculoskeletal System and Connective

Tissue)

In the September 1, 1995 final rule (60

FR 45790), we responded to a comment

we received regarding the DRG

assignment in MDC 8 of bipolar hip

replacement cases. The commenter

requested that cases of bipolar hip

replacement be assigned to DRGs 210,

211, and 212 (Hip and Femur

Procedures Except Major Joint) rather

than to its current assignment, DRG 209

(Major Joint and Limb Reattachment

Procedures of Lower Extremity). The

commenter stated that the procedure for

partial hip replacement (code 81.52) is

very similar to the procedure for open

reduction of fracture of the femur with

internal fixation (code 79.35), which is

assigned to DRGs 210, 211, and 212.

Further, the commenter believes that

partial hip replacement patients are

more frail individuals than the

population that elects total hip

replacement surgery and need longer

hospital stays to recover.

In the September 1, 1995 final rule,

we stated that we would reexamine this

assignment as part of our DRG agenda

for FY 1997. Using the FY 1995

MedPAR file, we compared charges and

lengths of stay for cases assigned to DRG

209 in which the procedures 81.51 (total

hip replacement), 81.52, and 81.53

(revision of hip replacement) were

performed with the charges for the

entire DRG. The average standardized

charges for these cases are very similar

to each other as well as the other cases

assigned to DRG 209. The average

charge was $18,310 for partial hip

replacement, $19,924 for total hip

replacement, and $23,094 for revision of

hip replacement. The $1,278 difference

between the average charge for partial

hip replacement cases in DRG 209 and

the average charge of $19,588 for all

cases in DRG 209 is within the normal

range of charges for that DRG. However,

the average charge for cases in DRG 210

was $15,119, or $2,157 less than the

partial hip replacement charges.

A comparison of lengths of stay yields

slightly different results. The partial hip

replacement cases in DRG 209 had an

average stay of 8.6 days. The overall

average lengths of stay for DRGs 209 and

210 were 6.7 days and 8.5 days,

respectively. Based on these data alone,

it would seem that the commenter is

correct that partial hip replacement

patients are more similar to the patients

in DRG 210, in terms of hospital length

of stay. However, we also must consider

these cases’ higher average charges. The

higher charges of the partial hip

replacement cases indicate that they are

more resource-intense than the cases in

DRG 210. The proposed relative weights

for DRG 209 and 210 are 2.2617 and

1.8458, respectively. Therefore, we

believe that DRG 209 is the most

appropriate assignment for procedure

code 81.52 so that payment will most

closely relate to the costs of care for

these patients.

6. Surgical Hierarchies

Some inpatient stays entail multiple

surgical procedures, each one of which,

occurring by itself, could result in

assignment of the case to a different

DRG within the MDC to which the

principal diagnosis is assigned. It is,

therefore, necessary to have a decision

rule by which these cases are assigned

to a single DRG. The surgical hierarchy,

an ordering of surgical classes from

most to least resource intensive,

performs that function. Its application

ensures that cases involving multiple

surgical procedures are assigned to the

DRG associated with the most 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 ‘‘coronary

bypass’’ consists of two DRGs (DRGs

106 and 107). Consequently, in many

cases, the surgical hierarchy has an

impact on more than one DRG. The

methodology for determining the most

resource-intensive surgical class,

therefore, involves weighting each DRG

for frequency to determine the average

resources for each surgical class. For

example, assume surgical class A

includes DRGs 1 and 2 and surgical

class B includes DRGs 3, 4, and 5, and

that the average charge of DRG 1 is

higher than that of DRG 3, but the

average charges of DRGs 4 and 5 are

higher than the average charge of DRG

2. To determine whether surgical class

A should be higher or lower than

surgical class B in the surgical

hierarchy, we would weight the average

charge of each DRG by frequency (that

is, by the number of cases in the DRG)

to determine average resource

consumption for the surgical class. The

surgical classes would then be ordered

from the class with the highest average

resource utilization to that with the

lowest, with the exception of ‘‘other OR

procedures’’ as discussed below.

This methodology may occasionally

result in a case involving multiple

procedures being assigned to the 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, which

may sometimes occur in cases involving

multiple procedures, this result is

unavoidable.

We note that, notwithstanding the

foregoing discussion, there are a few

instances when a surgical class with a

lower average relative weight is ordered

above a surgical class with a higher

average relative weight. For example,

the ‘‘other OR procedures’’ surgical

class is uniformly ordered last in the

surgical hierarchy of each MDC in

which it occurs, regardless of the fact

that the relative weight for the DRG or

DRGs in that surgical class may be

higher than that for other surgical

classes in the MDC. The ‘‘other OR

procedures’’ class is a group of

procedures that are least likely to be

related to the diagnoses in the MDC but

are occasionally performed on patients

with these diagnoses. Therefore, these

procedures should only be considered if

no other procedure more closely related

to the diagnoses in the MDC has been

performed.

A second example occurs when the

difference between the average weights

for two surgical classes is very small.

We have found that small differences

generally do not warrant reordering of

the hierarchy since, by virtue of the

hierarchy change, the relative weights

are likely to shift such that the 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
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27449

weights due to the unavailability of

revised GROUPER software at the time

this proposed rule is prepared. Rather,

we simulate most major classification

changes to approximate the placement

of cases under the proposed

reclassification and then determine the

average charge for each DRG. These

average charges then serve as our best

estimate of relative resource use for each

surgical class. We test the proposed

surgical hierarchy changes after the

revised GROUPER is received and

reflect the final changes in the DRG

relative weights in the final rule.

Further, as discussed below in section

II.C of this preamble, we anticipate that

the final recalibrated weights will be

somewhat different from those

proposed, since they will be based on

more complete data. Consequently,

further revision of the hierarchy, using

the above principles, may be necessary

in the final rule.

At this time, we would revise the

surgical hierarchy for the Pre-MDC

DRGs, MDC 3 (Diseases and Disorders of

the Ear, Nose, Mouth and Throat), and

MDC 10 (Endocrine, Nutritional and

Metabolic Diseases and Disorders) as

follows:

• In the Pre-MDC DRGs, we would

reorder Tracheostomy Except for Face,

Mouth and Neck Diagnoses (DRG 483)

above Liver Transplant (DRG 480).

• In MDC 3, we would reorder Cleft

Lip and Palate Repair (DRG 52) and

Sinus and Mastoid Procedures (DRGs 53

and 54) above Tonsillectomy and

Adenoidectomy, Except Tonsillectomy

and/or Adenoidectomy Only (DRGs 57

and 58).

• In MDC 10, we would reorder

Adrenal and Pituitary Procedures (DRG

286) above Amputation of Lower Limb

for Endocrine, Nutritional, and

Metabolic Disorders (DRG 285).

7. Refinement of Complications and

Comorbidities List

There is a standard list of diagnoses

that are considered complications or

comorbidities (CCs). We developed this

list using physician panels to include

those diagnoses that, when present as a

secondary condition, would be

considered a substantial complication or

comorbidity.

In previous years, we have made

changes to the standard list of CCs,

either by adding new CCs or deleting

CCs already on the list. At this time, we

do not propose to delete any of the

diagnosis codes on the CC list.

In the September 1, 1995 final rule (60

FR 45782), we added diagnosis code

008.49 (Bacterial enteritis) to the CC list.

In response to a request from one

commenter that we also add diagnosis

code 008.45 (Clostridium difficile), we

stated that we would review that request

as part of our DRG analysis for FY 1997.

We have reevaluated diagnosis code

008.45 as well as the remainder of the

‘‘family’’ of codes assigned to Intestinal

infections due to other specified

bacteria (008.41, 008.42, 008.43, 008.44,

008.46, and 008.47). Our analysis shows

that all of these diagnoses, when present

as a secondary condition, do lead to

higher resource use. Therefore, we are

proposing to add the following

diagnosis codes to the CC list:

008.41 Intestinal infections due to

staphylococcus

008.42 Intestinal infections due to

pseudomonas

008.43 Intestinal infections due to

campylobacter

008.44 Intestinal infections due to

yersinia enterocolitica

008.45 Intestinal infections due to

clostridium difficile

008.46 Intestinal infections due to

other anaerobes

008.47 Intestinal infections due to

other gram-negative bacteria

These diagnoses would be considered

CCs for any principal diagnosis not

shown in Table 6f, Additions to the CC

Exclusions List (see discussion of CC

Exclusions list in section V of the

Addendum below).

This same commenter also requested

that we add the following codes to the

CC list:

331.0 Alzheimer’s disease

423.9 Unspecified disease of the

pericardium

348.5 Cerebral edema

333.4 Huntington’s chorea

458.0 Orthostatic hypotension

458.9 Hypotension, not otherwise

specified

Our analysis of these codes

demonstrates that their presence as a

secondary diagnosis does not

significantly add to the resource use of

the case. Therefore, we are not

proposing to add them to the CC list.

Finally, the commenter suggested that

the following diagnoses be added as

cardiovascular complications for DRG

121 (Circulatory Disorders with AMI

and Cardiovascular Complications,

Discharged Alive):

434.xx Occlusion of cerebral arteries

436 Acute, but ill-defined,

cerebrovascular disease

Using the 10 percent analysis file of

the FY 1995 MedPAR data, we analyzed

the cases assigned to DRG 121 that had

these diagnoses coded as secondary

conditions. The charges associated with

those cases were indeed comparable to

the other cases assigned to DRG 121.

When we sought the advice of our

medical specialists (physicians who

work directly for or under contract with

HCFA), however, they strongly opposed

adding these codes to the list of

conditions for DRG 121 based on the

fact that these are not cardiovascular

complications. Therefore, they are not

clinically similar to other cases assigned

to this DRG.

However, our analysis of this DRG did

reveal a large variation in the charges

and lengths of stay within this DRG. We

believe that a close examination of the

list of complicating conditions assigned

to DRG 121 is needed. Therefore, we

plan to perform a thorough analysis of

the cases assigned to that DRG as part

of our DRG analysis agenda for FY 1998.

In the meantime, we are not proposing

any change to DRG 121.

In the September 1, 1987 final notice

concerning changes to the DRG

classification system (52 FR 33143), we

modified the GROUPER logic so that

certain diagnoses included on the

standard list of CCs would not be

considered a valid CC in combination

with a particular principal diagnosis.

Thus, we created the CC Exclusions

List. We made these changes to preclude

coding of CCs for closely related

conditions, to preclude duplicative

coding or inconsistent coding from

being treated as CCs, and to ensure that

cases are appropriately classified

between the complicated and

uncomplicated DRGs in a pair.

In the May 19, 1987 proposed notice

concerning changes to the DRG

classification system (52 FR 18877), we

explained that the excluded secondary

diagnoses were established using the

following five principles:

• Chronic and acute manifestations of

the same condition should not be

considered CCs for one another (as

subsequently corrected in the

September 1, 1987 final notice (52 FR

33154)).

• Specific and nonspecific (that is,

not otherwise specified (NOS))

diagnosis codes for a condition should

not be considered CCs for one another.

• Conditions that may not co-exist,

such as partial/total, unilateral/bilateral,

obstructed/unobstructed, and benign/

malignant, should not be considered

CCs for one another.

• The same condition in anatomically

proximal sites should not be considered

CCs for one another.

• Closely related conditions should

not be considered CCs for one another.

The creation of the CC Exclusions List

was a major project involving hundreds

of codes. The FY 1988 revisions were

intended to be only a first step toward

refinement of the CC list in that the
27450 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

criteria used for eliminating certain

diagnoses from consideration as CCs

were intended to identify only the most

obvious diagnoses that should not be

considered complications or

comorbidities of another diagnosis. For

that reason, and in light of comments

and questions on the CC list, we have

continued to review the remaining CCs

to identify additional exclusions and to

remove diagnoses from the master list

that have been shown not to meet the

definition of a CC. (See the September

30, 1988 final rule for the revision made

for the discharges occurring in FY 1989

(53 FR 38485); the September 1, 1989

final rule for the FY 1990 revision (54

FR 36552); the September 4, 1990 final

rule for the FY 1991 revision (55 FR

36126); the August 30, 1991 final rule

for the FY 1992 revision (56 FR 43209);

the September 1, 1992 final rule for the

FY 1993 revision (57 FR 39753); the

September 1, 1993 final rule for the FY

1994 revisions (58 FR 46278); the

September 1, 1994 final rule for the FY

1995 revisions (59 FR 45334); and the

September 1, 1995 rule for the FY 1996

revisions (60 FR 45782).)

We are proposing a limited revision of

the CC Exclusions List to take into

account the changes that will be made

in the ICD–9–CM diagnosis coding

system effective October 1, 1996, as well

as the proposed CC changes described

above. (See section II.B.8, below, for a

discussion of ICD–9–CM changes.)

These proposed changes are being made

in accordance with the principles

established when we created the CC

Exclusions List in 1987.

The changes discussed above have

been added to Table 6g, Additions to the

CC Exclusions List, in section V of the

Addendum to this proposed rule.

Tables 6g and 6h in section V of the

Addendum to this proposed rule

contain the proposed revisions to the CC

Exclusions List that would be effective

for discharges occurring on or after

October 1, 1996. Each table shows the

principal diagnoses with proposed

changes to the excluded CCs. Each of

these principal diagnoses is shown with

an asterisk and the additions or

deletions to the CC Exclusions List are

provided in an indented column

immediately following the affected

principal diagnosis.

CCs that are added to the list are in

Table 6g—Additions to the CC

Exclusions List. Beginning with

discharges on or after October 1, 1996,

the indented diagnoses will not be

recognized by the GROUPER as valid

CCs for the asterisked principal

diagnosis.

CCs that are deleted from the list are

in Table 6h—Deletions from the CC

Exclusions List. Beginning with

discharges on or after October 1, 1996,

the indented diagnoses will be

recognized by the GROUPER as valid

CCs for the asterisked principal

diagnosis.

Copies of the original CC Exclusions

List applicable to FY 1988 can be

obtained from the National Technical

Information Service (NTIS) of the

Department of Commerce. It is available

in hard copy for $92.00 plus $6.00

shipping and handling and on

microfiche for $20.50, plus $4.00 for

shipping and handling. A request for the

FY 1988 CC Exclusions List (which

should include the identification

accession number, (PB) 88–133970)

should be made to the following

address: National Technical Information

Service; United States Department of

Commerce; 5285 Port Royal Road;

Springfield, Virginia 22161; or by

calling (703) 487–4650.

Users should be aware of the fact that

all revisions to the CC Exclusions List

(FYs 1989, 1990, 1991, 1992, 1993,

1994, 1995, and 1996) and those in

Tables 6g and 6h of this document must

be incorporated into the list purchased

from NTIS in order to obtain the CC

Exclusions List applicable for

discharges occurring on or after October

1, 1996.

Alternatively, the complete

documentation of the GROUPER logic,

including the current CC Exclusions

List, is available from 3M/Health

Information Systems (HIS), which,

under contract with HCFA, is

responsible for updating and

maintaining the GROUPER program.

The current DRG Definitions Manual,

Version 13.0, is available for $195.00,

which includes $15.00 for shipping and

handling. Version 14.0 of this manual,

which will include the final FY 1997

DRG changes, will be available in

October 1996 for $195.00. These

manuals may be obtained by writing

3M/HIS at the following address: 100

Barnes Road; Wallingford, Connecticut

06492; or by calling (203) 949–0303.

Please specify the revision or revisions

requested.

8. Review of Procedure Codes in DRGs

468, 476, and 477 Each Year, We

Review Cases Assigned to DRG 468

(Extensive OR Procedure Unrelated to

Principal Diagnosis), DRG 476 (Prostatic

OR Procedure Unrelated to Principal

Diagnosis), and DRG 477 (Nonextensive

OR Procedure Unrelated to Principal

Diagnosis) in order to determine

whether it would be appropriate to

change the procedures assigned among

these DRGs.

DRGs 468, 476, and 477 are reserved

for those cases in which none of the OR

procedures performed is related to the

principal diagnosis. These DRGs are

intended to capture atypical cases, that

is, those cases not occurring with

sufficient frequency to represent a

distinct, recognizable clinical group.

DRG 476 is assigned to those discharges

in which one or more of the following

prostatic procedures are performed and

are unrelated to the principal diagnosis:

60.0 Incision of prostate

60.12 Open biopsy of prostate

60.15 Biopsy of periprostatic tissue

60.18 Other diagnostic procedures on

prostate and periprostatic tissue

60.21 Transurethral prostatectomy

60.29 Other transurethral

prostatectomy

60.61 Local excision of lesion of

prostate

60.69 Prostatectomy NEC

60.81 Incision of periprostatic tissue

60.82 Excision of periprostatic tissue

60.93 Repair of prostate

60.94 Control of (postoperative)

hemorrhage of prostate

60.95 Transurethral balloon dilation of

the prostatic urethra

60.99 Other operations on prostate

All remaining OR procedures are

assigned to DRGs 468 and 477, with

DRG 477 assigned to those discharges in

which the only procedures performed

are nonextensive procedures that are

unrelated to the principal diagnosis.

The original list of the ICD–9–CM

procedure codes for the procedures we

consider nonextensive procedures if

performed with an unrelated principal

diagnosis was published in Table 6C in

section IV of the Addendum to the

September 30, 1988 final rule (53 FR

38591). As part of the final rules

published on September 4, 1990, August

30, 1991, September 1, 1992, September

1, 1993, September 1, 1994, and

September 1, 1995, we moved several

other procedures from DRG 468 to 477.

(See 55 FR 36135, 56 FR 43212, 57 FR

23625, 58 FR 46279, 59 FR 45336, and

60 FR 45783, respectively.)

a. Adding Procedure Codes to MDCs

We annually conduct a review of

procedures producing DRG 468 or 477

assignments on the basis of volume of

cases in these DRGs with each

procedure. Our medical consultants

then identify those procedures

occurring in conjunction with certain

principal diagnoses with sufficient

frequency to justify adding them to one

of the surgical DRGs for the MDC in

which the diagnosis falls. This year’s

review did not identify any necessary

changes; therefore, we are not proposing
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27451

to move any procedures from DRG 468

or DRG 477 to one of the surgical DRGs.

b. Reassignment of Procedures Among

DRGs 468, 476, and 477

We also reviewed the list of

procedures that produce assignments to

DRGs 468, 476, and 477 to ascertain if

any of those procedures should be

moved from one of these DRGs to

another based on average charges and

length of stay. Generally, we move only

those procedures for which we have an

adequate number of discharges to

analyze the data. Based on our review

this year, we are proposing to move one

procedure from DRG 468 to DRG 477.

In reviewing the list of OR procedures

that produce DRG 468 assignments, we

analyzed the average charge and length

of stay data for cases assigned to that

DRG to identify those procedures that

are more similar to the discharges that

currently group to either DRG 476 or

477. We identified one procedure—

Closed endoscopic biopsy of lung (code

33.27), a needle biopsy—that is

significantly less resource intensive

than the other procedures assigned to

DRG 468. Therefore, we are proposing to

move procedure code 33.27 to the list of

procedures that result in assignment to

DRG 477.

In reviewing the list of procedures

assigned to DRG 477, we did not

identify any procedures that should be

assigned to either DRG 468 or 476. We

did, however, identify the following

procedures that we believe should be

reassigned from an OR to a non-OR

designation:

08.81 Linear repair of laceration of

eyelid or eyebrow

08.82 Repair of laceration involving

lid margin, partial-thickness

08.83 Other repair of laceration of

eyelid, partial thickness

08.84 Repair of laceration involving

lid margin, full-thickness

08.85 Other repair of laceration of

eyelid, full-thickness

08.86 Lower eyelid rhytidectomy

08.87 Upper eyelid rhytidectomy

08.89 Other eyelid repair

Our analysis of the data associated

with these eyelid repair procedures

leads us to conclude that the procedures

are performed following accidental

injury or falls, incurred while the

patient is in the hospital. These

procedures, which are normally

performed at bedside and do not

necessitate a trip to the operating room,

are significantly less resource intensive

than other procedures designated as OR

procedures. Therefore, we are proposing

to change the procedures from OR to

non-OR procedures. We note that these

procedures are assigned to surgical

DRGs in MDCs 2, 9, 21, 22, and 24. With

this proposed change, cases in which

procedure codes 08.81 through 08.89 are

the only OR procedure codes listed

would no longer be assigned to a

surgical DRG.

All of these proposed changes would

be effective with discharges occurring

on or after October 1, 1996.

9. Changes to the ICD–9–CM Coding

System

As discussed above in section II.B.1 of

this preamble, the ICD–9–CM is a

coding system that is used for the

reporting of diagnoses and procedures

performed on a patient. In September

1985, the ICD–9–CM Coordination and

Maintenance Committee was formed.

This is a Federal interdepartmental

committee charged with the mission of

maintaining and updating the ICD–9–

CM. That mission includes approving

coding changes, and developing errata,

addenda, and other modifications to the

ICD–9–CM to reflect newly developed

procedures and technologies and newly

identified diseases. The Committee is

also responsible for promoting the use

of Federal and non-Federal educational

programs and other communication

techniques with a view toward

standardizing coding applications and

upgrading the quality of the

classification system.

The Committee is co-chaired by the

National Center for Health Statistics

(NCHS) and HCFA. The NCHS has lead

responsibility for the ICD–9–CM

diagnosis codes included in Volume 1—

Diseases: Tabular List and Volume 2—

Diseases: Alphabetic Index, while

HCFA has lead responsibility for the

ICD–9–CM procedure codes included in

Volume 3—Procedures: Tabular List

and Alphabetic Index.

The Committee encourages

participation in the above process by

health-related organizations. In this

regard, the Committee holds public

meetings for discussion of educational

issues and proposed coding changes.

These meetings provide an opportunity

for representatives of recognized

organizations in the coding fields, such

as the American Health Information

Management Association (AHIMA)

(formerly American Medical Record

Association (AMRA)), the American

Hospital Association (AHA), and

various physician specialty groups as

well as physicians, medical record

administrators, health information

management professionals, and other

members of the public to contribute

ideas on coding matters. After

considering the opinions expressed at

the public meetings and in writing, the

Committee formulates

recommendations, which then must be

approved by the agencies.

The Committee presented proposals

for coding changes at public meetings

held on May 5 and November 30, 1995,

and finalized the coding changes after

consideration of comments received at

the meetings and in writing within 30

days following the November 1995

meeting. The initial meeting for

consideration of coding issues for

implementation in FY 1998 will be held

on June 6, 1996. Copies of the minutes

of these meetings may be obtained by

writing to one of the co-chairpersons

representing NCHS and HCFA. We

encourage commenters to address

suggestions on coding issues involving

diagnosis codes to: Donna Pickett, CoChairperson; ICD–9–CM Coordination

and Maintenance Committee; NCHS;

Room 1100; 6525 Belcrest Road;

Hyattsville, Maryland 20782. Comments

may be sent by E-mail to:

alb8@nch09a.em.cdc.gov.

Questions and comments concerning

the procedure codes should be

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

and Maintenance Committee; HCFA,

Office of Hospital Policy; Division of

Prospective Payment System; C5–06–27;

7500 Security Boulevard; Baltimore,

Maryland 21244–1850. Comments may

be sent by E-mail to: pbrooks@hcfa.gov.

The ICD–9–CM code changes that

have been approved will become

effective October 1, 1996. The new ICD–

9–CM codes are listed, along with their

proposed DRG classifications, in Tables

6a and 6b (New Diagnosis Codes and

New Procedure Codes, respectively) in

section V of the Addendum to this

proposed rule. As we stated above, the

code numbers and their titles were

presented for public comment in the

ICD–9–CM Coordination and

Maintenance Committee meetings. Both

oral and written comments were

considered before the codes were

approved. Therefore, we are soliciting

comments only on the proposed DRG

classification.

Further, the Committee has approved

the expansion of certain ICD–9–CM

codes to require an additional digit for

valid code assignment. Diagnosis codes

that have been replaced by expanded

codes, other codes, or have been deleted

are in Table 6c (Invalid Diagnosis

Codes). The procedure codes that have

been replaced by expanded codes or

have been deleted are in Table 6d

(Invalid Procedure Codes). These

invalid diagnosis and procedure codes

will not be recognized by the GROUPER

beginning with discharges occurring on

or after October 1, 1996. The
27452 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

corresponding new or expanded codes

are included in Tables 6a and 6b.

Revisions to diagnosis and procedure

code titles are in Tables 6e (Revised

Diagnosis Code Titles) and 6f (Revised

Procedure Code Titles), which also

include the proposed DRG assignments

for these revised codes.

C. Recalibration of DRG Weights

We are proposing to use the same

basic methodology for the FY 1997

recalibration as we did for FY 1996. (See

the September 1, 1995 final rule (60 FR

45791).) That is, we would recalibrate

the weights based on charge data for

Medicare discharges. However, we

would use the most current charge

information available, the FY 1995

MedPAR file, rather than the FY 1994

MedPAR file. The MedPAR file is based

on fully-coded diagnostic and surgical

procedure data for all Medicare

inpatient hospital bills.

The proposed recalibrated DRG

relative weights are constructed from FY

1995 MedPAR data, based on bills

received by HCFA through December

1995, from all hospitals subject to the

prospective payment system and shortterm acute care hospitals in waiver

States. The FY 1995 MedPAR file

includes data for approximately 10.6

million Medicare discharges.

The methodology used to calculate

the proposed DRG relative weights from

the FY 1995 MedPAR file is as follows:

• To the extent possible, all the

claims were regrouped using the

proposed DRG classification revisions

discussed above in section II.B of this

preamble. As noted in section II.B.6,

due to the unavailability of revised

GROUPER software, we simulate most

major classification changes to

approximate the placement of cases

under the proposed reclassification.

However, there are some changes that

cannot be modeled.

• Charges were standardized to

remove the effects of differences in area

wage levels, indirect medical education

costs, disproportionate share payments,

and, for hospitals in Alaska and Hawaii,

the applicable cost-of-living adjustment.

• The average standardized charge

per DRG was calculated by summing the

standardized charges for all cases in the

DRG and dividing that amount by the

number of cases classified in the DRG.

• We then eliminated statistical

outliers, using the same criteria as was

used in computing the current weights.

That is, all cases that are outside of 3.0

standard deviations from the mean of

the log distribution of both the charges

per case and the charges per day for

each DRG.

• The average charge for each DRG

was then recomputed (excluding the

statistical outliers) and divided by the

national average standardized charge

per case to determine the relative

weight. A transfer case is counted as a

fraction of a case based on the ratio of

its length of stay to the geometric mean

length of stay of the cases assigned to

the DRG. That is, a 5-day length of stay

transfer case assigned to a DRG with a

geometric mean length of stay of 10 days

is counted as 0.5 of a total case.

• We established the relative weight

for heart and heart-lung, liver, and lung

transplants (DRGs 103, 480, and 495) in

a manner consistent with the

methodology for all other DRGs except

that the transplant cases that were used

to establish the weights were limited to

those Medicare-approved heart, 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 1997. Using the

FY 1995 MedPAR data set, there are 37

DRGs that contain fewer than 10 cases.

We computed the weights for the 37

low-volume DRGs by adjusting the FY

1996 weights of these DRGs by the

percentage change in the average weight

of the cases in the other DRGs. We note

that the FY 1996 weights for the lowvolume DRGs were recalculated based

on non-Medicare data we acquired from

19 States. This was the first update of

the weights since they were initially

calculated for FY 1984 based on data

from Maryland and Michigan. For a

complete description of this process, see

the September 1, 1995 final rule (60 FR

45781).

The weights developed according to

the methodology described above, using

the proposed DRG classification

changes, result in an average case

weight that is different from the average

case weight before recalibration.

Therefore, the new weights are

normalized by an adjustment factor, so

that the average case weight after

recalibration is equal to the average case

weight before recalibration. This

adjustment is intended to ensure that

recalibration by itself neither increases

nor decreases total payments under the

prospective payment system.

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

requires that beginning with FY 1991,

reclassification and recalibration

changes be made in a manner that

assures that the aggregate payments are

neither greater than nor less than the

aggregate payments that would have

been made without the changes.

Although normalization is intended to

achieve this effect, equating the average

case weight after recalibration to the

average case weight before recalibration

does not necessarily achieve budget

neutrality with respect to aggregate

payments to hospitals because payment

to hospitals is affected by factors other

than average case weight. Therefore, as

we have done in past years and as

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

Addendum to this proposed rule, we are

proposing to make a budget neutrality

adjustment to assure that the

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

of the Act is met.

III. Proposed Changes to the Hospital

Wage Index

A. Background

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

requires that, as part of the methodology

for determining prospective payments to

hospitals, the Secretary must adjust the

standardized amounts ‘‘for area

differences in hospital wage levels by a

factor (established by the Secretary)

reflecting the relative hospital wage

level in the geographic area of the

hospital compared to the national

average hospital wage level.’’ In

accordance with the broad discretion

conferred by this provision, we

currently define hospital labor market

areas based on the definitions of

Metropolitan Statistical Areas (MSAs)

(and New England County Metropolitan

Areas), issued by the Office of

Management and Budget. In addition, as

discussed below, we adjust the wage
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27453

index to take into account the

geographic reclassification of hospitals

in accordance with sections

1886(d)(8)(B) and 1886(d)(10) of the Act.

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

requires that the wage index be updated

annually beginning October 1, 1993.

Furthermore, this section provides that

the Secretary base the update on a

survey of wages and wage-related costs

of short-term, acute care hospitals. The

survey should measure, to the extent

feasible, the earnings and paid hours of

employment by occupational category,

and must exclude the wages and wagerelated costs incurred in furnishing

skilled nursing services.

B. FY 1997 Wage Index Update

The proposed FY 1997 wage index

(effective for hospital discharges

occurring on or after October 1, 1996

and before October 1, 1997) is based on

the data collected from the Medicare

cost reports submitted by hospitals for

cost reporting periods beginning in FY

1993 (the FY 1996 wage index is based

on FY 1992 wage data). We propose to

use the same categories of data that were

used in the FY 1996 wage index.

Therefore, the proposed FY 1997 wage

index reflects the following:

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

• Home office costs and hours.

• Fringe benefits associated with

hospital and home office salaries.

• Direct patient care contract labor

costs and hours.

• The exclusion of salaries and hours

for nonhospital type services such as

skilled nursing facility services, home

health services, or other subprovider

components that are not subject to the

prospective payment system.

Finally, we are also proposing to

make a minor revision to § 412.63(s)(1)

to state clearly that we update the wage

index annually as required by section

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

1. Verification of Wage Data From the

Medicare Cost Report

The data for the proposed FY 1997

wage index were obtained from

Worksheet S–3, Part II of the Medicare

cost report. The data file used to

construct the proposed wage index

includes FY 1993 data submitted to the

Hospital Cost Report Information

System (HCRIS) file as of the end of

January 1996. As in past years, we

performed an intensive review of the

wage data, mostly through the use of

edits designed to identify aberrant data.

Of the 5,222 hospitals in the data

base, 2,814 hospitals had data elements

that failed an initial edit. In midFebruary 1996, intermediaries contacted

hospitals to revise or verify data

elements that resulted in the edit

failures. Next, to check any revisions

since the first edit, as well as to apply

additional edits based on the

distribution of the data, we subjected all

of the data to edits a second time. The

intermediaries were instructed to

transmit any revisions in hospitals’

wage data made as a result of this

second review. As of March 14, 1996,

only 21 hospitals still had unresolved

data elements. These unresolved data

elements are included in the calculation

of the proposed FY 1997 wage index

pending their resolution before

calculation of the final FY 1997 wage

index. We have instructed the

intermediaries to complete their

verification of questionable data

elements and to transmit any changes to

the wage data (through HCRIS) no later

than June 17, 1996. We expect that all

unresolved data elements will be

resolved by that date, and that the

revised data will be reflected in the final

rule.

2. Computation of the Wage Index

The method used to compute the

proposed wage index is as follows:

Step 1—As noted above, we are

proposing to base the FY 1997 wage

index on wage data reported on the FY

1993 cost reports. We gathered data

from each of the non-Federal short-term,

acute care hospitals for which data were

reported on the Worksheet S–3, Part II

of the Medicare cost report for the

hospital’s cost reporting periods

beginning on or after October 1, 1992

and before October 1, 1993. In addition,

we included data from a few hospitals

that had cost reporting periods

beginning in September 1992 and

reported a cost reporting period

exceeding 52 weeks. The data were

included because no other data from

these hospitals would be available for

the cost reporting period described

above, and particular labor market areas

might be affected due to the omission of

these hospitals. However, we generally

describe these wage data as FY 1993

data.

Step 2—For each hospital, we

subtracted the excluded salaries (that is,

direct salaries attributable to skilled

nursing facility services, home health

services, and other subprovider

components not subject to the

prospective payment system) from gross

hospital salaries to determine net

hospital salaries. To determine total

salaries plus fringe benefits, we added

direct patient care contract labor costs,

hospital fringe benefits, and any home

office salaries and fringe benefits

reported by the hospital, to the net

hospital salaries.

Step 3—For each hospital, we

adjusted the total salaries plus fringe

benefits resulting from Step 2 to a

common period to determine total

adjusted salaries. To make the wage

inflation adjustment, we used the

percentage change in average hourly

earnings for each 30-day increment from

October 14, 1992 through September 15,

1994, for hospital industry workers from

Standard Industry Classification 806,

Bureau of Labor Statistics Employment

and Earnings Bulletin. The annual

inflation rates used were 4.8 percent for

FY 1992, 3.6 percent for FY 1993, and

2.7 percent for FY 1994. The inflation

factors used to inflate the hospital’s data

were based on the midpoint of the cost

reporting period as indicated below.

MIDPOINT OF COST REPORTING

PERIOD

After Before Adjustment

factor

10/14/92 11/15/92 1.044482

11/14/92 12/15/92 1.041408

12/14/92 01/15/93 1.038343

01/14/93 02/15/93 1.035287

02/14/93 03/15/93 1.032240

03/14/93 04/15/93 1.029203

04/14/93 05/15/93 1.026174

05/14/93 06/15/93 1.023154

06/14/93 07/15/93 1.020143

07/14/93 08/15/93 1.017141

08/14/93 09/15/93 1.014147

09/14/93 10/15/93 1.011163

10/14/93 11/15/93 1.008920

11/14/93 12/15/93 1.006683

12/14/93 01/15/94 1.004450

01/14/94 02/15/94 1.002223

02/14/94 03/15/94 1.000000

03/14/94 04/15/94 0.997782

04/14/94 05/15/94 0.995570

05/14/94 06/15/94 0.993362

06/14/94 07/15/94 0.991159

07/14/94 08/15/94 0.988961

08/14/94 09/15/94 0.986767

For example, the midpoint of a cost

reporting period beginning January 1,

1993 and ending December 31, 1993 is

June 30, 1993. An inflation adjustment

factor of 1.020143 would be applied to

the wages of a hospital with such a cost

reporting period. In addition, for the

data for any cost reporting period that

began in FY 1993 and covers a period

of less than 360 days or greater than 370

days, we annualized the data to reflect

a 1-year cost report. Annualization is

accomplished by dividing the data by

the number of days in the cost report

and then multiplying the results by 365.

Step 4—For each hospital, we

subtracted the reported excluded hours

from the gross hospital hours to

determine net hospital hours. We
27454 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

increased the net hours by the addition

of any direct patient care contract labor

hours and home office hours to

determine total hours.

Step 5—As part of our editing

process, we deleted data for eight

hospitals for which we lacked sufficient

documentation to verify data that failed

edits because the hospitals are no longer

participating in the Medicare program

or are in bankruptcy status. We retained

the data for other hospitals that are no

longer participating in the Medicare

program because these hospitals

reflected the relative wage levels in their

labor market areas during their FY 1993

cost reporting period.

Step 6—Each hospital was assigned to

its appropriate urban or rural labor

market area prior to any reclassifications

under sections 1886(d)(8)(B) or

1886(d)(10) of the Act. Within each

urban or rural labor market area, we

added the total adjusted salaries plus

fringe benefits obtained in Step 3 for all

hospitals in that area to determine the

total adjusted salaries plus fringe

benefits for the labor market area.

Step 7—We divided the total adjusted

salaries plus fringe benefits obtained in

Step 6 by the sum of the total hours

(from Step 4) for all hospitals in each

labor market area to determine an

average hourly wage for the area.

Step 8—We added the total adjusted

salaries plus fringe benefits obtained in

Step 3 for all hospitals in the nation and

then divided the sum by the national

sum of total hours from Step 4 to arrive

at a national average hourly wage. Using

the data as described above, the national

average hourly wage is $19.5094.

Step 9—For each urban or rural labor

market area, we calculated the hospital

wage index value by dividing the area

average hourly wage obtained in Step 7

by the national average hourly wage

computed in Step 8.

3. Revisions to the Wage Index Based on

Hospital Redesignation

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

Act, hospitals in certain rural counties

adjacent to one or more MSAs are

considered to be located in one of the

adjacent MSAs if certain standards are

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

Act, the Medicare Geographic

Classification Review Board (MGCRB)

considers applications by hospitals for

geographic reclassification for purposes

of payment under the prospective

payment system.

The methodology for determining the

wage index values for redesignated

hospitals is applied jointly to the

hospitals located in those rural counties

that were deemed urban under section

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

hospitals that were reclassified as a

result of the MGCRB decisions under

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

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

the application of the wage index to

redesignated hospitals is dependent on

the hypothetical impact that the wage

data from these hospitals would have on

the wage index value for the area to

which they have been redesignated.

Therefore, as provided in section

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

values were determined by considering

the following:

• If including the wage data for the

redesignated hospitals reduces the MSA

wage index value by 1 percentage point

or less, the MSA wage index value

determined exclusive of the wage data

for the redesignated hospitals applies to

the redesignated hospitals.

• If including the wage data for the

redesignated hospitals reduces the wage

index value for the area to which the

hospitals are redesignated by more than

1 percentage point, the hospitals that are

redesignated are subject to the wage

index value of the area that results from

including the wage data of the

redesignated hospitals (the ‘‘combined’’

wage index value). However, the wage

index value for the redesignated

hospitals cannot be reduced below the

wage index value for the rural areas of

the State in which the hospitals are

located.

• If including the wage data for the

redesignated hospitals increases the

MSA wage index value, the MSA and

the redesignated hospitals receive the

combined wage index value.

• Rural areas whose wage index

values would be reduced by excluding

the data for hospitals that have been

redesignated to another area continue to

have their wage index calculated as if

no redesignation had occurred. Those

rural areas whose wage index values

increase as a result of excluding the

wage data for the hospitals that have

been redesignated to another area have

their wage indexes calculated exclusive

of the redesignated hospitals.

• The wage index value for an urban

area is calculated exclusive of the wage

data for hospitals that have been

reclassified to another area. However,

geographic reclassification may not

reduce the wage index for an urban area

below the Statewide rural average,

provided the wage index prior to

reclassification was greater than the

Statewide rural wage index value.

• A change in classification of

hospitals from one area to another may

not result in the reduction in the wage

index for any urban area whose wage

index is below the rural wage index for

the State. This provision also applies to

any urban area that encompasses an

entire State.

We note that, except for those rural

areas where redesignation would reduce

the rural wage index value, and those

urban areas whose wage index values

are already below the rural wage index

and would be reduced by

redesignations, the wage index value for

each area is computed exclusive of the

data for hospitals that have been

redesignated from the area for purposes

of their wage index. As a result, several

MSAs listed in Table 4a have no

hospitals remaining in the MSA. This is

because all the hospitals originally in

these MSAs have been reclassified to

another area by the MGCRB. These areas

receive the prereclassified wage index

value. The prereclassified wage index

value will apply as long as the MSA

remains empty.

The proposed revised wage index

values for FY 1997 are shown in Tables

4a, 4b, and 4c in the Addendum to this

proposed rule. Hospitals that are

redesignated should use the wage index

values shown in Table 4c. For some

areas, more than one wage index value

will be shown in Table 4c. This occurs

when hospitals from more than one

State are included in the group of

redesignated hospitals, and one State

has a higher Statewide rural wage index

value than the wage index value

otherwise applicable to the redesignated

hospitals. Tables 4d and 4e list the

average hourly wage for each labor

market area, prior to the redesignation

of hospitals, based on the FY 1993 wage

data. (We note that in Tables 4a, 4c, and

4d, we have revised several of the titles

for urban areas to be consistent with

OMB titles. For example, the title for

urban area 1123 is changed from

Boston-Brockton-Nashua, MA–NH to

Boston-Worcester-Lawrence-LowellBrockton, MA–NH. These are

nomenclature changes only.) In

addition, Table 3C in the Addendum to

this proposed rule includes the adjusted

average hourly wage for each hospital

based on the FY 1993 data. The MGCRB

will use the average hourly wage

published in the final rule to evaluate a

hospital’s application for

reclassification, unless that average

hourly wage is later revised in

accordance with the wage data

correction policy described in

§ 412.63(s)(2). In such cases, the MGCRB

will use the most recent revised data

used for purposes of the hospital wage

index. Hospitals that choose to apply

before publication of the final rule can

use the proposed wage data in applying

to the MGCRB for wage index

reclassifications that would be effective

for FY 1998. We note that in
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27455

adjudicating these wage reclassification

requests during FY 1997, the MGCRB

will use the average hourly wages for

each hospital and labor market area that

are reflected in the final FY 1997 wage

index.

At the time this proposed wage index

was constructed, the MGCRB had

completed its review. The proposed FY

1997 wage index values incorporate all

391 hospitals redesignated for purposes

of the wage index (hospitals

redesignated under section

1886(d)(8)(B) or 1886(d)(10) of the Act)

for FY 1997. The final number of

reclassifications may be different

because some MGCRB decisions are still

under review by the Administrator and

because some hospitals may withdraw

their requests for reclassification.

Any changes to the wage index that

result from withdrawals of requests for

reclassification, wage index corrections,

appeals, and the Administrator’s review

process will be incorporated into the

wage index values published in the final

rule. The changes may affect not only

the wage index value for specific

geographic areas, but also whether

redesignated hospitals receive the wage

index value for the area to which they

are redesignated, or a wage index that

includes the data for both the hospitals

already in the area and the redesignated

hospitals. Further, the wage index value

for the area from which the hospitals are

redesignated may be affected.

Under § 412.273, hospitals that have

been reclassified by the MGCRB are

permitted to withdraw their

applications within 45 days of the

publication of this Federal Register

document. The request for withdrawal

of an application for reclassification that

would be effective in FY 1997 must be

received by the MGCRB by July 15,

1996. A hospital that requests to

withdraw its application may not later

request that the MGCRB decision be

reinstated.

C. Requests for Wage Data Corrections

To allow hospitals more time to

evaluate the wage data used to construct

the proposed FY 1997 hospital wage

index, we have made available to the

public a diskette containing the FY 1993

hospital wage data. In a memorandum

dated March 1, 1996, we instructed all

Medicare intermediaries to inform the

prospective payment hospitals they

serve that the diskette would be

available approximately mid-March

1996. The intermediaries were also

instructed to advise hospitals of the

alternative availability of these data

either through their representative

hospital organizations or directly from

HCFA (using order forms provided by

the intermediary). Additional details on

ordering this data file are discussed

below in section VIII.B of this preamble,

‘‘Requests for Data from the Public.’’

In addition, as discussed above in

section III.B.3 of this preamble, Table

3C, in the Addendum to this proposed

rule, contains each hospital’s adjusted

average hourly wage used to construct

the proposed wage index values. A

hospital can verify its average hourly

wage as reflected on its cost report (after

taking into account any adjustments

made by the intermediary) by dividing

the adjusted average hourly wage in

Table 3C by the applicable wage

inflation adjustment factors as set forth

above in Step 3 of the computation of

the wage index. An updated Table 3C

(along with applicable wage inflation

adjustment factors) will be included in

the final rule.

We believe hospitals have had ample

time to ensure the accuracy of their FY

1993 wage data. Moreover, the ultimate

responsibility for accurately completing

the cost report rests with the hospital,

which must attest to the accuracy of the

data at the time the cost report is filed.

However, if after review of the diskette

or Table 3C, a hospital believes that its

FY 1993 wage data have been

incorrectly reported, the hospital must

submit corrections along with complete

supporting documentation to its

intermediary by May 15, 1996. To be

reflected in the final wage index, any

wage data corrections must be reviewed

by the intermediary and transmitted to

HCFA (through HCRIS) on or before

June 17, 1996. These deadlines, which

correspond to the deadlines we used

last year for the FY 1996 wage index, are

necessary to allow sufficient time to

review and process the data so that the

final wage index calculation can be

completed for development of the final

prospective payment rates to be

published by September 1, 1996. We

cannot guarantee that corrections

transmitted to HCFA after June 17, 1996,

will be reflected in the final wage index.

After reviewing requested changes

submitted by hospitals, intermediaries

will transmit any revised cost reports to

HCRIS and forward a copy of the

revised Worksheet S–3, Part II to the

hospitals. If requested changes are not

accepted, fiscal intermediaries will

notify hospitals in writing of reasons

why the changes were not accepted.

This procedure will ensure that

hospitals have every opportunity to

verify the data that will be used to

construct their wage index values. We

believe that fiscal intermediaries are

generally in the best position to make

evaluations regarding the

appropriateness of a particular cost and

whether it should be included in the

wage index data. However, if a hospital

disagrees with the intermediary’s

resolution of a requested change, the

hospital may contact HCFA in an effort

to resolve the dispute. We note that the

June 17 deadline also applies to these

requested changes.

We have created the process

described above to resolve all

substantive wage data correction

disputes before we finalize the wage

data for the FY 1997 payment rates.

Accordingly, hospitals that do not meet

the procedural deadlines set forth above

will not be afforded a later opportunity

to submit wage corrections or to dispute

the intermediary’s decision with respect

to requested changes.

We intend to make another diskette

available in mid-August that will

contain the wage data that will be used

to construct the wage index values in

the final rule. As with the diskette made

available in March 1996, HCFA will

make the August diskette available to

hospital associations and the public.

This August diskette, however, is being

made available only for the limited

purpose of identifying any potential

errors made by HCFA or the

intermediary in the entry of the final

wage data that result from the process

described above, not for the initiation of

new wage data correction requests.

Hospitals are encouraged to review their

hospital wage data promptly after the

release of the second diskette.

If, after reviewing the August diskette,

a hospital believes that its wage data are

incorrect due to a fiscal intermediary or

HCFA error in the entry or tabulation of

the final wage data, it should send a

letter to both its fiscal intermediary and

HCFA. The letters to the intermediary

and HCFA should outline why the

hospital believes an error exists. These

requests must be received by HCFA and

the intermediaries no later than

September 16, 1996. We have set this

year’s deadline one week earlier than

last year’s deadline because we found

the later deadline made it difficult to

evaluate the requests and recalculate the

wage index values before the start of FY

1997 (that is, October 1, 1996). Requests

should be sent to: Health Care Financing

Administration; Office of Hospital

Policy; Attention: Stephen Phillips,

Technical Advisor; Division of

Prospective Payment System; C5–06–27;

7500 Security Boulevard; Baltimore,

Maryland 21244–1850. The

intermediary will review requests upon

receipt, and, if it is determined that an

intermediary or HCFA error exists, the

fiscal intermediary will notify HCFA

immediately.
27456 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

After mid-August, we will make

changes to the hospital wage data only

in those very limited situations

involving an error by the intermediary

or HCFA that the hospital could not

have known about before its review of

the August diskette. Specifically, after

that point, neither the intermediary nor

HCFA will accept the following types of

requests in conjunction with this

process:

• Requests for wage data corrections

that were submitted too late to be

included in the data transmitted to the

HCRIS system on or before June 17,

1996;

• Requests for correction of errors

made by the hospital that were not, but

could have been, identified during the

hospital’s review of the March 1996

data; or,

• Requests to revisit factual

determinations or policy interpretations

made by the intermediary or HCFA

during the wage data correction process.

Verified corrections to the wage index

received timely (that is, by September

16, 1996) will be effective October 1,

1996.

Again, we believe the wage data

correction process described above

provides hospitals with sufficient

opportunity to bring errors made during

the preparation of the Worksheet S–3 to

the intermediary’s attention. Moreover,

because hospitals will have access to the

wage data in mid-August, they will have

the opportunity to detect any data entry

or tabulation errors made by the

intermediary or HCFA before the

implementation of the FY 1997 wage

index on October 1, 1996. If hospitals

avail themselves of this opportunity, the

wage index implemented on October 1

should be free of such errors.

Nevertheless, in the unlikely event that

such errors should occur, we retain the

right to make midyear changes to the

wage index under very limited

circumstances.

Specifically, in accordance with

§ 412.63(s)(2), we may make midyear

corrections to the wage index only in

those limited circumstances where a

hospital can show: (1) that the

intermediary or HCFA made an error in

tabulating its data, and (2) that the

hospital could not have known about

the error, or did not have an opportunity

to correct the error, before the beginning

of FY 1997 (that is, by the September 16,

1996 deadline). As indicated earlier,

since a hospital will have the

opportunity to verify its data, and the

intermediary will notify the hospital of

any changes, we do not foresee any

specific circumstances under which

midyear corrections would be made.

However, should a midyear correction

be necessary, the wage index change for

the affected area will be effective

prospectively from the date the

correction is made.

D. Contract Labor—Costs Included in

the Hospital Wage Index

Our policy concerning inclusion of

contract labor costs for purposes of

calculating the wage index has evolved

over the past several years. Primarily,

this has occurred as we recognized the

role of contract labor in meeting special

personnel needs of many hospitals. In

addition, improvements in the wage

data have allowed us to more accurately

identify contract labor costs and hours.

As a result, effective with the FY 1994

wage index, we included the costs of

direct patient care contract services in

the wage index calculation. Effective

with the FY 1999 wage index, which

will use data from FY 1995 cost reports,

we will begin to include the costs and

hours of certain management contract

services.

In this proposed rule, we are

soliciting comments from the public

regarding further expansion of the types

of contract labor costs included in the

wage index. The following background

discussion provides a general overview

of the issues related to including

contract labor costs in the wage index

calculation. We also list nine specific

issues for which we are seeking public

comment.

In the May 9, 1990 proposed rule (55

FR 19442), we reported the results of the

1988 wage index survey which

collected, among other information, data

on the costs and hours associated with

direct patient care contract labor. All

prospective payment hospitals

completed the wage survey for their cost

reporting periods ending in calendar

year 1988. The survey data indicated

that hospitals had difficulty in tracking

and recording the actual hours worked

associated with the contract labor. In

addition, there were reporting

inconsistencies. For example, some

hospitals inappropriately reported

patient care services furnished directly

by physicians, which are not included

in the wage data because they are paid

under Medicare Part B rather than Part

A.

In the May 9, 1990 proposed rule, we

also discussed public comments we

received in response to issues we raised

related to including contract labor costs

in the wage index. Specifically, in the

May 8, 1989 proposed rule (54 FR

19647), we requested comment on the

following issues:

• Should the wage index include data

on contract labor?

• Should the definition of contract

services in the wage index survey be

expanded to include services indirectly

related to patient care, such as billing or

housekeeping services?

A majority of the commenters

supported the inclusion of contract

services, and many argued for the

expansion of contract labor services to

include indirect patient care services.

Those opposed to including contract

services, in addition to some

commenters who supported including

contract service costs, were concerned

about the difficulty of accurately

tracking and recording hours worked for

all types of contract labor. Other

commenters were also concerned that if

a hospital contracts for services from

outside its labor market area, the

contract wages could artificially

increase or decrease the hospital’s area

wage index. Based on the comments and

the overall poor quality of the 1988

survey data, we decided to exclude all

contract labor from the FY 1991 wage

index.

We stated that we would continue our

analysis of contract labor. In addition,

we announced that we would develop a

new wage index survey with improved

instructions and auditing criteria to

facilitate the inclusion of contract labor

in future wage index updates. The new

survey, Worksheet S–3, Part II, was

included in the hospital cost report

effective with cost reporting periods

beginning on or after October 1, 1989.

The Worksheet S–3, Part II consists of

detailed information for use in the

hospital wage index including contract

labor for direct patient care services. In

the instructions for completing this

worksheet, contract labor costs and

hours were limited to labor-related

payments and hours attributable to

direct patient care contract services,

such as nursing services. Specifically,

we instructed hospitals to exclude

indirect patient care contract services

(for example, management and

housekeeping services), nonlaborrelated expenses (for example,

equipment and supplies), and any

contract services for which labor-related

payments and hours could not be

accurately determined.

In the September 4, 1990 final rule (55

FR 36036), we discussed additional

comments we received on the contract

labor issue. Those commenters who

supported the inclusion of contract

labor stated that some hospitals,

especially rural hospitals, are dependent

on contract labor for nursing services,

and it would be unfair not to include

these wage data. Other commenters

requested that the definition of contract
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27457

labor be expanded to include indirect

patient care services.

We also received several comments

requesting that we continue to exclude

contract labor from the wage index.

These commenters stated that the

contract labor data are not reliable

because of the difficulty in tracking and

reporting hours and the lack of

consistency in the reporting of contract

labor. In addition, inclusion of nonlabor

contract costs would inappropriately

drive up labor costs, and contract labor

brought in from outside the labor market

area would artificially increase or

decrease the area wage index value.

Finally, commenters were concerned

that contract labor costs are too variable,

temporary, and not reflective of true

wage costs. Therefore, some suggested

that contract labor should not be

included in the wage index.

The FY 1994 wage index, which was

based on the data collected on the

Worksheet S–3, Part II, was the first to

include direct patient care contract

labor costs. In making the decision to

include these costs, we analyzed

hospitals’ FY 1990 data to determine if

it was sufficiently complete for

inclusion in the wage index calculation

(see the May 26, 1993 proposed rule (58

FR 30236)). We noted that, in most labor

market areas, including contract labor in

the wage index computation had little

effect on the average hourly wage. We

further stated that, based on our analysis

of the data, including direct patient care

contract labor would more accurately

and fairly reflect wage levels across

hospitals and MSAs. In the September

1, 1993 final rule, we also responded to

comments from the hospital industry

expressing concern that we did not

recognize the costs of certain contract

management services (58 FR 46296). In

particular, many rural hospitals stated

they were either unable to recruit or

afford top managers such as hospital

administrators and must contract for

these services.

In the September 1, 1994 final rule (59

FR 45355), we expanded the definition

of contract labor for purposes of

determining the hospital wage index to

include the personnel costs and hours

associated with certain contract

management personnel. Contract

management services would be limited

to individuals working in the top four

positions in the hospital: the Chief

Executive Officer/Hospital

Administrator, Chief Operating Officer,

Chief Financial Officer, and Nursing

Administrator. We noted that while

exact titles may vary, individuals

should be performing essentially the

same duties as customarily assigned

these management positions.

We further noted that, since the cost

report did not provide at that time for

the collection of management contract

data, this revised definition would not

be effective until cost reporting periods

beginning on or after October 1, 1994

(FY 1995). Hospitals were instructed to

continue to exclude all management

contract costs and hours until the FY

1995 data were reported (these data will

be used to compute the FY 1999 wage

index). In addition, we began requiring

hospitals to provide descriptions and

aggregate totals for all management

contracts and complete details on all

direct patient care contracts on the Form

HCFA–339 (the Provider Cost Report

Reimbursement Questionnaire). A

hospital must file this form with its

corresponding cost report.

We continue to receive requests that

we expand our contract labor definition

to include more types of contract

services in the wage index. In particular,

we have been asked to include the costs

for pharmacy and laboratory services on

the basis that these services are

consistent with our definition of direct

patient care (see the September 1, 1995

final rule (60 FR 45792)). Others have

asked that we expand our definition to

include all contracted services, both

direct and indirect patient care services,

in order to more appropriately calculate

relative hospital wage costs.

We have limited the contract services

that are included in the wage index to

direct patient care services and specific

management services for several

reasons. First, hospitals reported

difficulty in accurately tracking the

hours associated with contract services,

especially for off-site facilities that serve

more than one hospital. Second, we are

concerned about the contractor’s ability

to separate nonlabor costs from labor

costs. We believe that the generally

higher costs for contract labor compared

to salaried labor, due at least in part to

the added costs of overhead and

supplies not separately identified in

most contracts, may distort the wage

index. Finally, we are concerned that it

is difficult to remove the costs and

hours for services such as legal and

accounting from total management

contracts.

Our goal is to ensure that our wage

index policy continues to be responsive

to the changing need for contract labor,

allowing those hospitals that must

depend on contract labor to supply

needed services to reflect those costs in

their wage data. At the same time,

however, we wish to avoid providing an

opportunity for hospitals to inflate their

average hourly wage inappropriately by

including nonlabor contract costs. The

advantage of our approach of including

only contract labor costs and hours

associated with direct patient care and

specific management services is that it

minimizes distortions in the wage index

that are due to a hospital’s inability to

identify and exclude nonlabor costs.

While changes to the wage index values

are made in a budget neutral manner

and are not expected to affect aggregate

payments, we strive for policies that are

equitable for all hospitals.

Finally, due to the 4-year time lag

between the cost reporting period itself

and the fiscal year when data for that

period are used in calculating the wage

index, it is important that we anticipate

any need to change our policy on

contract labor. Therefore, in order to

formulate the most responsive and

responsible policy, we are soliciting

comments on the following issues:

• To what extent do hospitals rely on

the use of contract services?

• For which services are contracts

typically used?

• Can hospitals accurately determine

hours related to contract services?

• Can hospitals accurately isolate

labor-related costs from nonlaborrelated costs?

• Should the contract labor definition

be expanded to include contract

services indirectly related to patient

care?

• If contract labor remains limited to

direct patient care, what categories of

services, if any, in addition to those

identified above, should be included?

• Would the wage index more

accurately reflect relative wage levels if

we did not limit contract labor to direct

patient care (generally high wage)

services?

• Would expanding the types of

contract labor that are included in the

wage index provide less incentive to

hospitals to keep their labor costs low,

as higher labor costs may result in a

higher wage index value for that

hospital or allow it to reclassify to a

labor market with a higher wage index?

• What other issues should be

considered in revising the policy for

including contract labor in the wage

index?

E. Puerto Rico Wage Index Values

For several years, hospitals in Puerto

Rico have experienced large swings in

their wage index values. In the

September 1, 1995 final rule, we

responded to two comments suggesting

changes to the wage index for hospitals

in Puerto Rico (60 FR 45796). One

suggestion was to establish a floor for

the wage index values of the Puerto Rico

labor market areas while the other was

to eliminate the rural area classification

in Puerto Rico and classify the rural
27458 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

hospitals to the nearest urban area.

Although we did not adopt either of

these suggestions, we stated that we

would continue to study the issue of

wage index values in Puerto Rico.

To evaluate the effect that these large

changes in wage index values have on

hospitals in Puerto Rico, we examined

the most recent Medicare cost data for

these hospitals. Of the 50 hospitals

contained in our data base, 64 percent

had improved Medicare operating

margins from 1992 to 1993. Of the 26

hospitals with data available for 1994,

we found that 65 percent improved

financially from 1993 to 1994. Based on

this analysis, we do not believe that the

wage index changes have had a

detrimental effect on these hospitals as

a group. However, there are individual

hospitals that are not faring as well.

We recognize that large shifts in the

wage index values can cause shifts in

the payment levels for a particular MSA.

Because three of the six MSAs in Puerto

Rico (Aguadilla, Arecibo, and Caguas) as

well as the rural area have four or fewer

hospitals, a large change in one

hospital’s wage data can cause a large

increase or decrease in the wage index

value for the entire MSA. One possible

method to limit these annual swings in

wage index values would be to create a

single labor market area encompassing

all the hospitals in Puerto Rico. That is,

the six MSAs and the rural area would

be combined into one area with one

wage index value. A single labor market

area would create a much larger set of

hospitals to develop aggregate wage

amounts and would mitigate situations

where a change in the wage data of a

single hospital has a large effect on the

wage index of an MSA.

Because creating one MSA for Puerto

Rico would be implemented in a budget

neutral manner, the effect would be to

raise wage index values for some

hospitals in Puerto Rico and to lower

the values for others. Using the FY 1993

wage data, the following table shows the

effect this change would have on the

proposed wage index levels.

Area Number of

hospitals

Proposed

wage index

One area

wage index

Percent

change

Rural ................................................................................................................................. 4 0.4182 0.4555 8.92

Aguadilla ........................................................................................................................... 2 0.4430 0.4555 2.82

Arecibo .............................................................................................................................. 2 0.4661 0.4555 ¥2.27

Caguas ............................................................................................................................. 4 0.4638 0.4555 ¥1.79

Mayaguez ......................................................................................................................... 5 0.4186 0.4555 8.82

Ponce ................................................................................................................................ 7 0.4500 0.4555 1.22

San Juan .......................................................................................................................... 29 0.4616 0.4555 ¥1.32

Because of the negative effects on

some hospitals, we are soliciting

comment on this approach for

mitigating the fluctuations in wage

index values for hospitals in Puerto

Rico. The potential change would have

no impact on hospitals outside Puerto

Rico.

F. Proposed Changes to the MGCRB

Composition and Criteria

Under section 1886(d)(10) of the Act,

the MGCRB considers applications by

hospitals for geographic reclassification

for purposes of payment under the

prospective payment system. Guidelines

concerning the criteria and conditions

for hospital reclassification are located

at §§ 412.230 through 412.236. The

purpose of these criteria is to provide

direction, to both the MGCRB and those

hospitals seeking geographic

reclassification, with respect to the

situations that merit an exception to the

rules governing the geographic

classification of hospitals under the

prospective payment system. The

composition of the MGCRB and the

procedures it follows in making

reclassification determinations are set

forth in §§ 412.246 through 412.280.

As discussed in detail below, we are

proposing to make one change to the

MGCRB regulations. In addition, we are

soliciting comments on sources of data

that could be used to identify the

occupational mix in a given MSA.

1. MGCRB Composition (§ 412.246)

Section 1886(d)(10)(B)(i) of the Act

provides that the MGCRB is composed

of five members appointed by the

Secretary. This provision is

implemented in regulations at

§ 412.246(a). Two of the members must

be representative of the concerns of

rural hospitals and at least one member

must be knowledgeable in the field of

analyzing costs of providing inpatient

hospital services. Under current

§ 412.246(b), the term of office for an

MGCRB member is 3 years, and

appointments are limited to two

consecutive 3-year terms. This section

further provides that to permit staggered

terms of office, initial appointments

may be for shorter terms. Finally, the

Secretary is permitted to terminate a

member’s tenure before his or her full

term has expired.

Since the establishment of the

MGCRB 6 years ago, we have never

modified the regulations that govern the

MGCRB’s composition, which were

originally modeled after the procedural

regulations of the Provider

Reimbursement Review Board (PRRB).

We believe that it is now appropriate to

update the regulations that govern

members’ terms of office in light of

agency experience.

Appointments to the Board must

comply with statutory requirements

concerning rural representatives and a

hospital cost expert. Since the

appointment of the initial Board, the

Secretary has had difficulty recruiting

additional, qualified persons to serve on

the MGCRB. In addition, we solicited

comment in the June 2, 1995 proposed

rule (60 FR 29218) on the idea of

eliminating the MGCRB and transferring

its functions back to HCFA. This may

have caused qualified members to lose

interest in becoming or remaining Board

members. We no longer believe that

there needs to be a limitation on the

number of terms a member may serve.

Deleting the term limit requirement

would allow for increased flexibility in

appointing and recruiting qualified

Board members. Flexibility in this area

will allow the Secretary to ensure that

Board members are in place to meet the

tight statutory deadlines associated with

filing and adjudicating MGCRB

applications. (Under sections

1886(d)(10)(C) (ii) and (iii) of the Act, a

hospital requesting a change in

geographic classification must submit

its application to the Board not later

than the first day of the preceding fiscal

year. Once the application is received

the Board must render a decision within

180 days.) Therefore, we are proposing

to eliminate the current requirement at

§ 412.246(b) that a Board member can

serve for only two consecutive 3-year

terms.

We also considered eliminating any

requirement on the length of an

individual term. However, we believe

that maintaining a term of office not to

exceed 3 years is appropriate. If we
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27459

deleted this requirement, then the

Secretary could not periodically

reevaluate membership of the Board. We

would, however, propose that a term of

office would not be limited only to a

term of exactly 3 years. Specifically, we

would revise § 412.246(b) to provide

that an appointment to the MGCRB may

be for any term not to exceed 3 years.

We believe that both of these proposed

changes would allow the Secretary

maximum flexibility to recruit and

retain qualified Board members.

Under the proposed revisions, the

Secretary would continue to be able to

terminate a member’s tenure before his

or her full term has expired. This

provision was modeled after the

provisions of the PRRB under which the

Secretary has the authority to terminate

a Board member for good cause. We

believe that it is appropriate for the

Secretary to be able to exercise a similar

termination authority over the MGCRB

in case a member of the MGCRB fails to

carry out his or her duties under the Act

and regulations. Therefore, we would

retain this provision. We note that the

Secretary has not invoked this authority

to date with either the PRRB or the

MGCRB.

2. Occupational Mix Adjustment

Section 1886(d)(10)(D)(i) of the Act

requires the Secretary to publish

guidelines to be utilized by the MGCRB

in rendering decisions on applications

submitted for geographic

reclassification. Those are to include

guidelines for ‘‘comparing wages, taking

into account (to the extent the Secretary

determines appropriate) occupational

mix, in the area in which the hospital

is classified and the area in which the

hospital is applying to be classified.’’

Section 412.230(e) describes the

criteria for hospital reclassification for

purposes of the wage index. One of the

criteria relates to the relationship

between the hospital’s wages and those

of the area to which it seeks

reclassification. Specifically,

§ 412.230(e)(1)(iv) provides that the

hospital must demonstrate that its

wages are at least 84 percent of the

average hourly wage of hospitals in the

area to which it seeks reclassification, or

that the hospital’s average hourly wage

weighted for occupational mix is at least

90 percent of the average hourly wage

of hospitals in the area to which it seeks

reclassification. Under §§ 412.232(c)

and 412.234(b), a group of hospitals

seeking to reclassify must demonstrate

that its aggregate average hourly wage is

at least 85 percent of the average hourly

wage of the hospitals in the area to

which it seeks reclassification. These

sections also provide that the threshold

for occupational-mix adjusted hourly

wage for hospital groups is the same as

that for a single hospital, that is, 90

percent.

In the September 6, 1990 interim final

rule (55 FR 36760), we stated that the

acceptable sources for occupational mix

data were the American Hospital

Association (AHA) or the Bureau of

Labor Statistics. Since publication of

that document, the Bureau of Labor has

discontinued its hospital wage surveys.

Thus, the only currently acceptable

occupational mix data source is the

AHA Survey Data. We have been

informed by the AHA that the survey for

1993 will be the last survey to collect

information on the Hospital Personnel

by Occupational Category. Therefore,

requests filed on or before October 1,

1996 for FY 1998 reclassification, which

use FY 1993 wage data, may be the last

for which we have an appropriate

source of occupational mix data.

As we stated in the June 4, 1991 final

rule with comment period (56 FR

25458), the reclassification process

requires the use of occupational mix

data that are comparable across areas

and can be consistently applied. We are

unaware of any sources other than the

AHA data that meet these criteria.

We have not proposed collecting

occupational mix data ourselves in light

of past experience. We attempted to

collect such data some time ago. In the

September 30, 1988 Federal Register (53

FR 38495), we reported on our efforts to

collect 1986 occupational mix data as

part of the Medicare National Uniform

Reporting Demonstration project, to

determine the feasibility of developing a

wage index that would take into account

occupational mix. The majority of

hospitals (more than 60 percent) failed

to complete or submit the survey. A

number of surveys that were submitted

were not filled out completely and

appeared to have numerous errors.

Moreover, we believe that collecting

occupational mix data from hospitals

would be inappropriately burdensome

to the hospitals. In the past, we have

received several comments from

hospitals opposing HCFA’s collection of

occupational mix data (56 FR 43222),

citing the prohibitive cost to hospitals of

furnishing occupational mix data.

Finally, even if we were to decide now

to begin collecting occupational mix

data, it would be at least 6 years before

the data would be available for use.

In order to continue to allow the use

of wage data weighted by occupational

mix in wage index reclassification, we

are seeking suggestions about any

occupational mix data sources that are

available on a national basis. In

addition, we are willing to consider

suggestions about other methods that

would account for occupational mix in

the wage index reclassification process.

IV. Rebasing and Revising of the

Hospital Market Baskets

A. Operating Costs

1. Background

Effective for cost reporting periods

beginning on or after July 1, 1979, we

developed and adopted a hospital input

price index (that is, the hospital ‘‘market

basket’’) for operating costs. Although

‘‘market basket’’ technically describes

the mix of goods and services used to

produce hospital care, this term is also

commonly used to denote the input

price index (that is, cost category

weights and price proxies combined)

derived from that market basket.

Accordingly, the term ‘‘market basket’’

as used in this document refers to the

hospital input price index.

The percentage change in the market

basket reflects the average change in the

price of goods and services hospitals

purchase in order to furnish inpatient

care. We first used the market basket to

adjust hospital cost limits by an amount

that reflected the average increase in the

prices of the goods and services used to

furnish hospital inpatient care. This

approach linked the increase in the cost

limits to the efficient utilization of

resources.

With the inception of the hospital

inpatient prospective payment system

on October 1, 1983, we continued to use

the hospital market basket to update

each hospital’s 1981 inpatient operating

cost per discharge used in establishing

the FY 1984 standardized payment

amounts. In addition, the projected

change in the hospital market basket has

been the integral component of the

update factor by which the prospective

payment rates are updated every year.

Under section 1886(b)(3)(B)(i)(XII) of the

Act, the prospective payment rates will

be updated in FY 1997 by the projected

increase in the hospital market basket

minus 0.5 percentage points. A detailed

explanation of the hospital market

basket used to develop the prospective

payment rates was published in the

Federal Register on September 3, 1986

(51 FR 31461). For additional

background information on general

development of hospital input price

indexes, we refer the reader to the

article by Freeland, Anderson, and

Schendler, ‘‘National Hospital Input

Price Index,’’ Health Care Financing

Review, Summer 1979, pp 37–61. We

also refer the reader to the September 4,

1990 Federal Register (55 FR 35990) in

which we discussed the previous
27460 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

rebasing of the hospital input price

index.

The hospital market basket is a fixedweight, Laspeyres-type price index that

is constructed in three steps. First, a

base period is selected and total base

period expenditures are estimated for

mutually exclusive and exhaustive

spending categories based upon type of

expenditure. Then, the proportion of

total costs that each category represents

is determined. These proportions are

called cost or expenditure weights.

Second, each expenditure category is

matched to an appropriate price/wage

variable, referred to as a price proxy.

These price proxies are price levels

derived from a publicly available

statistical series published on a

consistent schedule, preferably at least

on a quarterly basis. Third and finally,

the price level for each spending

category is multiplied by the

expenditure weight for that category.

The sum of these products (that is, the

expenditure weights multiplied by the

price levels) for all cost categories yields

the composite index level in the market

basket in a given year. Repeating this

step for other years produces a series of

market basket index levels over time.

Dividing one index level by an earlier

index level produces rates of growth in

the input price index.

The market basket is described as a

fixed-weight index because it answers

the question of how much it would cost,

at another time, to purchase the same

mix of goods and services that was

purchased in the base period. The

effects on total expenditures resulting

from changes in the quantity or mix of

goods and services purchased

subsequent to the base period are not

considered. For example, shifting a

traditionally inpatient type of care to an

outpatient setting might affect the

volume of inpatient goods and services

purchased by the hospital, but would

not be factored into the price change

measured by a fixed weight hospital

market basket.

We believe that it is desirable to

rebase the market basket periodically so

the cost weights reflect changes in the

mix of goods and services that hospitals

purchase (hospital inputs) in furnishing

inpatient care. We last rebased the

hospital market basket cost weights

effective for FY 1991. This market

basket, still used through FY 1996,

reflected base year data from FY 1987 in

the construction of the cost weights.

In its April 1, 1985 report to the

Secretary (Appendix C of the June 10,

1985 proposed rule (50 FR 24446)),

ProPAC supported HCFA’s position on

periodic rebasing, stating that the

market basket cost weights should be

recalculated or ‘‘rebased’’ at least every

5 years, or more frequently if significant

changes in the weights occur. We note

that there are separate market baskets

for prospective payment hospitals and

hospitals and hospital units excluded

from the prospective payment system.

The separate, excluded hospital market

basket is set forth in section IV.A.5 of

this preamble.

2. Rebasing and Revising the Hospital

Market Basket

The terms rebasing and revising,

while often used interchangeably,

actually denote different activities.

Rebasing means moving the base year

for the structure of costs of an input

price index (for example, we are

proposing to move the base year cost

structure from FY 1987 to FY 1992).

Revising means changing data sources,

cost categories, or price proxies used in

the input price index.

We are proposing to use a rebased and

revised hospital market basket in

developing the FY 1997 update factor

for the prospective payment rates. The

new market basket would be rebased to

reflect 1992, rather than 1987, cost data.

In developing the rebased and revised

market basket, we reviewed hospital

operating expenditure data for the

market basket cost categories. In a

change from previous methodology, we

are relying primarily on Medicare

hospital cost report data for the

proposed rebasing. For the proposed

market baskets, we used data on

hospital expenditures for four major

expense categories (wages and salaries,

employee benefits, pharmaceuticals,

and a residual ‘‘all other’’) from hospital

cost reporting periods beginning in FY

1992 (that is, periods beginning on or

after October 1, 1991 and before October

1, 1992). We refer to these as PPS–9 cost

reports (the 9th year of the prospective

payment system (PPS)). The market

basket was previously based on 1987

expense data from the 1988 American

Hospital Association (AHA) Annual

Survey.

Expenses for wages and salaries,

employee benefits, and pharmaceuticals

were determined using data from PPS–

9 cost reports as reported in the Hospital

Cost Report Information System (HCRIS)

files. We determined total professional

fees using AHA Annual Survey data.

Total professional fees include medical

and nonmedical professional fees. Since

the medical professional fees included

in the compensation of provider-based

physicians is paid under Medicare Part

B, we analyzed HCRIS data to determine

the professional component of providerbased physician compensation and

subtracted it from total professional fees

to obtain an estimate of nonmedical

professional fees. Malpractice insurance

costs were determined using the cost

share for PPS–6 (cost reporting periods

beginning in FY 1989), the last year

these costs had to be treated separately

from all other administrative and

general costs, trended forward to 1992

based on the relative importance of

malpractice costs found in the previous

market basket. The All Other Expenses

category was calculated in two steps.

First, from PPS–9 cost reports, total

operating expenses were tabulated by

subtracting capital-related expenses,

direct medical education expenses, and

the medical professional fees from total

expenses. Second, we subtracted the

total of the five cost category expenses

already determined from total operating

expenses to obtain the All Other

Expenses category.

After totals for these main cost

categories (wages and salaries, employee

benefits, professional fees,

pharmaceuticals, malpractice insurance,

and all other expenses) were calculated,

we then determined the proportion each

category represents of the total costs.

These proportions represent the major

rebased market basket weights. The

differences between the six major

categories for the proposed 1992-based

index and the previous 1987-based

index are summarized in Table 1 below.

TABLE 1.—COMPARISON OF 1992 AND 1987 PROSPECTIVE PAYMENT HOSPITAL OPERATING COST CATEGORIES AND

WEIGHTS

Expense categories

Rebased 1992

hospital market basket

1987-based

hospital market basket

Wages and Salaries ................................................................................................................................................. 50.244 52.2

Employee Benefits ................................................................................................................................................... 11.146 9.5

Nonmedical Professional Fees ................................................................................................................................ 2.127 1.6
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27461

TABLE 1.—COMPARISON OF 1992 AND 1987 PROSPECTIVE PAYMENT HOSPITAL OPERATING COST CATEGORIES AND

WEIGHTS—Continued

Expense categories

Rebased 1992

hospital market basket

1987-based

hospital market basket

Malpractice Insurance .............................................................................................................................................. 1.189 1.4

Pharmaceuticals ....................................................................................................................................................... 4.162 3.9

All Other ................................................................................................................................................................... 31.132 31.4

Total .................................................................................................................................................................. 100.000 100.0

Note: Although we rounded the weights to the tenths decimal position in the 1987-based market basket as published in the September 4,

1990 final rule, we are presenting the 1992 weights in greater specificity.

Table 2 sets forth the proposed market

basket cost categories, weights, and

price proxies. Weights for the ‘‘Utilities’’

and the ‘‘All Other’’ cost categories, as

well as the subcategories, were

determined using the 1987 Department

of Commerce’s Bureau of Economic

Analysis (BEA) Input-Output Table,

from which data for the hospital

industry were extracted. The BEA InputOutput database, which is updated at 5-

year intervals, was most recently

described in the Survey of Current

Business, ‘‘Benchmark Input-Output

Accounts for the U.S. Economy, 1987’’

(April 1994). We anticipate that the

Department of Commerce will soon

release 1992 cost data for use in

determining the cost weights. If the data

are released in time to be analyzed, we

will use them in the final market basket

for more refined estimates of cost

expenditure weights.

We aged the 1987 cost shares to 1992

using historical price changes between

1987 and 1992 for each category. The

aged shares were normalized to be

consistent with the 1992 hospital cost

report data. Relative weights for the new

base year were then calculated for

various expenditure categories. This

work resulted in the identification of 26

separate cost categories in the rebased

hospital market basket, two fewer

categories than were included in the

1987-based market basket. Detailed

descriptions of each category and

respective price proxy are provided in

Appendix C to this proposed rule.

TABLE 2.—PROPOSED 1992-BASED PROSPECTIVE PAYMENT HOSPITAL OPERATING COST CATEGORIES, WEIGHTS, AND

PRICE PROXIES

Expense categories

Rebased

1992 hospital market

basket

Price proxy

1. Compensation ............................................................. 61.390

A. Wages and Salaries1 .......................................... 50.244 HCFA Occupational Wage Index.

B. Employee Benefits1 ............................................. 11.146 HCFA Occupational Benefits Index.

2. Professional Fees1 ...................................................... 2.127 ECI—Compensation for Professional, Specialty & Technical.

3. Utilities ......................................................................... 2.469

A. Fuel, Oil, and Gasoline ....................................... 0.345 PPI Refined Petroleum Products.

B. Electricity ............................................................. 1.349 PPI Commercial Electric Power.

C. Natural Gas ......................................................... 0.670 PPI Commercial Natural Gas.

D. Water and Sewerage .......................................... 0.106 CPI–U Water & Sewerage Maintenance.

4. Professional Liability Insurance .................................. 1.189 HCFA Professional Liability Insurance Premium Index.

5. All Other ...................................................................... 32.824

A. All Other Products ............................................... 24.033

(1.) Pharmaceuticals ......................................... 4.162 PPI Ethical (Prescription) Drugs.

(2.) Food ........................................................... 3.459

a. Direct Purchase ..................................... 2.363 PPI Processed Foods & Feeds.

b. Contract Service .................................... 1.096 CPI–U Food Away From Home.

(3.) Chemicals ................................................... 3.795 PPI Industrial Chemicals.

(4.) Medical Instruments ................................... 3.128 PPI Medical Instruments & Equipment.

(5.) Photographic Supplies ............................... 0.399 PPI Photographic Supplies.

(6.) Rubber and Plastics ................................... 4.868 PPI Rubber & Plastic Products.

(7.) Paper Products .......................................... 2.062 PPI Converted Paper & Paperboard Products.

(8.) Apparel ....................................................... 0.875 PPI Apparel.

(9.) Machinery and Equipment ......................... 0.211 PPI Machinery & Equipment.

(10.) Miscellaneous Products ........................... 1.074 PPI Finished Goods.

B. All Other Services ............................................... 8.792

(1.) Business Services1 .................................... 3.823 ECI—Compensation for Private Workers in Business Services.

(2.) Computer Services1 ................................... 1.927 AHE Computer & Data Processing Services.

(3.) Transportation Services ............................. 0.188 CPI-U Transportation.

(4.) Telephone Services ................................... 0.531 CPI-U Telephone Services.

(5.) Postage1 ..................................................... 0.272 CPI-U Postage.

(6.) All Other: Labor Intensive* ......................... 1.707 ECI—Compensation for Private Service Occupations.

(7.) All Other: Nonlabor Intensive ..................... 0.344 CPI-U All Items.

Total ........................................................... 100.000

1 Labor-related.

NOTE: Due to rounding, weights may not sum to total.
27462 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

The 1987-based market basket

included a separate Blood Services cost

category. In the 1992-based market

basket, Blood Services is contained

within the Chemicals cost category. In

addition, the 1987-based cost category

for Fuel Oil, Coal, etc. has been

combined with the 1987-based Motor

Gasoline cost category to form the 1992-

based Fuel, Oil and Gasoline cost

category. Both of these changes are

based on revised cost categories from

BEA. For comparison purposes, the

1987-based cost categories are set forth

in Table 3.

TABLE 3.—1987-BASED PROSPECTIVE PAYMENT HOSPITAL OPERATING COST CATEGORIES, WEIGHTS, AND PRICE

PROXIES

Expense categories

1987 hospital market

basket

Price proxy

1. Compensation ............................................................. 61.7

A. Wages and Salaries1 ........................................... 52.2 HCFA Occupational Wage Index.

B. Employee Benefits1 ............................................. 9.5 HCFA Occupational Benefits Index.

2. Professional Fees1 ...................................................... 1.6 ECI—Wages & Salaries for Professional, Specialty & Technical.

3. Utilities ......................................................................... 2.4

A. Fuel, Oil, Coal, etc. ............................................. 0.6 WPI Light Fuel Oils.

B. Electricity ............................................................. 1.1 WPI Industrial Power.

C. Natural Gas ......................................................... 0.3 WPI Natural Gas.

D. Motor Gasoline .................................................... 0.2 WPI Gasoline.

E. Water and Sewerage .......................................... 0.0 CPI–U Water & Sewerage Maintenance.

4. Professional Liability Insurance .................................. 1.4 HCFA Professional Liability Insurance Premiums.

5. All Other ...................................................................... 32.8

A. All Other Products ............................................... 21.8

(1.)Pharmaceuticals .......................................... 3.9 WPI Prescription Drugs.

(2.) Food ........................................................... 3.3

a. Direct Purchase ..................................... 2.1 WPI Processed Foods.

b. Contract Service .................................... 1.2 CPI–U Food Away From Home.

(3.) Chemicals ................................................... 3.1 WPI Industrial Chemicals.

(4.) Medical Instruments ................................... 2.7 WPI Medical Instruments & Equipment.

(5.) Photographic Supplies ............................... 2.6 WPI Photographic Supplies.

(6.) Rubber and Plastics ................................... 2.3 WPI Rubber & Plastic Products.

(7.) Paper Products .......................................... 1.4 PPI Converted Paper & Paperboard Products.

(8.) Apparel ....................................................... 1.1 WPI Textile House furnishings.

(9.) Machinery and Equipment ......................... 0.4 WPI Machinery & Equipment.

(10.) Miscellaneous Products ........................... 0.8 WPI Finished Goods.

B. All Other Services ............................................... 11.1

(1.) Business Services1 .................................... 3.8 AHE Business Services.

(2.) Computer Services1 ................................... 2.0 AHE Computer & Data Processing Services.

(3.)Transportation Services .............................. 1.2 CPI–U Transportation.

(4.) Telephone Services ................................... 1.0 CPI–U Telephone Services.

(5.) Blood Services1 .......................................... 0.6 WPI Blood & Derivatives.

(6.) Postage1 ..................................................... 0.4 CPI–U Postage.

(7.) All Other: Labor Intensive1 ......................... 1.2 ECI—Wages and Salaries for Private Service Occupations.

(8.) All Other: Nonlabor Intensive ..................... 0.8 CPI–U All Items.

Total ........................................................... 100.0

1 Labor-related.

Note: Due to rounding, weights may not sum to total.

In the September 4, 1990 final rule,

for purposes of determining the laborrelated portion of the standardized

amounts, we summed the percentages of

the labor-related items (that is, wages

and salaries, employee benefits,

professional fees, business services,

computer and data processing, blood

services, postage, and all other laborintensive services) in the hospital

market basket. This summation resulted

in a labor-related portion of the hospital

market basket of 71.4 percent and

nonlabor-related portion of 28.6 percent.

Under sections 1886 (d)(2)(H) and

(d)(3)(E) of the Act, in making payments

under the prospective payment system,

the Secretary estimates from time to

time the proportion of payments that are

labor-related. Since October 1, 1990,

then, we have considered 71.4 percent

of costs to be labor-related for purposes

of the prospective payment system.

In connection with the rebasing of the

hospital market basket, we have reestimated the labor-related share of the

standardized amounts. Based on the

relative weights described in Table 2,

the labor-related portion that is subject

to hospital wage index adjustments

(based on wages and salaries, employee

benefits, professional fees, business

services, computer and data processing,

postage, and all other labor-intensive

services) is 71.246 percent and the

nonlabor-related portion is 28.754

percent. To implement this change,

effective with discharges occurring on

or after October 1, 1996, we are

proposing to recompute the laborrelated and nonlabor-related shares of

the large urban and other areas’

standardized amounts used to establish

the prospective payment rates.

The amounts in Table 4 reflect the

revised labor-related and nonlaborrelated portions. Due to the Bureau of

Economic Analysis’ reclassification of

Blood Services to Chemicals, we now

allocate Blood Services to a nonlabor

cost category. We note that, although

there are revisions of the labor and

nonlabor portions, due to both weight

changes and the Blood Services category

change, the labor-related portions of the

rates published in Table 4 have

remained essentially the same. The
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27463

labor-related portion has decreased by

0.146 percentage points.

TABLE 4.—LABOR-RELATED SHARE

Cost category Weight

Wages and Salaries ....................... 50.244

Employee Benefits .......................... 11.146

Professional Fees ........................... 2.127

Business Services .......................... 3.823

Computer Services ......................... 1.927

Postal Services ............................... 0.272

All Other Labor Intensive ................ 1.707

Total Labor-Related ................. 71.246

Total Nonlabor Related ........... 28.754

3. Selection of Price Proxies

After computing the 1992 cost

weights for the rebased hospital market

basket, it is necessary to select

appropriate wage and price proxies to

monitor the rate of increase for each

expenditure category. Most of the

indicators are based on Bureau of Labor

Statistics (BLS) data and are grouped

into one of the following BLS categories:

• Producer Price Indexes—Producer

Price Indexes (PPIs) measure price

changes for goods sold in other than

retail markets. For example, we used the

PPI for ethical drugs, rather than the

Consumer Price Index (CPI) for

prescription drugs. PPIs are preferable

price proxies for goods that hospitals

purchase as inputs in producing their

outputs. The PPIs we used measure

price change at the final stage of

production.

• Consumer Price Indexes—

Consumer Price Indexes (CPIs) measure

change in the prices of final goods and

services bought by the typical

consumer. Because they may not

represent the price faced by the

producer, the consumer price indexes

were used if no appropriate PPI was

available, or if the expenditure was

more similar to that of retail consumers

in general rather than a purchase at the

wholesale level. For example, the CPI

for food purchased away from home was

used as a proxy for contracted food

services.

• Employment Cost Indexes—

Employment Cost Indexes (ECIs)

measure the rate of change in employee

wage rates and employer costs for

employee benefits per hour worked.

These indexes are fixed-weight indexes

and strictly measure the change in wage

rates and employee benefits per hour.

They are not affected by shifts in

employment mix.

• Average Hourly Earnings—Average

Hourly Earnings (AHEs) measure the

rate of change of hourly earnings for

various occupations within a given

industry, and, therefore, reflect a

weighted occupational mix within a

particular industry. The AHE series is

calculated by dividing gross payrolls by

total hours and measures actual

earnings rather than pure wage rates. It

is a current-weight series rather than a

fixed-weight index and thus reflects

shifts in employment mix. An AHE

rather than an ECI is used when there

is no corresponding ECI category that is

an appropriate measure of growth for a

given labor category or when the ECI

does not have sufficient length of

history to be useful for our purpose.

Our proposed price proxies for the

rebased prospective payment hospital

market basket are shown in Table 2

above and are summarized in Appendix

C to this proposed rule.

4. The HCFA Blended Compensation

Index

Compensation includes the two

largest categories of the rebased hospital

market basket. Wages and salaries

account for 50.244 percent and

employee benefits account for 11.146

percent of the total weight in the

prospective payment hospital market

basket.

The proposed HCFA Blended

Compensation Index groups hospital

occupations into nine broad categories.

For eight of those occupational groups,

we believe that hospitals compete for

labor generally with employers outside

the health care sector. Accordingly, we

use economy-wide employment cost

indexes (ECI) as price proxies for these

eight occupational groups. In the case of

compensation for nurses, as well as for

certain other health care technicians

and professionals, the hospital labor

market may be predominant. However,

hospitals do compete with other

industries to obtain certain skilled

professional and technical staff (for

example, computer programmers).

Therefore, for professional and technical

workers, we believe a price proxy that

reflects an equal blend of internal and

external compensation variables is

appropriate.

Similar to the methodology used for

the previous rebasing, the weights for

the nine cost categories in the

occupational blend index were derived

from the 1992 Current Population

Survey (CPS) produced by BLS. Using

the CPS, private hospital workers were

classified into the nine occupational

categories. Private hospitals better

reflect the mix of occupations used to

produce acute care services for the

prospective payment hospital input

price index. Government hospitals were

excluded because their occupational

mix reflects the subset of nonacute care

hospitals. Once private hospital workers

were sorted by occupation into one of

the nine occupational groups, weights

were estimated using the share of wages

and salaries for each of the nine

occupations. These shares formed the

basis of the weights that were used for

the market basket of occupational

categories.

An additional adjustment was made

for contract labor costs. Rather than treat

contract labor as a distinct

noncompensation cost category, it was

integrated into the occupational blend

as a component of hospitals’

compensation costs for purposes of the

market basket index. Thus, contract

labor is treated the same as other labor

expenses. Contract labor was allocated

to the professional and technical and

service occupation categories. After

adjusting the professional and technical

and service workers’ shares to account

for contract labor, the weights for the

nine occupational blend categories were

renormalized to equal 100.00 percent.

The weights and proxies for the nine

cost categories of the HCFA Blended

Wages and Salaries Index are shown in

Table 5.

TABLE 5.—HCFA BLENDED WAGES AND SALARIES INDEX (WAGES AND SALARIES COMPONENT OF THE 1992-BASED

MARKET BASKET)

Cost category Weight Price proxy

Professional and Technical .................................... 65.729 Equal blend of ECI for wages and salaries of civilian hospital workers and ECI

for wages and salaries of professional, specialty and technical workers.

Managers and Administrators ................................ 9.554 ECI for wages and salaries for executive, administrative and managerial workers.

Sales ...................................................................... 0.402 ECI for wages and salaries for sales workers.

Clerical Workers ..................................................... 12.379 ECI for wages and salaries for administrative support including clerical workers.

Craft and Kindred ................................................... 1.689 ECI for wages and salaries for precision production, craft and repair workers.
27464 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 5.—HCFA BLENDED WAGES AND SALARIES INDEX (WAGES AND SALARIES COMPONENT OF THE 1992-BASED

MARKET BASKET)—Continued

Cost category Weight Price proxy

Operatives Except Transport ................................. 0.437 ECI for wages and salaries for machine operators, assemblers and inspectors.

Transport Equipment Operatives ........................... 0.122 ECI for wages and salaries for transportation and material moving workers.

Nonfarm Laborers .................................................. 0.084 ECI for wages and salaries for handlers, equipment cleaners, helpers and laborers.

Service Workers ..................................................... 9.606 ECI for wages and salaries for service occupations.

Total Wages and Salaries ...................................... 100.000 Total Weight for Wages and Salaries is 50.2.

Note: Due to rounding, weights may not sum to total.

5. Separate Market Basket for Hospitals

and Hospital Units Excluded From the

Prospective Payment System

In its March 1, 1990 report, ProPAC

recommended that we establish a

separate market basket for hospitals and

hospital units excluded from the

prospective payment system. Effective

with FY 1991, HCFA adopted ProPAC’s

recommendation to implement separate

market baskets. (See the September 4,

1990 final rule (55 FR 36044).)

Prospective payment and excluded

hospitals tend to have different case

mixes, practice patterns, and

composition of inputs. The fact that

these hospitals are not included under

the prospective payment system in part

reflects these differences.

Studies completed by HCFA, ProPAC,

and the hospital industry have

documented different weights for

excluded hospitals and prospective

payment hospitals. Table 7 compares

major weights in the rebased 1992

market basket for excluded hospitals

with weights in the rebased 1992 market

basket for prospective payment system

hospitals. Wages and salaries are 52.152

percent of total operating costs for

excluded hospitals compared to 50.244

percent for prospective payment

hospitals. Employee benefits are 11.569

percent for excluded hospitals

compared to 11.146 percent for

prospective payment hospitals. As a

result, compensation costs (wages and

salaries plus employee benefits) for

excluded hospitals are 63.721 percent of

costs compared to 61.390 percent for

prospective payment hospitals.

Noncompensation costs are 36.279

percent for excluded hospitals and

38.610 of costs for prospective payment

hospitals.

Two significant differences in the

category weights occur in

Pharmaceuticals and Business Services.

Pharmaceuticals represent 4.162 percent

of costs for prospective payment

hospitals and 3.070 percent for

excluded hospitals. Business services

represent 3.823 percent of costs for

prospective payment hospitals and

2.337 percent for excluded hospitals.

The weights for the excluded hospital

market basket were derived using the

same data sources and methods as for

the prospective payment market basket

(see Appendix C to this proposed rule).

Differences in weights between the

proposed excluded hospital and

prospective payment hospital market

baskets do not necessarily lead to

significant differences in the rate of

price growth for the two market baskets.

If the individual wages and prices move

at the approximately same annual rate,

both market baskets may have about the

same price growth even though weights

may differ substantially because both

market baskets use the same wages and

prices. Also, offsetting price increases

for various cost components can result

in similar composite price growth in

both market baskets.

The wage and price proxies are the

same for the excluded hospital and

prospective payment hospital market

baskets. As discussed in section IV.A.2

of this preamble, all of the cost

expenditure weights for both the

prospective payment and excluded

hospital market baskets are subject to

refinement if the U.S. Department of

Commerce data are released in time to

be analyzed and incorporated in the

final market basket.

The excluded hospital market basket

is a composite set of weights for

Medicare participating psychiatric,

long-term care, rehabilitation, and

children’s hospitals. We are proposing

to use cost report data for excluded

hospitals and units whose Medicare

average length of stay is within 15

percent (that is, 15 percent higher or

lower) of the total facility average length

of stay. This is a change from the 1987-

based market basket, for which data for

all excluded hospitals and units were

used. We believe that limiting our

sample to hospitals with a Medicare

average length of stay within 15 percent

of the total facility average length of stay

provides a more accurate reflection of

the structure of costs for Medicare. We

note that the proposed forecast for FY

1997 would be the same even if we had

included all excluded hospitals in the

calculation of weights. The forecast for

both the limited and full set of excluded

hospitals yields a rate of change for FY

1997 of 2.7 percent.

TABLE 6.—COMPARISON OF SIGNIFICANT WEIGHTS FOR 1992–BASED

EXCLUDED HOSPITAL AND PROSPECTIVE PAYMENT HOSPITAL MARKET

BASKETS

Category Excluded

hospitals

Prospective

payment

hospitals

Wages and Salaries ............... 52.152 50.244

Employee Benefits .................. 11.569 11.146

Professional

Fees ............... 2.098 2.127

Pharmaceuticals 3.070 4.162

All Other ............ 31.111 32.321

Total ........... 100.000 100.000
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27465

TABLE 7.—PROPOSED 1992-BASED EXCLUDED HOSPITAL OPERATING COST CATEGORIES, WEIGHTS, AND PRICE PROXIES

Expense categories

Rebased

1992 excluded

hospital

market

basket

Price proxy

1. Compensation ............................................................. 63.721

A. Wages and Salaries ............................................ 52.152 HCFA Occupational Wage Index.

B. Employee Benefits .............................................. 11.569 HCFA Occupational Benefits Index.

2. Professional Fees ....................................................... 2.098 ECI—Compensation for Professional, Specialty & Technical.

3. Utilities ......................................................................... 2.557

A. Fuel, Oil, and Gasoline ....................................... 0.357 PPI Refined Petroleum Products.

B. Electricity ............................................................. 1.396 PPI Commercial Electric Power.

C. Natural Gas ......................................................... 0.694 PPI Commercial Natural Gas.

D. Water and Sewerage .......................................... 0.110 CPI–U Water & Sewerage Maintenance.

4. Professional Liability Insurance .................................. 1.081 HCFA Professional Liability Insurance Premiums Index.

5. All Other ...................................................................... 30.543

A. All Other Products ............................................... 23.642

(1.) Pharmaceuticals ......................................... 3.070 PPI Ethical (Prescription) Drugs.

(2.) Food ........................................................... 3.581

a. Direct Purchase ..................................... 2.446 PPI Processed Foods & Feeds.

b. Contract Service .................................... 1.135 CPI–U Food Away From Home.

(3.) Chemicals ................................................... 3.929 PPI Industrial Chemicals.

(4.) Medical Instruments ................................... 3.238 PPI Medical Instruments & Equipment.

(5.) Photographic Supplies ............................... 0.413 PPI Photographic Supplies.

(6.) Rubber and Plastics ................................... 5.039 PPI Rubber & Plastic Products.

(7.) Paper Products .......................................... 2.134 PPI Converted Paper & Paperboard Products.

(8.) Apparel ....................................................... 0.906 PPI Apparel.

(9.) Machinery and Equipment ......................... 0.218 PPI Machinery & Equipment.

(10.) Miscellaneous Products ........................... 1.112 PPI Finished Goods.

B. All Other Services ............................................... 6.901

(1.) Business Services ...................................... 2.337 ECI—Compensation for Private Workers in Business Services.

(2.) Computer Services ..................................... 1.415 AHE Computer & Data Processing Services.

(3.) Transportation Services ............................. 0.195 CPI–U Transportation.

(4.) Telephone Services ................................... 0.549 CPI–U Telephone Services.

(5.) Postage ...................................................... 0.282 CPI–U Postage.

(6.) All Other: Labor Intensive .......................... 1.767 ECI—Compensation for Private Service Occupations.

(7.) All Other: Nonlabor Intensive ..................... 0.356 CPI–U All Items.

Total ........................................................... 100.000

Note: Due to rounding, weights may not sum to total.

Table 8, below, shows what the

excluded hospital weights would be if

cost data for all excluded hospitals had

been used.

TABLE 8.—1992 EXCLUDED HOSPITAL OPERATING COST CATEGORIES, WEIGHTS, AND PROXIES USING DATA FROM ALL

EXCLUDED HOSPITALS

Expense categories

Rebased 1992

excluded hospital market

basket

Price proxy

1. Compensation ........................................................... 68.074

A. Wages and Salaries .......................................... 55.714 HCFA Occupational Wage Index.

B. Employee Benefits ............................................ 12.360 HCFA Occupational Benefits Index.

2. Professional Fees ..................................................... 2.073 ECI—Compensation for Professional, Specialty & Technical.

3. Utilities ...................................................................... 2.191

A. Fuel, Oil, and Gasoline ..................................... 0.306 PPI Refined Petroleum Products.

B. Electricity ........................................................... 1.196 PPI Commercial Electric Power.

C. Natural Gas ....................................................... 0.595 PPI Commercial Natural Gas.

D. Water and Sewerage ........................................ 0.094 CPI–U Water & Sewerage Maintenance.

4. Professional Liability Insurance ................................ 1.081 HCFA Professional Liability Insurance Premiums Index.

5. All Other .................................................................... 26.582

A. All Other Products ............................................. 20.333

(1.) Pharmaceuticals ....................................... 2.704 PPI Ethical (Prescription) Drugs.

(2.) Food ......................................................... 3.069

a. Direct Purchase ................................... 2.096 PPI Processed Foods & Feeds.

b. Contract Service .................................. 0.973 CPI–U Food Away From Home.

(3.) Chemicals ................................................ 3.367 PPI Industrial Chemicals.

(4.) Medical Instruments ................................. 2.775 PPI Medical Instruments & Equipment.
27466 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 8.—1992 EXCLUDED HOSPITAL OPERATING COST CATEGORIES, WEIGHTS, AND PROXIES USING DATA FROM ALL

EXCLUDED HOSPITALS—Continued

Expense categories

Rebased 1992

excluded hospital market

basket

Price proxy

(5.) Photographic Supplies ............................. 0.354 PPI Photographic Supplies.

(6.) Rubber and Plastics ................................. 4.319 PPI Rubber & Plastic Products.

(7.) Paper Products ........................................ 1.829 PPI Converted Paper & Paperboard Products.

(8.) Apparel ..................................................... 0.777 PPI Apparel.

(9.) Machinery and Equipment ....................... 0.187 PPI Machinery & Equipment.

(10.) Miscellaneous Products ......................... 0.953 PPI Finished Goods.

B. All Other Services ............................................. 6.248

(1.) Business Services .................................... 2.337 ECI—Compensation for Private Workers in Business Services.

(2.) Computer Services .................................. 1.213 AHE Computer & Data Processing Services.

(3.) Transportation Services ........................... 0.167 CPI–U Transportation.

(4.) Telephone Services ................................. 0.471 CPI–U Telephone Services.

(5.) Postage .................................................... 0.242 CPI–U Postage.

(6.) All Other: Labor Intensive ........................ 1.514 ECI—Compensation for Private Service Occupations.

(7.) All Other: Nonlabor Intensive ................... 0.305 CPI–U All Items.

Total ......................................................... 100.000

The relatively small differences in

weights between the proposed excluded

hospital market basket data from

excluded hospitals that have a Medicare

length of stay within 15 percent of the

total facility average length of stay and

the excluded hospital market basket

using data from all excluded hospitals

do not lead to significant changes in the

rate of price growth for these two market

baskets. If all individual wages and

prices move at about the same annual

rate, both market baskets could have

about the same price growth even if

weights are somewhat different. Also,

offsetting price increases for various

costs components can result in the price

growth being the same.

To examine the sensitivity of the

change to the limited set of excluded

hospitals, we developed a comparison

for the period 1988–1998. Using

historical data and forecasts for the

market baskets, we compared limited

and full sets of excluded hospitals.

TABLE 9.—A COMPARISON OF THE

PROPOSED EXCLUDED HOSPITAL

MARKET BASKET AND THE EXCLUDED HOSPITAL MARKET BASKET

REBASED USING ALL EXCLUDED

HOSPITALS, PERCENT CHANGE,

1988–1998

Federal fiscal

year

Proposed

excluded

(+/

¥15%)

hospital

market

basket—

1992

base

Excluded

hospital

market

basket

using all

excluded

hospitals—

1992

base

Difference

Historical:

1988 ............ 4.8 4.8 0.0

1989 ............ 5.5 5.5 0.0

1990 ............ 4.5 4.6 (0.1)

1991 ............ 4.3 4.4 (0.1)

1992 ............ 3.1 3.2 (0.1)

1993 ............ 3.1 3.2 (0.1)

1994 ............ 2.6 2.7 (0.1)

1995 ............ 3.3 3.2 0.1

Forecasted:

1996 ............ 2.6 2.6 0.0

1997 ............ 2.7 2.7 0.0

1998 ............ 2.9 2.9 0.0

Historical average:

1988–1995 3.9 4.0 (0.1)

Forecasted average:

1996–1998 2.7 2.7 0.0

Note that the historical average rate of

growth for 1988–1995 for the proposed

excluded hospital market basket

including only excluded hospitals with

Medicare average length of stay within

15 percent of total facility average

length of stay is virtually identical to

that for the excluded hospital market

basket with all excluded hospitals. The

rates of growth using the two

methodologies are identical for FY 1996,

1997, and 1998.

B. Capital Costs

Rebasing the Capital Input Price Index

1. Background

Effective for cost reporting periods

beginning on or after October 1, 1995,

the Capital Input Price Index (CIPI) is

used to determine the price increase

associated with prospective payment

hospital capital-related expenses.

Capital-related expenses are defined as

depreciation expenses, capital-related

interest expenses, and other capitalrelated expenses, such as insurance and

taxes. The CIPI measures the input price

change of these capital-related expenses,

and is included in the capital

prospective payment update framework

to determine a rate of increase in capital

prospective payments.

Like the prospective payment hospital

operating input price index, the CIPI is

a fixed-weight price index. A fixedweight price index measures how much

it would cost at a later date to purchase

the same mix of goods and services

purchased in the base period. For the

prospective payment hospital operating

and capital input price indexes, the base

period is selected and cost category

weights are determined using available

data on hospitals. Next, appropriate

price proxy indexes are chosen for each

cost category. Then a price proxy index

level for each expenditure category is

multiplied by the comparable cost

category weight. The sum of these

products (that is, weights multiplied by

price proxy index levels) for all cost

categories yields the composite index

level of the market basket for a given
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27467

year. Repeating the step for other years

produces a time series of composite

market basket index levels. Dividing an

index level by a later index level

produces a rate of growth in the input

price index. Since the percent change is

computed for the fixed mix of total

capital inputs with a 1992 base, the

index is called fixed-weight.

Like the operating input price index,

the CIPI measures the price changes

associated with costs during a given

year. In order to do so, the CIPI must

differ from the operating input price

index in one important aspect. The CIPI

must reflect the vintage nature of

capital, which is the acquisition and use

of capital over time. Capital expenses in

any given year are determined by the

stock of capital in that year (that is,

capital that remains on hand from all

current and prior capital acquisitions).

An index measuring capital price

changes needs to reflect this vintage

nature of capital. Therefore, the CIPI

was developed to capture the vintage

nature of capital by using a weightedaverage of past capital purchase prices

up to and including the current year.

Using Medicare cost reports, AHA data,

and Securities Data Corporation data, a

vintage-weighted price index was

developed to measure price increases

associated with capital expenses. The

most recent discussion on the CIPI and

methodological background was

published in the September 1, 1995

final rule (60 FR 45817). The following

Federal Register documents describe

development and revisions of the

methodology involved with the

construction of the CIPI:

September 1, 1992 (57 FR 40016), May

26, 1993 (58 FR 30448),

September 1, 1993 (58 FR 46490), May

27, 1994 (59 FR 27876),

September 1, 1994 (59 FR 45517), June

2, 1995 (60 FR 29229), and September

1, 1995 (60 FR 45815).

We periodically update the base year

for the operating and capital input

prices to reflect the changing

composition of inputs for operating and

capital expenses. Currently, both the

operating input price index and the CIPI

are based to FY 1987. We are proposing

that the base year cost structure be

updated to FY 1992, the most recent

year with relatively complete data for

purposes of rebasing. We explain the

process of rebasing the cost structure

weights for the CIPI below.

2. Rebasing the Capital Input Price

Index

We are proposing to use a rebased

capital input price index (CIPI) in

developing the FY 1997 capital update

factor for capital prospective payment

rates. The new CIPI would be rebased to

reflect the 1992, rather than the 1987,

structure of capital costs. In developing

the rebased CIPI, we reviewed hospital

capital expenditure data for capital cost

categories (depreciation, interest, and

other). Two sets of weights had to be

developed in order to compute the

rebased CIPI: (1) cost category weights

which identify the proportion of total

hospital capital expenditures

attributable to each capital expenditure

category, and (2) relative vintage

weights for depreciation and interest

which identify the proportion of capital

expenditures within a cost category that

are attributable to each year over the life

of capital assets in that category.

Because capital expense data in the

Medicare Cost Reports is not available

prior to 1980 for use in computing

vintage weights, the two sets of weights

are measured using the best data sources

available as explained below and in

Appendix C to this proposed rule. The

computations involved with rebasing

the CIPI are explained for each of these

sets of weights.

a. Capital Cost Category Weights. The

capital cost category weights in Table 1

below were computed using a

combination of the FY 1992 Medicare

Cost Reports and 1992 AHA Annual

Survey data. Fiscal Year 1992 marked

the first year for expanded capital data

available in the Medicare Cost Reports.

After reviewing the data, we determined

that much of the data had been

reclassified into different expense

categories. Therefore, we removed

reports that appeared to have

reclassified data, and matched the

remaining reports to the corresponding

reports in the AHA Annual Survey data

set. These remaining 2724 reports were

used to compute capital cost category

weights and the expected life of capital,

which is used in determining vintage

weights for depreciation and interest.

In reviewing the data, we determined

that the Medicare Cost Reports provided

accurate data for depreciation and other

capital expenses, but had reclassified

interest data. We determined that AHA

Annual Survey data more accurately

reflected interest expense, based on past

trends in interest rates. Therefore, we

used the AHA Annual Survey interest

levels along with the Medicare Cost

Report levels for depreciation and other

capital expenses to develop a more

robust capital cost data base.

After removing depreciation, interest,

and other capital expenses from total

capital expenses, the remainder

constitutes lease expenses. Lease

expenses are not a separate cost category

in the CIPI. They are distributed to the

other cost categories (depreciation,

interest, other), reflecting an assumption

that the underlying cost structure of

leases is similar to capital costs in

general. We assigned 10 percent of lease

expenses to the other capital expenses

cost category as overhead, and the

remaining lease expenses were

distributed to the three cost categories

based on the weights of depreciation,

interest, and other capital expenses not

including lease expenses. (We base this

assignment of 10 percent of lease

expenses to overhead on the common

assumption that overhead is 10 percent

of costs.)

We also used the 1992 Medicare Cost

Reports to determine weights for the

building and fixed equipment category

and the movable equipment category.

Expenses for building and fixed

equipment and for movable equipment

were determined using the same sample

of reports as was used to compute the

major cost category weights. The split

between building and fixed equipment

and movable equipment was also used

to compute the vintage weights

described below. Table 10 presents a

comparison of the rebased 1992 capital

cost weights and the 1987 capital cost

weights.

We only used those hospital reports

which we considered to have capital

data that was not reclassified. Because

we did not use all hospital reports, we

were concerned that the hospitals used

may not be representative of the

universe. Therefore, we compared the

distribution of costs for the hospitals

used with the data re-weighted to reflect

the characteristics of the total universe

of hospitals. From this analysis we

validated that the cost weights derived

from the subset we used were

representative of the cost weights for the

entire universe of hospitals.
27468 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 10—COMPARISON OF 1987 AND 1992 COST CATEGORY WEIGHTS

Expense categories FY1987 Rebased

FY1992 Price proxy

Total ................................................................................................... 1.0000 1.0000

Total depreciation .............................................................................. .6510 .6484

1. Building and fixed equipment depreciation ............................ .3054 .3009 Boeckh Institutional Construction Index—vintage weighted (22 yrs)

2. Movable equipment depreciation ........................................... .3456 .3475 PPI for Machinery and Equipment—vintage weighted (10 yrs)

Total interest ...................................................................................... .3274 .3184

1. Government/Non Profit Interest .............................................. .2783 .2706 Average Yield on Domestic Municipal Bonds (Bond Buyer 20

bonds)—vintage weighted (22 yrs)

2. For-Profit Interest ................................................................... .0491 .0478 Average Yield on Moody’s AAA Bonds—vintage weighted (22 yrs)

Other .................................................................................................. .0216 .0332 CPI (U) for Residential Rent

Source: 1992 Medicare Cost Reports, PPS year 9; 1992 AHA Annual Survey.

Note: Due to rounding, weights may not sum to totals.

We had planned to incorporate the

1992 data from the Department of

Commerce for developing capital cost

category weights. However, these data

were not available when we developed

this proposed rule. If the data become

available in time to for us to analyze it,

we plan to incorporate it as a data input

for the final rule.

b. Relative Vintage Weights for Prices.

As we have explained in previous

Federal Register documents (September

1, 1995, 60 FR 45817), the CIPI was

developed to capture the vintage nature

of capital; that is, because capital is

acquired and consumed over time, the

capital expenses in any given year are

determined by past and current

purchases of physical and financial

capital. Therefore, a vintage-weighted

CIPI was developed which used vintage

weights for depreciation (physical

capital) and interest (financial capital)

to capture the long-term consumption of

capital. These vintage weights reflect

the purchase patterns of building and

fixed equipment and movable

equipment over time. Because

depreciation and interest expenses are

determined by the amount of past and

current capital purchases, we use the

vintage weights to compute vintageweighted price changes associated with

depreciation and interest expense,

which is the purpose of the CIPI.

To compute the vintage weights for

depreciation and interest expenses, we

used a time series of capital purchases

for building and fixed equipment and

movable equipment. We found no single

source that provides the best time series

of capital purchases by hospitals for all

of the above components of capital

purchases. The Medicare Cost Reports

did not have sufficient capital data to

meet this need. The AHA Panel Survey

provides a consistent database back to

1963. While the AHA Panel Survey data

does not provide annual capital

purchases, it does provide a time series

of depreciation and interest expenses,

which can be used to infer capital

purchases over time. The process of

using the AHA data to estimate a time

series of capital purchases, and

eventually vintage weights, is explained

in detail below.

In order to estimate capital purchases

from AHA data on depreciation and

interest expenses, the expected life for

building and fixed equipment, for

movable equipment, and for debt

instruments is needed. The expected life

is used in the calculation of vintage

weights for building and fixed

equipment, movable equipment, and

debt instruments as we explain below.

We used the same sample of hospitals

from FY 1992 Medicare Cost Reports

and the 1992 AHA Annual Survey

explained above in computing cost

category weights to compute the

expected life of building and fixed

equipment and movable equipment.

(The AHA Panel Survey is a monthly

survey of a sample of hospitals, while

the AHA Annual Survey is a more

detailed survey of all hospitals.) The

expected life of any piece of equipment

can be determined by dividing the

historical asset cost (excluding fully

depreciated assets) by the current year

depreciation amount. This calculation

yields the estimated useful life of an

asset if depreciation continued at

current year levels, assuming straightline depreciation, which is the only

depreciation method allowed under

Medicare. From the FY 1992 costs

reports, the expected life of building

and fixed equipment was determined to

be 22 years, and the expected life of

movable equipment was determined to

be 10 years. By comparison, the

expected life using FY 1987 data was 25

years for building and fixed equipment

and 10 years for movable equipment.

It was also necessary to compute the

expected life of debt instruments held

by hospitals. As in prior exercises, we

used hospital issuances of municipal

and commercial bonds from Securities

Data Corporation to determine the

expected life of hospital debt

instruments, which is used in the

estimation of vintage weights for

interest expense. This data source

produced a weighted average life for the

two types of bonds of 22 years for FY

1992, the same expected life as was

computed for the 1987-based CIPI.

An annual series of total expenses and

depreciation expenses was obtained

from the AHA Panel Survey. For the

calculation of vintage weights, this

expense data was needed back to 1963.

However, the depreciation expense data

in the AHA Panel survey was available

only back to 1976. We noticed an

increasing trend in depreciation

expenses as a percentage of total

expenses. We performed a regression on

this percentage, and used the regression

equation to estimate depreciation

expenses back to 1963. We then used

the fixed and movable weights derived

from the FY 1992 Medicare Cost Reports

to partition the AHA Panel Survey

depreciation expenses into annual

amounts of building and fixed

depreciation and movable depreciation.

Multiplying the annual depreciation

amounts by the expected life

calculations from the FY 1992 Medicare

cost reports, year-end asset costs for

building and fixed equipment and

movable equipment were determined.

Then by subtracting the previous year

asset costs from the current year asset

costs, annual purchases of building and

fixed equipment and movable

equipment were estimated back to 1963.

This capital purchase time series is then

used to compute the vintage weights for

building and fixed equipment, movable

equipment, and debt instruments. Each

of these sets of vintage weights is

explained in detail below.

For building and fixed equipment

vintage weights, the real annual capital

purchase amounts for building and

fixed equipment derived from the AHA

Panel Survey were used. The real

annual purchase amount was used to

capture the actual amount of the

physical acquisition, net of the effect of

price inflation. This real annual

purchase amount for building and fixed

equipment was produced by deflating
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27469

the nominal annual purchase amount by

the building and fixed equipment price

proxy, the Boeckh institutional

construction index. Because building

and fixed equipment has an expected

life of 22 years, the vintage weights for

building and fixed equipment were

deemed to represent the average

purchase pattern of building and fixed

equipment over 22-year periods. With

real building and fixed equipment

purchase estimates available back to

1963, nine 22-year periods could be

averaged to determine the average

vintage weights for building and fixed

equipment. Averaging different periods

produces vintage weights that are

representative of average building and

fixed equipment purchase patterns over

time. Vintage weights for each 22-year

period are calculated by dividing the

real building and fixed capital purchase

amount in any given year by the total

amount of purchases in the 22-year

period. For example, for the 22-year

period of 1964–1985, the vintage weight

for year 1 is calculated by dividing the

real annual capital purchase amount of

building and fixed equipment in 1964

into the total amount of real annual

capital purchases of building and fixed

equipment over the entire 1964–1985

period. This calculation is done for each

year in the 22-year period, and for each

of the nine 22-year periods. An average

is taken of the nine 22-year periods to

determine the FY 1992 average building

and fixed equipment vintage weights,

presented in Table 11 with the FY 1987

vintage weights.

For movable equipment vintage

weights, the real annual capital

purchase amounts for movable

equipment derived from the AHA Panel

Survey were used. The real annual

purchase amount was used to capture

the actual amount of the physical

acquisition, net of price inflation. This

real annual purchase amount for

movable equipment was produced by

deflating the nominal annual purchase

amount by the movable equipment price

proxy, the Producer Price Index for

machinery and equipment. Because

movable equipment has an expected life

of 10 years, the vintage weights for

movable equipment were deemed to

represent the average purchase pattern

of movable equipment over 10-year

periods. With real movable equipment

purchase estimates available back to

1963, 21 10-year periods could be

averaged to determine the average

vintage weights for movable equipment.

Averaging different periods produces

vintage weights which are

representative of average movable

equipment purchase patterns over time.

Vintage weights for each 10-year period

are calculated by dividing the real

movable capital purchase amount for

any given year by the total amount of

purchases in the 10-year period. For

example, for the 10-year period of 1976–

1985, the vintage weight for year 1 is

calculated by dividing the real annual

capital purchase amount of movable

equipment in 1976 into the total amount

of real annual capital purchases of

movable equipment over the entire

1976–1985 period. This calculation is

done for each year in the 10-year period,

and for each of the 21 10-year periods.

The average of the 21 10-year periods is

used to determine the FY 1992 average

movable equipment vintage weights,

presented in Table 11 with the FY 1987

vintage weights.

For interest vintage weights, the

nominal annual capital purchase

amounts for total equipment (building

and fixed, and movable) derived from

the AHA Panel Survey were used.

Nominal annual purchase amounts were

used to capture the value of the debt

instrument. Because debt instruments

have an expected life of 22 years, the

vintage weights for interest were

deemed to represent the average

purchase pattern of total equipment

over 22-year periods. With nominal total

equipment purchase estimates available

back to 1963, nine 22-year periods could

be averaged to determine the average

vintage weights for interest. Averaging

different periods produces vintage

weights which are representative of

average capital purchase patterns over

time. Vintage weights for each 22-year

period are calculated by dividing the

nominal total capital purchase amount

for any given year by the total amount

of purchases in the 22-year period. For

example, for the 22-year period of 1964–

1985, the vintage weight for year 1 is

calculated by dividing the nominal

annual capital purchase amount of total

equipment in 1964 into the total amount

of nominal annual capital purchases of

total equipment over the entire 1964–

1985 period. This calculation is done for

each year in the 22-year period, and for

each of the nine 22-year periods. The

average of the nine 22-year periods is

used to determine the FY 1992 average

interest vintage weights, presented in

Table 11 with the FY 1987 weights.

TABLE 11.—VINTAGE WEIGHTS FOR CAPITAL-RELATED PRICE PROXIES

Year

Building and fixed equipmentMovable equipment Interest

FY1987

25 yrs

Rebased

FY1992

22 yrs

FY1987

10 yrs

Rebased

FY1992

10 yrs

FY1987

22 yrs

Rebased

FY1992

22 yrs

1 ........................................................................................ .015 .019 .064 .069 .007 .007

2 ........................................................................................ .019 .020 .072 .075 .009 .008

3 ........................................................................................ .022 .023 .077 .083 .010 .010

4 ........................................................................................ .024 .026 .085 .091 .011 .012

5 ........................................................................................ .023 .028 .095 .097 .013 .014

6 ........................................................................................ .022 .030 .101 .103 .015 .016

7 ........................................................................................ .020 .031 .109 .109 .017 .018

8 ........................................................................................ .021 .032 .122 .115 .020 .021

9 ........................................................................................ .025 .036 .132 .124 .023 .024

10 ...................................................................................... .030 .039 .142 .133 .027 .029

11 ...................................................................................... .033 .043 .................... .................... .032 .035

12 ...................................................................................... .034 .047 .................... .................... .038 .041

13 ...................................................................................... .034 .050 .................... .................... .043 .047

14 ...................................................................................... .035 .052 .................... .................... .050 .052

15 ...................................................................................... .038 .055 .................... .................... .057 .059

16 ...................................................................................... .043 .059 .................... .................... .064 .067

17 ...................................................................................... .049 .062 .................... .................... .074 .074

18 ...................................................................................... .053 .065 .................... .................... .083 .081

19 ...................................................................................... .056 .067 .................... .................... .090 .088
27470 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 11.—VINTAGE WEIGHTS FOR CAPITAL-RELATED PRICE PROXIES—Continued

Year

Building and fixed equipmentMovable equipment Interest

FY1987

25 yrs

Rebased

FY1992

22 yrs

FY1987

10 yrs

Rebased

FY1992

10 yrs

FY1987

22 yrs

Rebased

FY1992

22 yrs

20 ...................................................................................... .057 .069 .................... .................... .098 .093

21 ...................................................................................... .060 .072 .................... .................... .105 .099

22 ...................................................................................... .066 .073 .................... .................... .114 .103

23 ...................................................................................... .071 .................... .................... .................... .................... ....................

24 ...................................................................................... .075 .................... .................... .................... .................... ....................

25 ...................................................................................... .077 .................... .................... .................... .................... ....................

Total ....................................................................... 1.000 1.000 1.000 1.000 1.000 1.000

Sources: AHA Panel Survey, 1963–1993; 1992 Medicare Cost Reports; Securities Data Corporation.

3. Selection of Price Proxies

After the 1992 capital cost category

weights were computed, it was

necessary to select appropriate price

proxies to monitor the rate of increase

for each expenditure category. Our

proposed price proxies for the FY 1992

based CIPI are the same as those for the

FY 1987 based CIPI. The rationale for

selecting the price proxies is explained

in the June 2, 1995 proposed rule (60 FR

29227) and the September 1, 1995 final

rule (60 FR 45817). The proposed price

proxies are presented in Table 10.

4. Forecast of the CIPI for Federal Fiscal

Year 1997

DRI forecasts a 1.0 percent increase in

the rebased 1992 CIPI for FY 1997, as

indicated in Table 12. This is the

outcome of a 2.5 percent increase in

projected depreciation prices (building

and fixed equipment, and movable

equipment) and a 2.3 percent increase

in other capital expense prices in FY

1997, partially offset by a 3.0 percent

decline in vintage-weighted interest

rates in FY 1997.

TABLE 12.—HCFA CAPITAL INPUT PRICE INDEX PERCENT CHANGES, TOTAL AND COMPONENTS, FISCAL YEARS 1979 TO

2000

Fiscal Year Total

Depreciation

Interest Other

Total

Building and

fixed equipment

Movable

equipment

Weights (FY92) ................................................................. 1.0000 0.6484 0.3009 0.3475 0.3184 0.0332

Price Changes

1979 .................................................................................. 5.4 7.4 7.0 7.7 2.7 7.1

1980 .................................................................................. 6.9 8.0 7.3 8.5 5.4 8.6

1981 .................................................................................. 8.7 8.5 7.7 9.1 9.1 8.8

1982 .................................................................................. 9.2 8.5 8.0 9.0 10.2 8.0

1983 .................................................................................. 6.7 8.1 7.9 8.2 4.8 6.3

1984 .................................................................................. 6.3 7.3 7.6 7.1 4.9 5.0

1985 .................................................................................. 5.2 6.3 7.0 5.8 3.5 5.9

1986 .................................................................................. 3.7 5.7 6.4 5.1 0.7 6.2

1987 .................................................................................. 3.1 5.1 5.9 4.5 ¥0.1 4.5

1988 .................................................................................. 3.0 4.6 5.4 4.0 0.3 3.8

1989 .................................................................................. 2.6 4.4 5.2 3.7 ¥0.5 3.8

1990 .................................................................................. 2.3 4.0 4.9 3.2 ¥0.7 4.2

1991 .................................................................................. 2.0 3.6 4.6 2.7 ¥1.1 3.9

1992 .................................................................................. 1.5 3.2 4.4 2.1 ¥2.0 2.6

1993 .................................................................................. 1.1 2.9 4.1 1.8 ¥2.8 2.4

1994 .................................................................................. 1.1 2.7 3.9 1.7 ¥2.7 2.3

1995 .................................................................................. 1.3 2.6 3.8 1.6 ¥2.0 2.5

1996 .................................................................................. 0.9 2.5 3.7 1.5 ¥3.1 2.4

1997 .................................................................................. 1.0 2.5 3.5 1.5 ¥3.0 2.3

1998 .................................................................................. 1.0 2.5 3.4 1.5 ¥3.1 3.0

1999 .................................................................................. 1.0 2.4 3.4 1.5 ¥3.1 2.4

2000 .................................................................................. 1.1 2.4 3.4 1.5 ¥3.2 2.8

Source: DRI/McGraw-Hill HCC, 1st Qtr 1996; @USSIM/TREND25YR0296 @CISSIM/CONTROL961.

Released By: HCFA, OACT, Office of National Health Statistics.
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27471

5. Comparison of Percent Changes in the

FY 1992 Based CIPI and the FY 1987

Based CIPI

Rebasing the CIPI from 1987 to 1992

decreased the percent change in the FY

1997 forecast by only 0.2 percentage

points, from 1.2 to 1.0 as indicated in

Table 4. The effect of rebasing is

analyzed by comparing the 1992-based

CIPI forecasted percent changes to the

1987-based CIPI forecasted percent

changes using the same DRI forecast of

component prices. As shown in Table

13, there is only a 0.2 percentage point

difference between the percent changes

in the 1992-based CIPI and the 1987-

based CIPI using the first quarter 1996

forecast. The difference is caused by

changes to: (1) cost category weights, (2)

expected life, and (3) vintage weights.

The changes to cost category weights

coupled with the wide disparity in price

changes between the different cost

categories contributed to lowering the

CIPI percent change in the FY 1997

forecast. This was the case with fixed

depreciation, which has faster price

growth than the other cost categories

and now has a lower weight by nearly

one-half of a percentage point because

of rebasing to 1992. Also contributing to

the 0.2 percentage point difference in

FY 1997 forecast is the change in the

expected life of building and fixed

equipment and the change in the

vintage weights for all three

components: building and fixed

equipment, movable equipment, and

interest. The shorter expected life (22

years in 1992 versus 25 years in 1987)

of building and fixed equipment slightly

decreased the FY 1997 forecast CIPI

percent change because years with

higher price increases were not

included as they had been before. The

change in vintage weights also tended to

decrease the FY 1997 CIPI percent

change because vintage weights in all

cases changed to be spread more evenly

over the life of the asset, decreasing the

weight of more recent years and

increasing the weight of past years. In

the years around FY 1997, prices for

depreciation and interest are projected

to increase slightly faster than prices in

earlier years.

TABLE 13.—COMPARISON OF 1987

AND 1992 BASED CAPITAL INPUT

PRICE INDEX USING THE SAME DRI

FORECAST, PERCENT CHANGE,

1979–1997

Federal fiscal year

CIPI

1987 Rebased

1992

1979 .............................. 5.6 5.4

TABLE 13.—COMPARISON OF 1987

AND 1992 BASED CAPITAL INPUT

PRICE INDEX USING THE SAME DRI

FORECAST, PERCENT CHANGE,

1979–1997—Continued

Federal fiscal year

CIPI

1987 Rebased

1992

1980 .............................. 7.1 6.9

1981 .............................. 8.8 8.7

1982 .............................. 9.3 9.2

1983 .............................. 6.7 6.7

1984 .............................. 6.3 6.3

1985 .............................. 5.1 5.2

1986 .............................. 3.7 3.7

1987 .............................. 3.1 3.1

1988 .............................. 3.0 3.0

1989 .............................. 2.7 2.6

1990 .............................. 2.4 2.3

1991 .............................. 2.1 2.0

1992 .............................. 1.7 1.5

1993 .............................. 1.3 1.1

1994 .............................. 1.3 1.1

1995 .............................. 1.5 1.3

1996 .............................. 1.2 0.9

1997 .............................. 1.2 1.0

Source: DRI/McGraw-Hill HCC, 1st Qtr

1996; @USSIM/TREND25YR0296 @CISSIM/

CONTROL961.

Released by: HCFA, OACT, Office of National Health Statistics.

6. Comparison of Percent Changes in the

FY 1997 CIPI Forecast in the September

1, 1995 Federal Register and the current

FY 1997 CIPI Forecast

The previously published CIPI

forecast for FY 1997 of 1.7 percent has

been revised to 1.0 percent in this

proposed rule. As explained above in

section IV.B.5, 0.2 percentage points of

the decline was the result of rebasing

the CIPI from 1987 to 1992. The

remaining 0.5 percentage point

difference in FY 1997 between the 1992-

based CIPI and the 1987-based CIPI

previously published is the result of

revised projections by DRI. Since

making a forecast in the second quarter

of 1995 for the September 1, 1995

Federal Register, DRI has revised their

projections of price changes downward

for every cost category in the CIPI. This

revised projection accounts for 0.5 of

the 0.7 difference between the 1992-

based CIPI percent changes and the

1987-based CIPI percent changes

previously published.

V. Other Decisions and Proposed

Changes to the Prospective Payment

System for Inpatient Operating Costs

A. Sole Community Hospital Criteria

(§ 412.92)

Under the prospective payment

system, special payment protections are

provided to hospitals that, by reason of

factors such as isolated location,

weather conditions, travel conditions, or

absence of other hospitals, are the sole

source of hospital inpatient services

reasonably available to Medicare

beneficiaries. The criteria a hospital

must meet to be classified as a sole

community hospital (SCH) as well as

the special payment adjustments

available are set forth in the regulations

at § 412.92.

One of the ways in which a hospital

can qualify for sole community status is

to be located between 25 and 35 miles

from other like hospitals and prove that

no more than 25 percent of residents

who become inpatients or no more than

25 percent of the Medicare beneficiaries

who become inpatients in the hospital’s

‘‘service area’’ are admitted to other like

hospitals located within a 35-mile

radius of the hospital (or its service area,

if larger).

In the rulemaking process for FY

1989, we addressed the criteria for

qualification as a sole community

hospital. ProPAC had recommended

that we issue guidelines before the

beginning of FY 1989 to promote greater

uniformity in the criteria applied by

regional offices to designate sole

community hospitals. In the final rule

published on September 30, 1988, we

stated: ‘‘A hospital may delineate its

service area by identifying the zip codes

of all its inpatients for the cost reporting

period ending before the date it applies

for SCH status. The lowest number of

zip codes accounting for at least 75

percent of its inpatients would then

constitute its service area.’’ (53 FR

35810–11).

In March 1990, we issued a revised

manual which inadvertently reflected

policy prior to October 1, 1988;

specifically, section 2810 A.2.c of the

Medicare Provider Reimbursement

Manual, Part 1 (HCFA Pub. 15–1) stated,

‘‘A hospital may define its service area

as the lowest number of contiguous zip

codes from which the hospital draws at

least 75 percent of its inpatients.’’

(Emphasis added.) This revision does

not accurately reflect the definition of

‘‘service area’’ that we set forth in the

FY 1989 final rule in response to

ProPAC’s recommendation that we

address the criteria for SCH status. It has

come to our attention that, accordingly,

some hospitals have raised questions

about the definition of service area. In

this proposed rule, we are clarifying

that, consistent with the language in the

September 30, 1988 final rule, our

definition of ‘‘service area’’ for purposes

of determining SCH status does not

require contiguous zip code areas. We

have applied this definition since

October 1, 1988 (the effective date of the

September 30, 1988 final rule). The
27472 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

current manual inadvertently reflects

previous policy, and does not reflect our

current policy as set forth in the Federal

Register and applied since October 1,

1988. We intend to revise the current

manual accordingly at our earliest

opportunity.

B. Rural Referral Centers (§ 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 are the same.

However, rural referral centers continue

to receive special treatment under both

the disproportionate share hospital

payment adjustment and the criteria for

geographic reclassification.

One of the criteria under which a

rural hospital may qualify as a referral

center is to have 275 or more beds

available for use. A rural hospital that

does not meet the bed size criterion can

qualify as a rural referral center if the

hospital meets two mandatory criteria

(number of discharges and case-mix

index) and at least one of three optional

criteria (medical staff, source of

inpatients, or volume of referrals). With

respect to the two mandatory criteria, a

hospital may be classified as a rural

referral center if its—

• Case-mix index is at least equal to

the lower of the median case-mix index

for urban hospitals in its census region,

excluding hospitals with approved

teaching programs, or the median 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.

In determining the proposed national

and regional case-mix index values, we

follow the same methodology we used

in the November 24, 1986 final rule, as

set forth in regulations at

§ 412.96(c)(1)(ii). Therefore, the

proposed national case-mix index value

includes all urban hospitals nationwide,

and the proposed regional values are the

median values of urban hospitals within

each census region, excluding those

with approved teaching programs (that

is, those hospitals receiving indirect

medical education payments as

provided in § 412.105).

These values are based on discharges

occurring during FY 1995 (October 1,

1994 through September 30, 1995) and

include bills posted to HCFA’s records

through December 1995. Therefore, in

addition to meeting other criteria, we

are proposing that to qualify for initial

rural referral center status or to meet the

triennial review standards for cost

reporting periods beginning on or after

October 1, 1996, a hospital’s case-mix

index value for FY 1995 would have to

be at least—

• 1.3332; or

• Equal to the median case-mix index

value for urban hospitals (excluding

hospitals with approved teaching

programs as identified in § 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

Casemix

index

value

1. New England (CT, ME, MA, NH,

RI, VT) ......................................... 1.2292

2. Middle Atlantic (PA, NJ, NY) ...... 1.2224

3. South Atlantic (DE, DC, FL, GA,

MD, NC, SC, VA, WV) ................ 1.3375

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

OH, WI) ....................................... 1.2450

5. East South Central (AL, KY, MS,

TN) .............................................. 1.2911

6. West North Central (IA, KS, MN,

MO, NE, ND, SD) ........................ 1.2178

7. West South Central (AR, LA,

OK, TX) ....................................... 1.3080

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

NM, UT, WY) ............................... 1.3284

9. Pacific (AK, CA, HI, OR, WA) .... 1.3333

The above numbers will be revised in

the final rule to the extent required to

reflect the updated MedPAR file, which

will contain data from additional bills

received for discharges through

September 30, 1995.

For the benefit of hospitals seeking to

qualify as referral centers or those

wishing to know how their case-mix

index value compares to the criteria, we

are publishing each hospital’s FY 1995

case-mix index value in Table 3C in

section V of the Addendum to this

proposed rule. In keeping with our

policy on discharges, these case-mix

index values are computed based on all

Medicare patient discharges subject to

DRG-based payment.

2. Discharges

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

HCFA will set forth the national and

regional numbers of discharges in each

year’s annual notice of prospective

payment rates for purposes of

determining referral center status. As

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

the Act, the national standard is set at

5,000 discharges. However, we are

proposing to update the regional

standards. The proposed regional

standards are based on discharges for

urban hospitals’ cost reporting periods

that began during FY 1994 (that is,

October 1, 1993 through September 30,

1994). That is the latest year for which

we have complete discharge data

available.

Therefore, in addition to meeting

other criteria, we are proposing that to

qualify for initial rural referral center

status or to meet the triennial review

standards for cost reporting periods

beginning on or after October 1, 1996,

the number of discharges a hospital

must have for its cost reporting period

that began during FY 1995 would have

to be at least—

• 5,000; or

• Equal to the median number of

discharges for urban hospitals in the

census region in which the hospital is

located, as indicated in the table below.

Region

Number

of discharges.

1. New England (CT, ME, MA, NH,

RI, VT) ......................................... 6812

2. Middle Atlantic (PA, NJ, NY) ...... 9067

3. South Atlantic (DE, DC, FL, GA,

MD, NC, SC, VA, WV) ................ 6972

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

OH, WI) ....................................... 6958

5. East South Central (AL, KY, MS,

TN) .............................................. 5007

6. West North Central (IA, KS, MN,

MO, NE, ND, SD) ........................ 4216

7. West South Central (AR, LA,

OK, TX) ....................................... 4002

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

NM, UT, WY) ............................... 6992

9. Pacific (AK, CA, HI, OR, WA) .... 5669

We reiterate that, to qualify for rural

referral center status for cost reporting

periods beginning on or after October 1,

1996, an osteopathic hospital’s number

of discharges for its cost reporting

period that began during FY 1995 would

have to be at least 3,000.

3. Retention of Referral Center Status

Section 412.96(f) states that each

hospital receiving the referral center

adjustment is reviewed every 3 years to
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27473

determine if the hospital continues to

meet the criteria for referral center

status. To retain status as a referral

center, a hospital must meet the criteria

for classification as a referral center

specified in § 412.96 (b)(1) or (b)(2) or

(c) for 2 of the last 3 years, or for the

current year. A hospital may meet any

one of the three sets of criteria for

individual years during the 3-year

period or the current year. For example,

a hospital may meet the two mandatory

requirements in § 412.96(c)(1) (case-mix

index) and (c)(2) (number of discharges)

and the optional criterion in paragraph

(c)(3) (medical staff) during the first

year. During the second or third year,

the hospital may meet the criteria under

§ 412.96(b)(1) (rural location and

appropriate bed size).

A hospital must meet all of the

criteria within any one of these three

sections of the regulations in order to

meet the retention requirement for a

given year. That is, it will have to meet

all of the criteria of § 412.96(b)(1) or

§ 412.96(b)(2) or § 412.96(c). For

example, if a hospital meets the casemix index standards in § 412.96(c)(1) in

years 1 and 3 and the number of

discharge standards in § 412.96(c)(2) in

years 2 and 3, it will not meet the

retention criteria. All of the standards

would have to be met in the same year.

In accordance with § 412.96(f)(2), the

review process is limited to the

hospital’s compliance during the last 3

years. Thus, if a hospital meets the

criteria in effect for at least 2 of the last

3 years or if it meets the criteria in effect

for the current year (that is, the criteria

for FY 1997 outlined above in this

section of the preamble), it will retain

its status for another 3 years. We have

constructed the following chart and

example to aid hospitals that qualify as

referral centers under the criteria in

§ 412.96(c) in projecting whether they

will retain their status as a referral

center.

Under § 412.96(f), to qualify for a 3-

year extension effective with cost

reporting periods beginning in FY 1997,

a hospital must meet the criteria in

§ 412.96(c) for FY 1997 or it must meet

the criteria for 2 of the last 3 years as

follows:

For the cost reporting period beginning

during FY Use hospital’s case-mix index for FY

Use the discharges for the hospital’s

cost reporting period beginning during

FY

Use numerical standards as published in

the FEDERAL REGISTER on

1996 ..................................................... 1994 .................................................... 1994 .................................................... September 1, 1995.

1995 ..................................................... 1993 .................................................... 1993 .................................................... September 1, 1994.

1994 ..................................................... 1992 .................................................... 1992 .................................................... September 1, 1993.

Example: A hospital with a cost reporting

period beginning July 1 qualified as a referral

center effective July 1, 1994. The hospital has

fewer than 275 beds. Its 3-year status as a

referral center is protected through June 30,

1997 (the end of its cost reporting period

beginning July 1, 1996). To determine if the

hospital should retain its status as a referral

center for an additional 3-year period, we

will review its compliance with the

applicable criteria for its cost reporting

periods beginning July 1, 1994, July 1, 1995,

and July 1, 1996. The hospital must meet the

criteria in effect either for its cost reporting

period beginning July 1, 1997, or for two out

of the three past periods. For example, to be

found to have met the criteria at § 412.96(c)

for its cost reporting period beginning July 1,

1995, the hospital’s case-mix index value

during FY 1993 must have equaled or

exceeded the lower of the national or the

appropriate regional standard as published in

the September 1, 1994 final rule with

comment period. The hospital’s total number

of discharges during its cost reporting year

beginning July 1, 1993, must have equaled or

exceeded 5,000 or the regional standard as

published in the September 1, 1994 final rule

with comment period.

For those hospitals that seek to retain

referral center status by meeting the

criteria of § 412.96(b)(1) (i) and (ii) (that

is, rural location and at least 275 beds),

we will look at the number of beds

shown for indirect medical education

purposes (as defined at § 412.105(b)) on

the hospital’s cost report for the

appropriate year. We will consider only

full cost reporting periods when

determining a hospital’s status under

§ 412.96(b)(1)(ii). This definition varies

from the number of beds criterion used

to determine a hospital’s initial status as

a referral center because we believe it is

important for a hospital to demonstrate

that it has maintained at least 275 beds

throughout its entire cost reporting

period, not just for a particular portion

of the year.

C. Disproportionate Share Adjustment

(§ 412.106)

Section 1886(d)(5)(F) of the Act

provides for additional payments for

hospitals that serve a disproportionate

share of low income patients. The

disproportionate share adjustment,

which was added to the prospective

payment system by section 9105 of the

Consolidated Omnibus Budget

Reconciliation Act of 1985 (Public Law

99–272), was intended to address the

higher Medicare costs associated with

treating a large number of low-income

patients. Under this provision, patients

who are eligible for Medicaid and

Supplemental Security Income (SSI)

benefits were used as a proxy measure

of the proportion of low-income

patients.

A hospital’s disproportionate share

adjustment is determined by calculating

the sum of two patient percentages

(Medicare Part A/Supplemental

Security Income (SSI) covered days to

total Medicare Part A covered days, and

Medicaid but not Medicare Part A

covered days to total inpatient hospital

days). Based on the location and size of

the hospital, a formula determines if the

hospital’s patient percentage qualifies

the hospital for an adjustment and how

much that adjustment will be.

With respect to the Medicare-SSI

calculation, hospitals have expressed

dissatisfaction with these proxy

measures, and have challenged HCFA’s

implementation of them in recent

litigation. Since SSI beneficiary

information is confidential, hospitals do

not have access to lists of patients who

are eligible for both Medicare Part A and

SSI benefits. Hospitals are increasingly

frustrated by their inability to monitor

these data.

With respect to the Medicaid fraction,

hospitals have complained that, because

of Medicaid coverage restrictions,

Medicaid covered days may not be a

consistent measure of indigent care

across States. Medicaid reforms under

consideration by the President and

Congress may further interfere with the

utility of Medicaid covered days as a

measure of the proportion of lowincome patients.

Because of these concerns, we have

been examining alternative measures of

indigent care. Some of the measures we

have explored using are estimates of

patient income in a hospital’s service

area, hospital levels of bad debt, and

proportion of emergency room

admissions in a hospital. Because of

data and other limitations, however, we

have yet to find an alternative that

appears promising as a replacement to
27474 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

the present measure. We are, therefore,

soliciting comments from the industry

on better and more direct measures of

indigent care than the present measure

that relies on SSI and Medicaid data.

Our preference would be to use data

that are already available. We would,

however, be open to considering

measures that require new data

collection if we were convinced that the

result would be beneficial to hospitals

and HCFA. We note that since HCFA is

bound by the current statutory

provisions, we cannot revise the

disproportionate share adjustment

without legislative action.

We note that ProPAC is also

concerned with these issues. In its

March 1, 1996 report, ProPAC

recommended that the structure of the

disproportionate share adjustment be

reviewed to make certain that available

funds are distributed equitably among

the hospitals most in need of assistance.

(Recommendation 18.) The Commission

believes that Medicaid utilization has

never been an optimal measure of

service to low-income patients and is

also concerned with the impact of

possible reform in the structure of

Medicaid. Thus, ProPAC recommends

that a comprehensive review of the

disproportionate share adjustment be

undertaken, including assessment of the

objectives of this payment and defining

the population and scope of care to be

covered. Alternative measures of lowincome patient care could then be

considered, including any data

collection necessary. As discussed

above, we agree with ProPAC that new

measures should be explored. We

believe that this is a first step in

reforming the payment formula for the

disproportionate share adjustment. We

also recognize that the development of

a better measure of the services

hospitals provide to indigent patients

may require the collection of new data.

In addition, ProPAC is concerned

about the potential impact of reductions

in the disproportionate share payments.

(Recommendation 17.) The Commission

believes that hospitals that treat a large

number of the uninsured could be

particularly vulnerable because of

recent changes in the health care

environment. ProPAC cautions against

large reductions in disproportionate

share payments that would threaten the

continued ability of many hospitals to

serve populations who depend on them

for access to care. We note that the

President’s FY 1997 budget does not

include any reduction in payment for

disproportionate share hospitals.

D. Direct Graduate Medical Education

(§ 413.86)

1. Initial Residency Period Limitations

We are updating the Initial Residency

Period Limitations for direct graduate

medical education (GME), originally

published in the Federal Register on

September 29, 1989 (54 FR 40286). The

regulations in § 413.86(g)(1) state that,

‘‘[e]ffective July 1, 1995, an initial

residency period is defined as the

minimum number of years required for

board eligibility.’’

The update reflects the following:

• Effective July 1, 1995, section

1886(h)(5)(F) of the Act, as amended by

Public Law 103–66, defines an initial

residency period as the minimum

number of years required for initial

board eligibility. Previously, this period

had been defined as minimum number

of years ‘‘plus one.’’ The prior listing

had included the additional year, not to

exceed five years.

• Changes in curriculum

requirements regarding the number of

years needed for board eligibility for

previously approved programs.

• Addition of newly approved

graduate medical education programs.

INITIAL RESIDENCY PERIOD LIMITATIONS

Residency type

Initial Residency Period

Limitation (No.

of years)

Allopathy

ANESTHESIOLOGY ............................................................................................................................................................................ 4

Critical Care Medicine .................................................................................................................................................................. 4

Pain Management ......................................................................................................................................................................... 4

COLON AND RECTAL SURGERY ..................................................................................................................................................... 5

DERMATOLOGY ................................................................................................................................................................................. 4

Dermatopathology ......................................................................................................................................................................... 4

Clinical & Laboratory Dermatological Immunology ...................................................................................................................... 4

EMERGENCY MEDICINE ................................................................................................................................................................... 3/4

Sports Medicine ............................................................................................................................................................................ 3

FAMILY PRACTICE ............................................................................................................................................................................. 3

Geriatric Medicine ......................................................................................................................................................................... 5

Sports Medicine ............................................................................................................................................................................ 3

INTERNAL MEDICINE ......................................................................................................................................................................... 3

Adolescent Medicine ..................................................................................................................................................................... 3

Cardiovascular Disease ................................................................................................................................................................ 3

Clinical Cardiac Electrophysiology ............................................................................................................................................... 3

Clinic & Laboratory Immunology .................................................................................................................................................. 3

Critical Care Medicine .................................................................................................................................................................. 3

Endocrinology, Diabetes, and Metabolism ................................................................................................................................... 3

Gastroenterology .......................................................................................................................................................................... 3

Geriatric Medicine ......................................................................................................................................................................... 5

Hematology ................................................................................................................................................................................... 3

Hematology and Oncology ........................................................................................................................................................... 3

Infectious Disease ........................................................................................................................................................................ 3

Medical Oncology ......................................................................................................................................................................... 3

Nephrology .................................................................................................................................................................................... 3

Pulmonary Disease ....................................................................................................................................................................... 3

Pulmonary Disease and Critical Care Medicine ........................................................................................................................... 3

Rheumatology ............................................................................................................................................................................... 3

Sports Medicine ............................................................................................................................................................................ 3

MEDICAL GENETICS .......................................................................................................................................................................... 4
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27475

INITIAL RESIDENCY PERIOD LIMITATIONS—Continued

Residency type

Initial Residency Period

Limitation (No.

of years)

NEUROLOGICAL SURGERY .............................................................................................................................................................. 5

Pediatric Neurological Surgery ..................................................................................................................................................... 5

NEUROLOGY ...................................................................................................................................................................................... 4

Child Neurology ............................................................................................................................................................................ 4

Clinical Neurophysiology .............................................................................................................................................................. 4

NUCLEAR MEDICINE ......................................................................................................................................................................... 3

OBSTETRICS AND GYNECOLOGY ................................................................................................................................................... 4

Critical Care Medicine .................................................................................................................................................................. 4

Gynecological Oncology ............................................................................................................................................................... 4

Maternal and Fetal Medicine ........................................................................................................................................................ 4

Reproductive Endocrinology ......................................................................................................................................................... 4

OPHTHALMOLOGY ............................................................................................................................................................................ 4

ORTHOPAEDIC SURGERY ................................................................................................................................................................ 5

Adult Reconstructive Orthopaedics .............................................................................................................................................. 5

Foot and Ankle Orthopaedics ....................................................................................................................................................... 5

Hand Surgery ................................................................................................................................................................................ 5

Musculoskeletal Oncology ............................................................................................................................................................ 5

Pediatric Orthopaedics ................................................................................................................................................................. 5

Spinal Cord Injury ......................................................................................................................................................................... 5

Sports Medicine ............................................................................................................................................................................ 5

OTOLARYNGOLOGY .......................................................................................................................................................................... 5

Neurotology/Otolaryngology ......................................................................................................................................................... 5

Pediatric Otolaryngology ............................................................................................................................................................... 5

PATHOLOGY, ANATOMIC AND CLINICAL ....................................................................................................................................... 4

Blood Banking/Transfusion Medicine ........................................................................................................................................... 4

Chemical Pathology ...................................................................................................................................................................... 4

Cytopathology ............................................................................................................................................................................... 4

Dermatopathology ......................................................................................................................................................................... 4

Forensic Pathology ....................................................................................................................................................................... 4

Hematology ................................................................................................................................................................................... 4

Immunopathology ......................................................................................................................................................................... 4

Medical Microbiology .................................................................................................................................................................... 4

Neuropathology ............................................................................................................................................................................. 4

Pediatric Pathology ....................................................................................................................................................................... 4

PEDIATRICS ........................................................................................................................................................................................ 3

Adolescent Medicine ..................................................................................................................................................................... 3

Clinical and Laboratory Immunology ............................................................................................................................................ 3

Neonatal-Perinatal Medicine ......................................................................................................................................................... 3

Pediatric Cardiology ...................................................................................................................................................................... 3

Pediatric Critical Care Medicine ................................................................................................................................................... 3

Pediatric Emergency Medicine ..................................................................................................................................................... 3

Pediatric Endocrinology ................................................................................................................................................................ 3

Pediatric Gastroenterology ........................................................................................................................................................... 3

Pediatric Hematology/Oncology ................................................................................................................................................... 3

Pediatric Infectious Disease ......................................................................................................................................................... 3

Pediatric Nephrology .................................................................................................................................................................... 3

Pediatric Opthamology ................................................................................................................................................................. 3

Pediatric Pulmonology .................................................................................................................................................................. 3

Pediatric Rheumatology ................................................................................................................................................................ 3

Pediatric Sports Medicine ............................................................................................................................................................. 3

PHYSICAL MEDICINE AND REHABILITATION ................................................................................................................................. 4

PLASTIC SURGERY ........................................................................................................................................................................... 5

Hand Surgery ................................................................................................................................................................................ 5

PREVENTIVE MEDICINE .................................................................................................................................................................... 3

Aerospace Medicine ..................................................................................................................................................................... 3

Medical Toxicology ....................................................................................................................................................................... 3

Occupational Medicine ................................................................................................................................................................. 3

Public Health & General Preventive Medicine ............................................................................................................................. 3

PSYCHIATRY ...................................................................................................................................................................................... 4

Addiction Medicine ........................................................................................................................................................................ 4

Child & Adolescent Psychiatry ..................................................................................................................................................... 4

Forensic Psychiatry ...................................................................................................................................................................... 4

Geriatric Psychiatry ....................................................................................................................................................................... 4

RADIOLOGY, DIAGNOSTIC ............................................................................................................................................................... 4

Neuroradiology .............................................................................................................................................................................. 4

Nuclear Radiology ........................................................................................................................................................................ 4

Pediatric Radiology ....................................................................................................................................................................... 4

Vascular and Interventional Radiology ......................................................................................................................................... 4

Radiation Oncology ...................................................................................................................................................................... 4
27476 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

INITIAL RESIDENCY PERIOD LIMITATIONS—Continued

Residency type

Initial Residency Period

Limitation (No.

of years)

SURGERY, GENERAL ........................................................................................................................................................................ 5

Critical Care Medicine .................................................................................................................................................................. 5

Hand Surgery ................................................................................................................................................................................ 5

Pediatric Surgery .......................................................................................................................................................................... 5

Thoracic Surgery .......................................................................................................................................................................... 5

Vascular Surgery .......................................................................................................................................................................... 5

UROLOGY ........................................................................................................................................................................................... 5

Pediatric Urology .......................................................................................................................................................................... 5

Osteopathy

ANESTHESIOLOGY ............................................................................................................................................................................ 4

Critical Care Medicine .................................................................................................................................................................. 4

DERMATOLOGY ................................................................................................................................................................................. 4

Dermatopathology ......................................................................................................................................................................... 4

MOHS Micrographic Surgery ........................................................................................................................................................ 4

EMERGENCY MEDICINE ................................................................................................................................................................... 4

Sports Medicine ............................................................................................................................................................................ 4

FAMILY PRACTICE ............................................................................................................................................................................. 3

Adolescent and Young Adult Medicine ........................................................................................................................................ 3

Geriatrics ....................................................................................................................................................................................... 5

Sports Medicine ............................................................................................................................................................................ 3

INTERNAL MEDICINE ......................................................................................................................................................................... 4

Clinical Allergy and Immunology .................................................................................................................................................. 4

Cardiology ..................................................................................................................................................................................... 4

Endocrinology ............................................................................................................................................................................... 4

Gastroenterology .......................................................................................................................................................................... 4

Hematology ................................................................................................................................................................................... 4

Infectious Diseases ....................................................................................................................................................................... 4

Nephrology .................................................................................................................................................................................... 4

Oncology ....................................................................................................................................................................................... 4

Pulmonary Diseases ..................................................................................................................................................................... 4

Rheumatology ............................................................................................................................................................................... 4

Clinical Cardiac Electrophysiology ............................................................................................................................................... 4

Critical Care Medicine .................................................................................................................................................................. 4

Geriatrics ....................................................................................................................................................................................... 6

Sports Medicine ............................................................................................................................................................................ 4

NUCLEAR MEDICINE ......................................................................................................................................................................... 4

In-Vivo and In-Vitro Nuclear Medicine .......................................................................................................................................... 4

Nuclear Cardiology ....................................................................................................................................................................... 4

Nuclear Imaging and Therapy ...................................................................................................................................................... 4

NEUROLOGY ...................................................................................................................................................................................... 4

Child Neurology ............................................................................................................................................................................ 4

PSYCHIATRY ...................................................................................................................................................................................... 4

Child Psychiatry ............................................................................................................................................................................ 4

OBSTETRICS/GYNECOLOGY ............................................................................................................................................................ 5

Maternal and Fetal Medicine ........................................................................................................................................................ 5

Gynecological Oncology ............................................................................................................................................................... 5

Reproductive Endocrinology ......................................................................................................................................................... 5

FACIAL PLASTIC SURGERY ............................................................................................................................................................. 5

OPHTHALMOLOGY ............................................................................................................................................................................ 4

OTORHINO/FACIAL PLASTIC SURGERY ......................................................................................................................................... 5

OTORHINOLARYNGOLOGY .............................................................................................................................................................. 5

ORTHOPEDIC SURGERY .................................................................................................................................................................. 5

PATHOLOGY, ANATOMIC .................................................................................................................................................................. 4

PATHOLOGY, ANATOMIC/LABORATORY MEDICINE ..................................................................................................................... 5

PATHOLOGY, LABORATORY MEDICINE ......................................................................................................................................... 4

Forensic Pathology ....................................................................................................................................................................... 5

Blood Banking/Transfusion Medicine ........................................................................................................................................... 5

Chemical Pathology ...................................................................................................................................................................... 5

Cytopathology ............................................................................................................................................................................... 5

Dermatopathology ......................................................................................................................................................................... 5

Hematology ................................................................................................................................................................................... 5

Immunopathology ......................................................................................................................................................................... 5

Medical Microbiology .................................................................................................................................................................... 5

Neuropathology ............................................................................................................................................................................. 5

PEDIATRICS ........................................................................................................................................................................................ 3

Adolescent and Young Adult Medicine ........................................................................................................................................ 3

Neonatal Medicine ........................................................................................................................................................................ 3

Pediatric Allergy/Immunology ....................................................................................................................................................... 3

Pediatric Cardiology ...................................................................................................................................................................... 3
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27477

INITIAL RESIDENCY PERIOD LIMITATIONS—Continued

Residency type

Initial Residency Period

Limitation (No.

of years)

Pediatric Hematology/Oncology ................................................................................................................................................... 3

Pediatric Infectious Diseases ....................................................................................................................................................... 3

Pediatric Intensive Care ............................................................................................................................................................... 3

Pediatric Nephrology .................................................................................................................................................................... 3

Pediatric Pulmonology .................................................................................................................................................................. 3

Pediatric Sports Medicine ............................................................................................................................................................. 3

PREVENTATIVE MEDICINE ............................................................................................................................................................... 4

PROCTOLOGY .................................................................................................................................................................................... 3

RADIATION ONCOLOGY .................................................................................................................................................................... 4

RADIOLOGY, DIAGNOSTIC ............................................................................................................................................................... 5

Angiography and Interventional Radiology ................................................................................................................................... 5

Diagnostic Ultrasound ................................................................................................................................................................... 5

Neuroradiology .............................................................................................................................................................................. 5

Nuclear Radiology ........................................................................................................................................................................ 5

Radiological Imaging .................................................................................................................................................................... 5

Pediatric Radiology ....................................................................................................................................................................... 5

REHABILITATION MEDICINE ............................................................................................................................................................. 4

Sports Medicine ............................................................................................................................................................................ 4

GENERAL SURGERY ......................................................................................................................................................................... 5

NEUROSURGERY .............................................................................................................................................................................. 5

PLASTIC AND RECONSTRUCTIVE SURGERY ................................................................................................................................ 5

THORACIC CARDIOVASCULAR SURGERY ..................................................................................................................................... 5

UROLOGICAL SURGERY ................................................................................................................................................................... 5

GENERAL VASCULAR SURGERY .................................................................................................................................................... 5

CRITICAL CARE SURGERY ............................................................................................................................................................... 5

OSTEOPATHIC MANIPULATIVE MEDICINE ..................................................................................................................................... 3

Podiatry

ROTATING PODIATRIC RESIDENCY (PRIMARY CARE) ................................................................................................................ 2

PODIATRIC ORTHOPEDIC RESIDENCY .......................................................................................................................................... 2

PODIATRIC SURGICAL RESIDENCY ................................................................................................................................................ 2

Dentistry

DENTAL PUBLIC HEALTH ................................................................................................................................................................. 1

ENDODONTICS ................................................................................................................................................................................... 2

ORAL PATHOLOGY ............................................................................................................................................................................ 3

ORAL AND MAXILLOFACIAL SURGERY .......................................................................................................................................... 4

ORTHODONTICS ................................................................................................................................................................................ 2

PEDIATRIC DENTISTRY .................................................................................................................................................................... 2

PERIODONTICS .................................................................................................................................................................................. 3

PROSTHODONTICS ........................................................................................................................................................................... 3

PROSTHODONTICS/MAXILLOFACIAL .............................................................................................................................................. 3

GENERAL DENTISTRY ...................................................................................................................................................................... 1

ADVANCED GENERAL DENTISTRY ................................................................................................................................................. 2

Allopathy Combined Programs *

FAMILY PRACTICE(3) AND PSYCHIATRY(4) ................................................................................................................................... 4

INTERNAL MEDICINE(3) & EMERGENCY MEDICINE(3) ................................................................................................................. 3

INTERNAL MEDICINE(3) & FAMILY PRACTICE(3) ........................................................................................................................... 3

INTERNAL MEDICINE(3) & NEUROLOGY(4) .................................................................................................................................... 4

INTERNAL MEDICINE(3) & PEDIATRICS(3) ..................................................................................................................................... 3

INTERNAL MED(3) & PHYS MED & REHABILITATION(4) ............................................................................................................... 4

INTERNAL MEDICINE(3) & PREVENTIVE MEDICINE(3) ................................................................................................................. 3

INTERNAL MEDICINE(3) & PSYCHIATRY(4) .................................................................................................................................... 4

NEUROLOGY(4) & PHYS MEDICINE AND REHAB(4) ...................................................................................................................... 4

PEDIATRICS(3) & EMERGENCY MEDICINE(3) ................................................................................................................................ 3

PEDIATRICS(3) & PHYSICAL MEDICINE AND REHAB(4) ............................................................................................................... 4

PEDIATRICS(3)/PSYCHIATRY(4)/CHILD & ADOL PSYCH(4) .......................................................................................................... 4

PSYCHIATRY(4) AND NEUROLOGY(4) ............................................................................................................................................ 4

* For residents participating in combined programs, Medicare limits the initial residency period to the time required for individual certification in

the longer of the two programs.

2. Combined Residency Programs

While updating the listing of the

Initial Residency Period Limitations for

GME, we noted many new programs

were combined specialty residency

programs. The combined programs run

concurrently for a period of time that is

longer than the required time for

certification in either specialty, but

shorter than would be required if the

programs were taken sequentially.

Residents completing these programs

are eligible for board certification in

both specialties.

We use the Internal Medicine and

Pediatrics combined program as an

example: Taken individually, Internal

Medicine is a 3-year program and

Pediatrics is also a 3-year program.

However, taken as a combined program,

Internal Medicine and Pediatrics is a 4-
27478 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

year program, with certification in both

specialties.

Currently, we are aware of 13

combined programs, including Internal

Medicine/Pediatrics, Pediatrics/

Emergency Medicine, Family Practice/

Psychiatry, and Neurology/Physical

Medicine and Rehabilitation.

Due to the increasing prevalence of

combined residency programs since our

September 29, 1989 final rule, we

propose to clarify how the definition of

initial residency period applies in such

cases. While the combined programs

may have advantages from an

educational standpoint, the statutory

limitation on payment for GME still

applies. In the initial legislation for a

per resident payment to hospitals for

GME, Congress limited Medicare’s

liability for those payments to residents

in their initial residency period plus one

year. The plus-one-year provision

allowed for payment for an additional

year as a full FTE for residents who

continued on in a second approved

program after completing their initial

certification. However, regardless of the

number of additional years the second

program required for certification, at

most only the first year could be paid as

a full FTE. All subsequent years are paid

at a 0.5 FTE rate. When Congress

revised section 1886(h) of the Act to

remove the plus-one-year provision,

Congress further restricted payment to

allow payment as a full FTE for the first

residency program only. All years of a

subsequent program are now limited to

the 0.5 FTE rate. Congress clearly

wanted to further limit Medicare’s

payment obligations. Accordingly, we

believe that the initial residency period

limitation is designed to allow full

Medicare payment only for the period

required to train in one specialty.

For residents enrolled in combined

programs, we are therefore proposing to

define the initial residency period as the

time required for individual

certification in the longer of the two

programs. Continuing to use Internal

Medicine and Pediatrics as an example,

we would define the initial residency

for Internal Medicine and Pediatrics as

3 years. The remaining year of the

combined program would be treated as

0.5 FTE, in accordance with the

regulations at § 413.86(g)(3).

E. Distribution of an ‘‘Important

Message from Medicare’’ (§ 489.27)

Under § 489.27 of our provider

agreement regulations, all hospitals that

participate in Medicare (including those

not paid under the prospective payment

system) must agree to furnish each

Medicare beneficiary with a notice, at or

about the time of admission, that

explains the patient’s discharge rights.

This statement, entitled ‘‘An Important

Message from Medicare,’’ advises a

beneficiary of his or her rights to be

fully informed about decisions affecting

Medicare coverage or payment and

about his or her appeal rights in

response to any hospital’s notice to the

effect that Medicare will no longer cover

the patient’s care. The ‘‘Important

Message’’ also advises the patient of

what to do when he or she receives such

a hospital statement and how to elicit

more information.

In November 1993, the Medicare

Technical Advisory Group (M–TAG)

established the Beneficiary Protection

and Documentation Issues Task Force.

The task force consists of HCFA staff as

well as representatives from health care

industry organizations, beneficiary

advocate groups, fiscal intermediaries,

and peer review organizations (PROs).

The task force was charged with

reviewing various issues that impact

beneficiaries and the health care

community, including how to improve

the effectiveness of ‘‘An Important

Message from Medicare.’’

We are proposing to adopt a

recommendation of this task force that

would respond to numerous requests for

clarification on the timing of the written

notice of discharge rights that must be

given to hospital inpatients. As noted

above, existing § 489.27 specifies that a

hospital must distribute the statement

‘‘at or about the time of admission.’’ We

understand that for monitoring purposes

some PROs have interpreted this

requirement to mean ‘‘within 24 hours

preceding or following the admission.’’

However, we agree with the task force’s

determination that the PRO’s

interpretation is unnecessarily narrow.

We believe that during the first 24 hours

of a patient’s admission, the hospital is

primarily concerned with ensuring

appropriate treatment of the patient’s

illness or injury. Therefore, we are

proposing to change § 489.27 to specify

that the hospital must provide timely

notice during the course of the hospital

stay.

For purposes of this requirement, we

would consider the course of the

hospital stay to begin when the hospital

provides the individual with a package

of information regarding scheduled

preadmission testing and registration for

a planned hospital admission. This

would give hospitals more flexibility in

meeting the requirement, as well as

encourage the distribution of the

‘‘Important Message’’ at a time when the

beneficiary is better able to receive and

more likely to understand its contents.

In complying with the requirement to

provide timely notice during the course

of the patient’s hospital stay, the

hospital must give the patient the

‘‘Important Message’’ far enough in

advance of the hospital’s written notice

regarding continued stay to provide the

beneficiary time to appeal the hospital’s

decision. Finally, ‘‘timely notice’’ would

also include adherence to any State

requirements on the provision of patient

rights notices.

The current version of the ‘‘Important

Message’’ has been in use since 1988. As

part of our effort to improve

communication with Medicare

beneficiaries, we will continue to

evaluate the effectiveness of the

‘‘Important Message’’ and welcome

suggestions for its improvement.

VI. Changes and Clarifications to the

Prospective Payment System for

Capital-Related Costs

A. Consistent Cost Finding During the

Capital Transition Period (§ 412.302(d))

Section 412.302(d) of the regulations

requires that, during the transition

period to full prospective payment for

capital-related costs, a hospital must

follow consistent cost-finding methods

for classifying and allocating capitalrelated costs. Specifically, the regulation

requires that unless there is a change of

ownership, a hospital must continue the

same cost-finding methods for old

capital costs, including its practices for

direct assignment of costs and its costallocation bases, that were in effect in

the hospital’s last cost-reporting period

before becoming subject to payment

under the capital prospective payment

transition system. A hospital may

request a change in its cost-finding

methods for new capital, provided that

the request is made in a timely fashion

as provided in the regulation, the

hospital provides justification for the

change, and the intermediary

determines that the justification is

reasonable.

It is important to note that, while the

regulation does permit changes in costfinding methods for new capital, such

changes are only permitted where they

do not involve any changes in costfinding for old capital. In practice, this

means that if a hospital claims any old

capital, the intermediary cannot permit

a change in any of the allocation bases

on Worksheet B–1 of the cost report

from the bases used in the last cost

reporting period prior to the capital

prospective payment system transition

period. Otherwise, the consistency rule

governing old capital cost-finding

would be violated.

As we discussed in the preamble to

the August 30, 1991 final rule for the

capital prospective payment system (56
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27479

FR 43396), our primary reason for

establishing this consistency rule was to

prevent hospitals from using changes in

cost-finding methodologies to shift costs

to areas where payment continues to be

made on a reasonable cost basis.

Allowing changes in cost-finding

methodologies to accomplish such costshifting would obviously defeat the

purpose of adopting a prospective

payment system.

In response to concerns expressed by

the hospital industry about the costs of

the recordkeeping required under the

cost-reporting rules, HCFA has

developed new cost reporting

instructions, which will be released

later this year, that permit hospitals to

voluntarily adopt a simplified cost

allocation methodology. This

methodology reduces the number of

statistical bases that a hospital is

required to maintain. Under the new

instructions for HCFA Form 2552–96

(the cost report instructions for FY 1996

cost reporting periods), hospitals may

request the simplified cost allocation

methodology. However, hospitals that

elect this methodology must employ a

prescribed list of statistical bases with

no deviations. Hospitals may not pick

and choose among the prescribed

statistics for the combination that is

most advantageous. Furthermore, a

hospital that elects the simplified

methodology must continue to use it for

at least 3 years, unless a change of

ownership occurs. We expect that,

while election of the simplified method

will always result in reduced

recordkeeping costs for the hospital, it

will also result frequently in reduced

Medicare payment for the hospital. In

fact, the instructions for HCFA Form

2552–96 will caution hospitals to

compare the reduced costs of program

compliance with the reduced costs of

the simplified recordkeeping before

electing the simplified method.

We believe this proposal to permit

election of the simplified cost allocation

methodology, as provided in the

instructions for HCFA Form 2552–96,

reasonably reconciles concerns about

recordkeeping costs with the

requirement of consistent cost-finding

during the transition. Specifically, we

propose to add a new paragraph (d)(4)

to § 412.302, to provide that, hospitals

may elect to adopt the simplified cost

allocation methodology, as will be

provided in the instructions for HCFA

Form 2552–96.

B. Possible Adjustments to the Capital

Prospective Payment System Federal

Rate and Hospital-Specific Rates

(§§ 412.308(b) and 412.328)

In the proposed and final rules for FY

1996 (60 FR 29238–29239 and 60 FR

45830–45831), we discussed the effects

of the expiration of the statutory budget

neutrality provision on rates and

aggregate payments under the capital

prospective payment system. Under the

budget neutrality provision, we set the

capital-prospective payment system

rates during FY 1992 through FY 1995

so that payments were projected to

equal 90 percent of Medicare payments

that would have been made on a

reasonable cost basis for each fiscal

year. As a result of the provision’s

expiration in FY 1996, the capitalprospective payment system rates and

payments under the transition system

increased significantly. The FY 1996

Federal rate is 22.59 percent higher than

the FY 1995 Federal rate. We now

estimate that aggregate capital payments

will increase 27.7 percent in FY 1996

relative to FY 1995, and that payments

will exceed capital costs by 9.6 percent

in FY 1996. Under current law and

regulations, we estimate that aggregate

payments will further increase by 7.3

percent in FY 1997, for an increase of

37.0 percent over 2 years. We do not

believe that such large increases in

capital payments are necessary or

warranted.

During the FY 1996 rulemaking

process, we solicited comments on

possible revisions to the capital

prospective payment rates that would

have moderated these substantial

increases in payments. At that time, we

noted that section 1886(g) of the Act

gives the Secretary broad discretion in

the determination of the appropriate

level of rates and payments. However,

we decided not to implement any

reduction to the capital rates at that

time, in the expectation that Congress

would be considering revisions to rates

and payments under the capital

prospective payment system within

more comprehensive legislation dealing

with Medicare and the Federal budget.

In its March 1, 1996 Report to

Congress, the Prospective Payment

Assessment Commission (ProPAC)

observed that the base capital rate was

reduced during the first 4 years of the

transition to full prospective payment

for capital to meet the statutory budget

neutrality requirement. In the light of

the large increase in rates and payments

as a result of that provision’s expiration

in FY 1996, ProPAC recommends

(Recommendation 11) that the capital

payment rates should be set by

developing an appropriate base payment

rate and applying an annual update. The

Commission notes that there are several

ways to determine an appropriate base

capital payment rate.

We agree with ProPAC that the large

increase in rates and payments caused

by the expiration of the statutory budget

neutrality provision raises an issue

concerning the proper level for future

rates and payments. We also agree that

there are several possible approaches to

establishing an appropriate level for the

rates. We considered a range of options

in developing this proposed rule. For

example, we considered proposing to

freeze the inflation updates for the rates

in FY 1997, on the grounds that such an

update was unnecessary and

unwarranted in light of the large

increase in the rates for FY 1996.

Alternatively, we considered proposing

actual reductions in the base rates. For

example, we considered proposing to

implement the provision contained in

the Administration’s budget plan. The

Administration’s FY 1997 budget

includes a provision to reduce the base

Federal and hospital-specific rates by

15.7 percent. Such a reduction would

build the budget neutrality adjustment

for FY 1995 (0.8432, or –15.68 percent)

permanently into the base rates,

effectively using the FY 1995 base

payment rate as the base for future

years. The actual payment rates for

future years would then be determined

by applying the analytical update

framework that we adopted in the final

rule for FY 1996 (60 FR 45815–45829).

We also considered proposing to

implement a part of the

Administration’s proposal, that is, to

reduce the standard Federal rate by 7.38

percent and the hospital-specific rates

by 9.48 percent. The rationale for each

of these options to reduce the base rate

derives from an analysis of current data

compared to data on which the rate was

originally based.

Under § 412.308, HCFA determined

the standard Federal rate, which is used

to determine the Federal rate for each

fiscal year, on the basis of an estimate

of the FY 1992 national average

Medicare capital cost per discharge. The

FY 1992 national average Medicare

capital cost per discharge was estimated

by updating the FY 1989 national

average Medicare capital cost per

discharge by the estimated increase in

Medicare inpatient capital cost per

discharge. As we discussed in the

preamble to the August 30, 1991 capital

prospective payment system final rule

(56 FR 43366–43384), HCFA used the

July 1991 update of HCRIS data to

estimate an FY 1989 national average

Medicare cost per case of $527.22.
27480 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

HCFA then updated that amount to FY

1992 by using an actuarial projection of

a 31.3 percent increase in Medicare

capital cost per discharge from FY 1989

to FY 1992. The standard Federal rate

was thus based on an estimated FY 1992

national average Medicare capital cost

per discharge of $692.24 (before the

application of a transfer adjustment and

a payment parameter adjustment).

Section 13501(a)(3) of Public Law

103–66 amended section 1886(g)(1)(A)

of the Social Security Act to require

that, for discharges occurring after

September 30, 1993, the unadjusted

standard Federal rate be reduced by 7.4

percent. As we discussed in the

September 1, 1993 final rule for FY 1994

(58 FR 46316ff.), the purpose of that

reduction was to reflect revised inflation

estimates, as of May 1993, for the

increases in Medicare capital costs per

discharge during FY 1989 through FY

1992. By that time, the estimate of

increases in Medicare inpatient capital

costs per discharge from FY 1989

through FY 1992 had declined from 31.3

percent to 21.57 percent. The 7.4

percent reduction to the Federal rate

was calculated to account for these

revised estimates (1.2157/1.313=0.926, a

7.4 percent decrease). That provision of

Public Law 103–66 also required that,

for cost reporting periods beginning on

or after October 1, 1993, the Secretary

redetermine which hospital payment

methodology should be applied under

the capital prospective payment system

transition rules to take into account the

7.4 percent reduction to the Federal

rate.

As a result of the reduction required

by Public Law 103–66, the standard

Federal rate is now based on an

estimated FY 1992 Medicare inpatient

capital cost per case of $641.01

($692.24×0.926). At the time of the

Public Law 103–66 reduction to the

Federal rate, actual cost report data on

the FY 1992 Medicare capital cost per

discharge were not yet available. The

reduction was based on cost report data

for FY 1990 and FY 1991, and a revised

projection of the rate of increase in

Medicare capital costs per discharge

during FY 1992. We now have extensive

cost report data for FY 1992. The March

1996 update of HCRIS data shows an

audit-adjusted FY 1992 Medicare

inpatient capital cost per discharge of

$593.72, or an additional 7.38 percent

lower than the estimate on which the

Federal rate is currently based.

Under § 412.328, HCFA determined

the FY 1992 hospital-specific rate by

using a process similar to the process for

determining the FY 1992 Federal rate.

The intermediary determined each

hospital’s allowable Medicare inpatient

capital cost per discharge for the

hospital’s latest cost reporting period

ending on or before December 31, 1990.

The intermediary then updated each

hospital’s FY 1990 allowable Medicare

capital cost per discharge to FY 1992

based on the estimated increase in

Medicare inpatient capital cost per case.

As with the Federal rate updates,

current data demonstrate that the

estimates used to update the hospital

specific rates from FY 1990 to FY 1992

were overstated. Specifically, the

hospital-specific rates are 9.48 percent

higher than they would have been if the

rates of increase had reflected actual

data. Thus, revising the Federal and the

hospital-specific rates only for the

known overestimations in the actual

costs on which rates were based would

call for reductions of 7.38 percent and

9.48 percent, respectively.

The proposal in the Administration’s

budget to reduce the rates 15.7 percent

reflects the preceding factors, as well as

analysis of capital cost increases before

the implementation of the prospective

payment system for capital-related

costs. That analysis suggests that the

Federal and hospital-specific rates may

reflect levels of cost in excess of what

can be accounted for by the rate of

inflation in capital input prices, quality

enhancing intensity increases, and real

case mix growth. Economic theory

suggests that an industry with a

guaranteed return on capital (such as

the hospital industry prior to

prospective payment for capital-related

costs) would have a tendency to be

overly capitalized relative to more

competitive industries. This is because

the incentive for firms in such an

industry is to compete on the basis of

more capital-intensive production

processes than firms in other industries.

As a result, capital costs per case, and

therefore base year prospective capital

rates, may be higher than would have

been consistent with capital acquisition

policy in more efficiency-oriented

markets.

To examine this issue, in our June 2,

1995 proposed rule (60 FR 29237) we

analyzed the change in actual Medicare

capital cost per case for FY 1986

through FY 1992 in relation to the

change in the capital input price index

(which accounts for change in the input

prices for capital-related costs), and the

other adjustment factors that we were

then proposing to include in the

framework. (The other adjustment

factors are the increase in real case mix

and the increase in intensity due to

quality-enhancing technological change

and within-DRG complexity.) We found

rates of increase in actual spending per

case that exceeded the rate of increase

attributable to inflation in capital input

prices, quality-enhancing intensity

increases, and real case-mix growth. Our

last analysis (60 FR 45826–45829)

suggested that the FY 1992 capital costs

used to set the Federal and hospitalspecific capital rates exceeded by

approximately 28 percent the level that

could be accounted for by known

factors.

We seriously considered proposing

one of these options—reducing the

standard (base) Federal rate either 7.38

percent to address overstated inflation

estimates or 15.7 percent, as reflected in

the Administration’s budget proposal—

in this proposed rule. We believe that

either of these options is well justified

on the basis of current data and

analysis. As ProPAC has observed,

hospitals do not seem to have been

adversely affected by the level of the

rates during the years in which the

statutory budget neutrality provision

was in effect. However, we still believe

that Congress and the Administration

may be able to reach an agreement on

budget issues, including Medicare

savings, in the near future. Therefore, as

discussed in section III of the

Addendum to this proposed rule, at this

time we are proposing to update the

capital rates in accordance with the

capital update framework, without

implementing any of the reductions

discussed above. Our hope is that the

legislative process will produce an

appropriate adjustment to the rate level

in time for implementation in the final

rule. In the event that no such

agreement is reached before the final

rule for FY 1997, we may implement

one of the above-described options at

that time. We invite public comment on

the merits of these options, and on the

advisability of implementing one or the

other in the final rule, in the absence of

legislative action. We will reconsider all

the options in the light of public

comments.

C. Possible Adjustment to Capital

Prospective Payment System Minimum

Payment Levels

Section 412.348(b) of the regulations

provides that, during the capital

prospective payment system transition

period, any hospital may receive an

additional payment under an exceptions

process if its total inpatient capitalrelated payments under its payment

methodology (i.e., fully prospective or

hold-harmless) are less than a minimum

percentage of its allowable Medicare

inpatient capital-related costs. The

minimum payment levels are

established by class of hospitals under

§ 412.348(c). The minimum payment
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27481

levels for portions of cost reporting

periods occurring in FY 1996 are:

• Sole community hospitals (located

in either an urban or rural area), 90

percent;

• Urban hospitals with at least 100

beds and a disproportionate share

patient percentage of at least 20.2

percent and urban hospitals with at

least 100 beds that qualify for

disproportionate share payments under

§ 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 for previous cost

reporting periods exceed its cumulative

minimum payment is deducted from the

additional payment that would

otherwise be payable for a cost reporting

period.

Section 412.348(h) further provides

that total estimated exceptions

payments under the exceptions process

may not exceed 10 percent of the total

estimated capital prospective payments

(exclusive of hold-harmless payments

for old capital) for the same fiscal year.

In the final rule implementing the

prospective payment system for capitalrelated costs we stated that the

minimum payment levels in subsequent

transition years would be revised, if

necessary, to keep the projected

percentage of payments under the

exceptions process at no more than 10

percent of capital prospective payments.

In section III of the Addendum to this

proposed rule, we discuss the factors

and adjustments used to develop the FY

1997 Federal and hospital-specific rates.

In particular, we discuss the FY 1997

exceptions payment reduction factor.

This factor adjusts the annual payment

rates for the estimated amount of

additional payments for exceptions in

FY 1997. In this proposed rule, we

estimate that exceptions will equal 6.07

percent of aggregate payments based on

the Federal rate and the hospitalspecific rate. We will develop a new

estimate of the level of exceptions

payments in FY 1997, and revise the

exceptions payment adjustment factor

accordingly, on the basis of the data that

becomes available to us in time for

developing the final rule for FY 1997.

While it is not necessary at this time to

propose reductions in the minimum

payment levels, it is possible that it will

be necessary to implement adjustments

to the minimum payment levels in the

final rule. Our current projections show

that it will almost certainly be necessary

to adjust the minimum payment levels

for FY 1998. We are therefore providing

public notification that adjustments to

the minimum payment levels are

possible in the final rule, and almost

certain for FY 1998.

When it does become necessary to

adjust the minimum payment levels in

accordance with § 412.348(h), our

current intent is to adjust each of the

existing levels (i.e., 90 percent for sole

community hospitals, 80 percent for

large urban DSH hospitals, and 70

percent for all other hospitals) by 5

percentage point increments until

estimated exceptions payments are

within the 10 percent limit. For

example, we would set minimum

payment levels at 85 percent for sole

community hospitals, 75 percent for

large urban DSH hospitals, and 65

percent for all other hospitals, provided

that aggregate exceptions payments at

those minimum payment levels were

projected to be no more than 10 percent

of total rate-based payments. If aggregate

exceptions payments at those minimum

payment levels still exceeded 10 percent

of total rate-based payments, we would

continue to reduce the minimum

payment levels by 5 percentage point

increments each until the requirement

of § 412.348(h) was satisfied. We are

providing notification of our current

thinking on this issue in order to allow

opportunity for public comment on the

appropriate method for adjusting the

minimum payment levels. We invite

public comment on this matter, and will

consider those comments fully

whenever it becomes necessary to adjust

the minimum payment levels in

accordance with § 412.348(h).

VII. Proposed Changes for Hospitals

and Units Excluded From the

Prospective Payment Systems

Application of Ceiling in Calculating

Payment for Hospital Inpatient

Operating Costs (§ 413.40 (d) and (g))

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

provides for an additional payment to a

hospital excluded from the prospective

payment system when the hospital’s

reasonable operating costs exceed its

target amount. The additional payment

is based on the lesser of 50 percent of

the amount by which the operating costs

exceed the target amount, or 10 percent

of the target amount. The Medicare

statute further provides that this

comparison is made ‘‘after any

exceptions or adjustments are made to

such target amount for any cost

reporting period.’’ The regulations, at 42

CFR § 413.40(d)(3), state that the total

payment to the hospital for inpatient

operating costs (including the additional

payment described above) is based on

the lesser of the following: the ‘‘ceiling’’

(target amount multiplied by the

number of Medicare discharges) plus 50

percent of the allowable net inpatient

operating costs in excess of the ceiling,

or 110 percent of the ceiling. However,

the regulations do not explicitly include

the additional statutory requirement

regarding the effect of exceptions or

adjustments.

It is our understanding that there are

questions about the calculation of the

additional payment under the

regulations, which require comparison

of two amounts: the ‘‘ceiling’’ plus 50

percent of the difference between

allowable costs and the ceiling, and 110

percent of the ‘‘ceiling.’’ Specifically,

where a hospital has received an

adjustment to the target amount under

§ 413.40(g), there has been confusion as

to whether the ‘‘ceiling’’ used for

purposes of calculating the additional

payment under § 413.40(d) is the

unadjusted ceiling (the amount

determined without consideration of

any adjustments granted to the hospital)

or the adjusted ceiling.

We believe that the amount of the

additional payment should be

determined using the adjusted ceiling

when hospitals receive adjustments to

the ceiling. That is, the calculation of

the amounts compared—50 percent of

the allowable net inpatient operating

costs in excess of the ceiling, or 10

percent of the ceiling—should reflect

the adjusted target amount (and

adjusted ceiling). To address any

confusion about these issues, we

propose to revise § 413.40(d)(3) to

specifically indicate that calculation of

payments for hospital inpatient

operating costs under that provision

reflects the adjusted ceiling amount (the

amount determined after an adjustment

under § 413.40(g)). This would apply to

all adjustments, including adjustments

based on a longer average length of stay

in the hospital’s rate year as compared

to the base year and adjustments for

increased routine services.

We note that an adjusted ceiling is not

used to adjust permanently the

hospital’s target amount or ceiling on

the hospital’s cost report. Instead, it is

used only for purposes of calculating

payments for the year the adjustment is

granted. We also note that, depending

on the specifics of the data in a

particular case, use of an adjusted

ceiling can result in either an increase

or decrease in the additional payment to

a hospital relative to use of an

unadjusted ceiling. If the additional

payment to a hospital is 50 percent of
27482 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

the allowable net inpatient operating

costs in excess of the ceiling, the

additional payment would be lower

using an adjusted ceiling (as under

proposed § 413.40(d)(3)) than an

unadjusted ceiling. This would occur

because an adjusted ceiling reduces the

difference between the hospital’s costs

and the ceiling. However, if the

additional payment to the hospital is 10

percent of the ceiling, the additional

payment would be higher using an

adjusted ceiling than an unadjusted

ceiling.

VIII. ProPAC Recommendations

We have reviewed the March 1, 1996

report submitted by ProPAC to Congress

and have given its recommendations

careful consideration in conjunction

with the proposals set forth in this

document. Recommendations 10 and

12, concerning the update factors for

inpatient operating costs, and the

update factor for hospitals excluded

from the prospective payment system

and distinct-part units, are discussed in

Appendix F to this proposed rule.

Recommendation 11, on the setting of

capital payment rates, is discussed in

section VI of this proposed rule.

Recommendations 17 and 18,

concerning disproportionate share

hospitals, are discussed in section V of

this proposed rule. The remaining

recommendations are discussed below.

A. Slowing the Rise in Medicare

Spending (Recommendation 1)

Recommendation: The Commission

supports the efforts of the Congress and

the President to reduce the growth in

Medicare expenditures. Over time,

spending for services furnished to

Medicare enrollees should increase at

rates comparable to those in a cost- and

quality-conscious private sector.

Response: We agree with ProPAC

about the importance of slowing the

growth in Medicare spending. We

support ProPAC’s assertion that the

experience in the private sector with

market forces that encourage cost

containment represents a useful factor

in considering appropriate growth in

Medicare. We also agree with those

factors upon which ProPAC urges this

comparison: spending growth on a perperson basis and recognizing the health

care needs of an aged and disabled

Medicare population. We caution,

however, that while it may be

appropriate to compare growth service

by service, aggregate comparisons

would not be meaningful due to

differences in the mix of services.

Medicare and private health

insurance provide a different array of

services. Medicare covers more longterm care services, such as home health

visits and skilled nursing facility (SNF)

stays, than private insurance. Although

their share of total Medicare spending is

small, SNF and home health services are

growing more quickly than other

services within Medicare, and therefore

spending for these services has been

growing at a much faster rate than for

other services. Data from 1992 and 1993

indicate that payments increased for

SNF and home health services by 40.6

percent and 35.2 percent, respectively,

whereas the growth in physician and

hospital payments were only 4.5 percent

and 8.3 percent, respectively. In order

for Medicare and private health

insurance to grow, in aggregate, at the

same rate, spending for hospital and

physician services would have to be

growing more slowly in Medicare than

in private health insurance to offset

differences in long-term care growth.

Due to these differences in mix of

services, meaningful comparisons

between Medicare and the private sector

can only be made on a service-byservice basis.

B. The Failsafe Budget Mechanism

(Recommendation 2)

Recommendation: Any failsafe budget

mechanism should include a more

effective risk adjustment factor to ensure

payment equity between the Medicare

capitation and traditional fee-for-service

programs. In addition, changes in

inflation that differ substantially from

Congressional Budget Office (CBO)

forecasts could require modifications to

the Medicare benefit budget over time.

Revisions to the proposed fee-for-service

sector budget allocations could also be

needed as medical practices change.

Response: We believe that using a

failsafe budget mechanism (that is, an

arbitrary cap on spending) to achieve

targeted spending levels would be bad

public policy. A failsafe mechanism

would fundamentally change the nature

of the Medicare program by breaking the

link between benefits and payments. To

meet the cap, benefits might have to be

reduced, beneficiaries might have to pay

more, and payments to providers might

have to be reduced, all of which would

impede access. A failsafe mechanism

would encourage cost shifting to

beneficiaries and other payers in order

to achieve the targeted goal in

government spending.

These arbitrary reductions in

payments would make government an

unreliable business partner. As

Medicare moves toward a more marketoriented approach to setting payments,

arbitrary reductions imposed by the

government, after providers have

negotiated in good faith, would sour

relations and threaten the market

pricing process.

The failsafe mechanism is a substitute

for policy choices to achieve the desired

level of spending. This arbitrary

Medicare budget cap could potentially

have adverse effects on the Medicare

program.

We note that, while ProPAC

recommends using a more effective risk

adjustment factor to ensure payment

equity between Medicare capitated and

fee-for-service programs, no adequate

case-mix measure currently exists that

could serve this purpose.

C. Expanding Medicare’s Capitation

Program (Recommendation 3)

Recommendation: The Commission

supports reforming the Medicare

capitation program to control spending

while expanding beneficiary choice.

Response: HCFA agrees with this

recommendation and has specifically

developed legislation to allow for

Preferred Provider Organizations (PPOs)

and Provider Sponsored Organizations

(PSOs) to contract with the Medicare

program. Furthermore, in October 1995,

HCFA issued guidelines that notified

HMOS that they were permitted to

develop Point of Service (POS)

Programs, which allow beneficiaries to

go out of network for services. HCFA is

currently conducting the Choices

Demonstration, through which it is

soliciting applications for the above

types of provider arrangements.

D. Setting and Updating the Capitation

Rates (Recommendation 4)

Recommendation: Geographic

variation in the capitation rates and the

volatility of the rates from year to year

should be reduced. The Secretary

should develop and test alternative

payment methods that would allow the

payment rates to reflect changes in local

market conditions.

Response: We agree that geographic

variations in HCFA’s payment rates

should be reduced. Some of the current

legislative proposals would reduce the

degree of variation over time.

We have been looking at ways to

reduce these variations. Several

demonstrations that should provide

information needed to develop

alternative payment methods are either

currently being run or in the process of

getting started. We have developed and

are conducting several research and

demonstration projects to review

additional risk adjustors, which would

modify current payment rates to reflect

the health status of the members of

managed care organizations. Another

project would pay, from a separate pool

of funds being shared by several
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27483

organizations in an area, for enrollees

who have high Medicare costs. Also,

HCFA is in the process of starting

another project that would incorporate

the payment principles associated with

competitive bidding.

E. Improving Risk Adjustment Methods

(Recommendation 5)

Recommendation: The risk

adjustment methods used to set

Medicare capitation payments should

better reflect variation in the likely use

of services. Even as research on the

development of new methods continues,

the Secretary should implement interim

improvements as soon as possible.

Response: We plan to test health

status risk adjusters, such as Diagnostic

Cost Groups or Ambulatory Care

Groups, as part of the Choices

Demonstration. Furthermore, in this

demonstration, we will test reinsurance

and partial capitation arrangements. We

are also considering demonstrations

which use health status measures as

part of the Adjusted Community Rate

Determination, as well as part of the

payment formula.

F. Medical Savings Accounts (MSAs)

(Recommendation 6)

Recommendation: The Congress’ high

deductible/MSA option would provide

an additional choice for Medicare

enrollees. However, ProPAC is

concerned that the current Medicare

risk adjustment method is not sufficient

to protect the program from adverse

selection and resulting excess spending.

The likelihood that rates would better

reflect risk would be enhanced if

Medicare enrollees were required to

remain in the MSA option at least for

several years.

Response: As ProPAC states, the

Congressional Budget Office estimated

that the MSA option would cost the

Medicare program $4.6 billion over 7

years, in part because of the current

state-of-the-art in risk adjustment

methods (discussed in recommendation

5, above). The CBO estimate of the cost

of the MSA option is consistent with the

cost estimates of other reputable

organizations. We fail to see the

rationale for including an option that

provides no new benefits but is

expected to result in increased costs,

particularly at a time when the public

and Congress are concerned about the

long-term financial viability of the

Medicare program.

G. The Medicare Plus Fee-for-Service

Option (Recommendation 7)

Recommendation: Enrollees choosing

the fee-for-service option under the

proposed Medicare Plus program could

be responsible for substantially higher

fees than what their plans would pay.

The Secretary should monitor the

impact of this option on beneficiary

liability and on possible reductions in

physician and other provider

participation in traditional Medicare.

Response: We agree with ProPAC that

beneficiaries could be responsible for

substantially higher fees. We also agree

that, as suggested in this

recommendation, allowing physicians

and other providers to elect to serve

Medicare beneficiaries through private

fee-for-service plans that place no limits

on extra-billing amounts may well result

in (1) increases in beneficiary liability

and (2) reductions in physicians and

other providers participating in

traditional Medicare. Further, as the

payment methods contained in pending

legislation described in H.R. 2491 are

structured, the payment increases for

MedicarePlus plans, relative to those in

fee-for-service Medicare, mean that

MedicarePlus plans would be able to

pay physicians and other providers

more than fee-for-service Medicare.

These higher payments would create

additional incentives for physicians and

other providers to cease participation in

traditional Medicare. Finally, while

managed care plans potentially provide

value added because their

organizational structure facilitates

coordination of care, it is not clear what,

if any, value is added by creating a

private fee-for-service plan option,

under which the private plans receive

higher payments relative to fee-forservice Medicare and physicians and

providers are permitted to charge

unlimited extra-billing amounts.

H. Information for Beneficiary Health

Plan Choices (Recommendation 8)

Recommendation: Medicare should

make available to beneficiaries

information about the performance of

plans and local providers. The Secretary

should identify the information

beneficiaries need to make appropriate

choices and develop innovative ways to

improve access to it.

Response: Current HCFA initiatives to

improve beneficiary information about

health insurance options, which are

summarized below, are consistent with

ProPAC’s recommendation.

Development of Prototype Materials and

Strategies

We are currently engaged in two

projects that will develop prototype

beneficiary information strategies

related to health insurance options.

The first project, which focuses

mostly on managed care issues, is

examining through Medicare and

Medicaid beneficiary focus groups, the

types of information and dissemination

media that beneficiaries would find

most useful in selecting health

insurance plans. Based on this

information, and case studies, the

project will produce and test a range of

prototype beneficiary information

materials, including beneficiary health

plan comparison booklets and charts,

and informational videos. Draft

prototype materials (for Medicare, preMedicare and Medicaid beneficiaries)

are nearing completion and are

scheduled for beneficiary testing in

Spring 1996.

The second project will design

beneficiary information and education

materials and dissemination strategies

to support the Medicare Open

Enrollment/Competitive Pricing

demonstration. This project will

develop printed materials that explain

the experimental open enrollment

process; printed general informational

materials on Medicare health insurance

options; and booklets outlining the

specific Medicare fee-for-service and

managed care options available to

beneficiaries in their area. A plan

comparison chart template, which

would include information on specific

benefits and premiums, will also be

developed, as will other information

and educational approaches (including

educational seminars, public service

announcements (PSAs), informational

videos, and a toll-free counseling phone

line, all sponsored by HCFA). In

addition, a dissemination strategy for

HCFA and its partners in the

demonstration sites will be developed

(for example, Insurance Counseling and

Assistance (ICA) programs and

beneficiary advocacy groups).

Draft materials and strategies were

tested on Medicare beneficiaries in

April 1996. Final products should be

available for adaptation to specific

demonstration sites by Summer 1996.

Medicare Program Activities

We have currently outlined a strategy

to produce and disseminate a managed

care plan comparison chart to Medicare

beneficiaries, initially through the

HCFA Regional Offices and HCFAsponsored ICA programs. We will use

comparison chart prototypes developed

(under both of the projects discussed

above) as models for the comparison

chart. Prototypes will be available by

Spring 1996. We plan to begin

dissemination of the basic comparability

charts in 1996.

We may also choose to adapt some of

the prototype materials for application

to the Medicare program, depending on

feedback and evaluations from
27484 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

beneficiaries in the Open Enrollment

Demonstration. These new materials

could ultimately supplement or replace

current materials, such as the Medicare

Handbook. New prototype materials

could also be provided and adapted

individually by the State ICA programs.

We have contributed recommendations

during the development of these

projects and will continue to do so.

Many of the Regional Offices have

developed area specific informational

materials related to Medicare managed

care. The Regional Offices typically use

these materials to assist in their

responsibilities as the local HCFA

contact for beneficiaries.

Related Major Initiatives

While current activities have centered

on efforts to provide better information

on health insurance options (such as

focusing on comparisons of benefits,

premiums, and locations), the next

major steps in improving information

and educational strategies will likely be

in the area of quality or performance

indicators.

The prototypes discussed above will

include templates for eventual

dissemination of quality/performance

indicators for health plans. In addition,

strategies for introducing the concept of

indicators to Medicare and Medicaid

beneficiaries will be produced. One

project, short Medicare and Medicaid

focused video tapes describing quality

indicators using a ‘‘grocery shopping’’

analogy, has already been completed.

A final version of a set of Medicaidspecific National Committee on Quality

Assurance (NCQA) Health Plan

Employer Data and Information Set

(HEDIS) quality indicators is nearly

completed. We are currently sponsoring

the revision (with NCQA) of HEDIS

version 3.0 to include Medicarespecific measures. Once both Medicareand Medicaid-specific measures are

available, HCFA will have available the

basic tools necessary to report

comparative quality indicators to

beneficiaries. A specific dissemination

strategy will then be determined.

We are currently in the

developmental stages of a proposed

plan-specific Medicare beneficiary

satisfaction survey. When completed,

we would have comparative satisfaction

information on all Medicare managed

care plans, which could then be

disseminated to beneficiaries as a

companion to plan benefit/premium

comparison charts.

Based on these initiatives, HCFA

should be well prepared to expand and

improve both the level and types of

health insurance information resources

available to Medicare beneficiaries.

I. Health Plan Accountability

(Recommendation 9)

Recommendation: Medicare must

hold health plans accountable for the

appropriate use of Medicare funds. In

addition, standards must be developed

and enforced to ensure that Medicare

beneficiaries will receive services of

appropriate quality.

Response: We agree with these

recommendations and have several

plans for implementing them. First, we

are working with the National

Committee for Quality Assurance to

develop HEDIS 3.0 for the Medicare

program. Second, we plan to conduct

beneficiary satisfaction surveys for a

significant sample of beneficiaries from

each health plan participating in the

Medicare HMO program. Third, we are

working with the Foundation of

Accountability to develop conditionspecific outcome measures. Finally, we

are working with Peer Review

Organizations to develop several

condition-specific outcome measures

that will be risk adjusted.

J. Broadening Financial Support to

Teaching Hospitals (Recommendation

13)

Recommendation: Explicit financial

support for graduate medical education

activities should not be limited to the

Medicare program. Mechanisms to

broaden financial support for teachingrelated activities in hospitals and other

locations should be developed.

Response: The Commission is

concerned that Medicare is the only

payer that provides explicit financial

support for teaching activities. Even

though private payers provide implicit

support through higher prices for

patient care services, funding is

unrelated to the amount of actual

teaching activity.

While we would agree that all payers

should contribute their fair share toward

physician training and particularly for

the patient care services that are

provided in the course of this training,

we wish to emphasize that Medicare’s

support for graduate medical education

is limited only to Medicare’s share of

the total cost of graduate medical

education. That is, although we believe

the current level of the indirect medical

education adjustment is higher than

necessary to compensate for the indirect

costs associated with residents’

involvement in patient care, it is set at

a level that at one time was thought to

equal those costs. Furthermore, because

this adjustment is made only for

Medicare prospective payment system

discharges, it is inherently only

associated with Medicare’s share of the

indirect costs of graduate medical

education. In addition, the direct

graduate medical education payment is

calculated based on Medicare’s

inpatient utilization rate, thereby

ensuring that it, too, reflects only

Medicare’s share of direct graduate

medical education. In that vein, we

would support a mechanism to broaden

support for physician training that did

not result in Medicare contributing

more than its fair share, relative to the

Medicare utilization rate.

We note also that some Medicaid

programs explicitly pay hospitals for the

indirect and direct costs of graduate

medical education similar to Medicare.

In addition, some States (for example,

New York, through its Prospective

Hospital Reimbursement Methodology)

provide explicit support for teaching

hospitals through private payers.

Nevertheless, we join ProPAC in calling

for more uniform support across all

payers.

We would note that although the

President’s health care reform bill

attempted to involve private insurers in

directly supporting medical education,

we do not currently have a proposal to

broaden support for teaching hospitals

beyond that currently provided by

Medicare. We have, however, proposed

to broaden financial support for

teaching hospitals by changing the way

Medicare funds medical education

through its managed care programs.

Currently, Medicare payments to HMOs

are based on the average cost of

providing services to Medicare patients

in the fee for service part of Medicare.

These payments to HMOs include

Medicare’s costs for medical education.

The President’s FY 1997 budget would

revise Medicare’s payments to HMOs so

as not to include the portion associated

with medical education and paying

these funds directly to teaching

hospitals and to managed care plans

with teaching programs. This change

would benefit teaching hospitals, as

well as more appropriately target

Medicare funds designated for medical

education.

K. Medicare Payments for Graduate

Medical Education Costs

(Recommendation 14)

Recommendation: ProPAC supports

changes in Medicare teaching payments

that would encourage an appropriate

distribution of residents across

specialties and discourage inappropriate

growth in the total number of residents.

Response: The Commission states that

both the proposals of Congress and the

President’s budgets would move

Medicare direct graduate medical

education payments in the direction of
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27485

encouraging appropriate distribution of

residents across specialties and

discourage inappropriate growth in the

total number of residents.

The Administration is very concerned

with the issue of Medicare payments to

hospitals for graduate medical

education. Consistent with numerous

reports that the nation has an excess of

specialty physicians, and that the

growth of managed care is increasing

the demand for primary care physicians

relative to other specialties, the focus of

the President’s graduate medical

education proposal is to encourage

greater hospital participation in primary

care residencies and less in specialty

residencies. In addition, a significant

amount of training of residents in

primary care is more appropriately done

in non-hospital settings. Accordingly,

the President’s budget includes a cap on

the total number of residents and on the

number of nonprimary care residents for

whom Medicare will make graduate

medical education payments. We would

also encourage ambulatory training by

including residents who rotate to nonhospital settings in the hospital’s FTE

count for IME purposes. We would

further encourage ambulatory training

by providing direct medical education

payments to facilities that are not

hospitals (for example, federally

qualified health centers) for residents,

when the residents’ salaries are not paid

by hospitals.

The Administration has also proposed

to create a Commission on Medical

Education and Workforce Priorities

within HHS to develop and recommend

policies to address the preservation of

academic health centers’ research and

educational capacity and the supply of

the future health care workforce. This

commission would also make

recommendations regarding the most

effective allocation of training resources

to ensure that the numbers and

competencies of health care

professionals are responsive to national

needs.

L. Medicare Indirect Medical Education

Payments (Recommendation 15)

Recommendation: The Medicare

indirect medical education adjustment

should be reduced from its current 7.7

percent level to 7.0 percent.

Response: As we’ve said in response

to similar ProPAC recommendations in

previous years, we agree with ProPAC

that the current level of payment for the

indirect costs of medical education is

too high. The President’s FY 1997

budget would reduce the adjustment

over 3 years to a final level of 6.0

percent effective for FY 1999. In

addition, residents working in

nonhospital settings could be counted

in a hospital’s resident count for

indirect medical education purposes if

the hospital incurs all, or substantially

all, of the costs for the training program

in that setting. Finally, the President’s

budget would cap the number of

residents that could be included in the

count, with an exception provided for

primary care residents and those in the

specialties of obstetrics or gynecology.

The Commission also supported the

provision in the President’s FY 1996

budget that would apply the direct

graduate medical education resident

count and weighting rules to the

indirect medical education count.

However, ProPAC recommended

proceeding with caution as additional

analysis would be needed to examine

the effect of this policy on individual

teaching hospitals. We note that this

provision is not contained in the FY

1997 budget proposal. Therefore,

residents would continue to be counted

for IME as long as they are enrolled in

an approved program.

M. Distributing Additional TeachingRelated Payments (Recommendation 16)

Recommendation: Funds that provide

broader financial support for graduate

medical education should be distributed

in a way that corresponds to the

additional costs incurred by teaching

facilities. Providers that treat enrollees

in capitation plans should receive

teaching-related payments for those

patients as well as for the other patients

they serve.

Response: This recommendation is

related to Congress’ proposal to create

new trust funds to provide broader

support for educational activities.

Congress would create new trust funds

that include accounts for general direct

medical education, general indirect

medical education, and a Medicare Plus

Incentive Account financed by new

appropriations. This funding would be

in addition to payments currently being

made by Medicare for direct and

indirect medical education. The

Commission is concerned that the new

funding would be distributed based on

previous Medicare payment levels even

though general revenues will fund the

newly established trust funds. With

regard to the Medicare Plus Incentive

Account, ProPAC is concerned that

payments should give Medicare’s

managed care participants an incentive

to use teaching hospitals and pay

providers appropriately for serving

patients in capitation plans.

Like the Commission, we are

concerned about appropriating general

revenues to finance medical education,

particularly given our concern that the

indirect medical education adjustment

already overcompensates hospitals and

Medicare already pays its share of costs

of direct medical education. The

President’s original proposal was to

create an all payer fund to finance

graduate medical education. However,

this proposal was made in the context

of overall health care reform. We

continue to remain concerned that

medical education should be supported

to a greater extent by payers other than

Medicare but have reservations about

financing of medical education with

additional Federal money.

As we explained above in

Recommendation 13, under the

President’s FY 1997 budget, we would

revise payments made through our

managed care programs to ensure that

teaching programs are supported more

appropriately by existing Medicare

resources designated for medical

education. Under the President’s FY

1997 budget, payments for medical

education would be eliminated from

HMO rates and redistributed to teaching

hospitals and managed care plans with

teaching programs.

N. Discharges from Hospitals to Other

Facilities (Recommendation 19)

Recommendation: Medicare payments

should be modified to account for the

shift in services from acute to postacute

settings. Broadening the definition of

transfer cases, however, is not an

appropriate approach.

Response: In both the September 1,

1994 and September 1, 1995 final rules,

we expressed our concern that the

current trend of declining average

lengths of stay as hospitals discharge

Medicare patients into alternative health

care settings (other than acute care

prospective payment hospitals) in less

time may result in a misalignment of

payments and costs under our existing

payment systems (59 FR 45362; 60 FR

29221). In particular, we expressed

concern over the potential for hospitals

paid under the prospective payment

system to shift costs (for which they are

compensated through the DRG

payments) to alternative settings, which

are in turn paid on a cost basis.

Although we solicited comments on

possible solutions to this problem, we

did not propose any change in policy.

The President’s FY 1997 budget

includes a proposal to redefine

discharges from acute care hospitals to

excluded hospitals and units and skilled

nursing facilities as transfers for

payment purposes. Currently, for cases

transferred from one acute care hospital

paid under the prospective payment

system to another like hospital, the

sending hospital is paid a per diem rate
27486 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

instead of the full DRG amount. For

cases transferred to an excluded

hospital or unit or to a skilled nursing

facility (as well as cases discharged

home or home with home health care),

hospitals receive the full DRG payment

amount, regardless of the length of stay

in the hospital. Under the per diem

transfer payment methodology,

hospitals receive a per diem amount

(doubled for the first day of the stay)

until the full DRG amount is reached.

Therefore, under the President’s budget

proposal, hospitals transferring patients

to excluded facilities or skilled nursing

facilities prior to the geometric mean

length of stay for the DRG, minus one

day (to account for the double per diem

on the first day), would receive less than

the full DRG amount for that case.

The basis for ProPAC’s opposition to

this proposal is that it ‘‘* * * thinks

this policy would discourage the use of

postacute providers. Moreover, it could

result in longer inpatient stays, which

may not be desirable or cost effective in

the long run.’’ We acknowledge that the

change in the definition of a transfer is

not the ultimate solution to this health

care trend. In response to immediate

concerns about overpaying hospitals for

the reduced services they are providing

and the rate of increase in expenditures

for postacute care services, however, we

believe this is an appropriate interim

measure while we continue to explore

long-term policy alternatives that will

better integrate our payment systems for

care provided to Medicare beneficiaries

across the acute and postacute care

settings.

O. Prospective Payment for PostAcute

Care (Recommendation 20)

Recommendation: Prospective

payment systems should be

implemented for all postacute services.

The payment method for each service

should be consistent across delivery

sites. The Secretary should explore

methods to control volume of postacute

service use, such as bundling services

for a single payment.

Response: We agree that HCFA should

develop prospective payment systems

for all postacute services, and we have

made significant progress in this area.

As we discuss in our responses to

Recommendations 22 and 23, we have

developed detailed implementation

plans for interim prospective payment

systems for skilled nursing facilities

(SNFs) and home health agencies

(HHAs) that do not require patient

classification systems. Execution of

these plans will, of course, require

legislative action.

Beyond our interim plan, we have

developed a strategy for developing a

full-fledged prospective payment system

for SNFs. In the absence of legislation,

we have been pursuing data that could

be used to support a case-mix

prospective payment system through

our Multi-State Case Mix Demonstration

Project. This demonstration project,

now in its operational phase, is

collecting data on patient case mix

using a modified version of the

minimum data set, the assessment tool

SNFs use in developing patient care

plans. Through the course of the

demonstration, we hope to gather data

on the full range of SNF resources

needed for each resource utilization

group. We are proceeding to require by

regulation that all facilities provide

resident assessment data. Consolidated

billing of SNF services (that is, requiring

SNFs to bill for all services furnished to

their patients) and uniform coding of

SNF services are also prerequisites for a

SNF prospective payment system.

Consolidated billing and uniform

coding are needed to determine the

appropriate payment for the ancillary

services component of SNF services and

to provide useful data on the range of

services SNFs furnish.

We have also been working on a

strategy to develop a full-fledged

prospective payment system for HHAs.

We have funded a project to develop

outcome measures for home care that

can be used for an outcome-based

quality improvement system. These

measures will be based largely on a core

standard assessment data set that

includes items measuring

sociodemographic, environmental,

support system, health status, functional

status, and health service utilization

characteristics of patients. Many of

these data items included in the core

standard assessment data set are not

only essential for assessing patient

outcomes but are also critical for

designing an adequate case-mix system

for payment purposes. To test and refine

Medicare’s approach to outcome based

quality improvement for home health

care, HCFA is currently sponsoring the

Medicare Quality Assurance and

Improvement Demonstration, which

uses this instrument. We plan to publish

regulations identifying the required data

elements and addressing the collection

of information from the core standard

assessment data set. We also plan to

sponsor additional research that would

lead to an appropriate case-mix adjuster

that can be used in a national

prospective payment system.

In addition to the developmental

work underway on SNF and HHA

prospective payment systems, we have

begun work on the preliminary steps

necessary for the development of a

prospective payment system for hospital

inpatient rehabilitation services. The

biggest obstacle we have faced in this

effort is the lack of appropriate patient

classification systems for the types of

patients treated by rehabilitation

hospitals. We have recently contracted

with the Rand Corporation to evaluate a

rehabilitation coding system known as

the Functional Impairment Measure

(FIM), which is a scoring system that

measures the degree of functional

independence of rehabilitation patients.

These researchers will also evaluate the

patient classification system known as

functional related groups (FRGs), which

are based on FIM, as a possible basis for

a Medicare prospective payment system

for rehabilitation services. If the

research confirms functional status

measures can be used to develop an

appropriate patient classification

system, we will begin the additional

work necessary to put a prospective

payment system into place. This would

require collecting patient assessment

data from Medicare rehabilitation

hospitals and units and developing all

the necessary components of the new

payment system. It will take at least 3

years to design and implement such a

system. To facilitate implementation,

we are considering initiating collection

of patient assessment data in advance of

legislation establishing a prospective

payment system. We will be seeking

public input on whether to proceed

with a requirement for patient

assessment data in the absence of

legislation and what data elements

should be included in a core data set

that could be used not only as the basis

for a patient classification system but

also to assess outcomes.

We recognize that there are

advantages to a coordinated approach in

developing prospective payment

systems for postacute services and we

will be evaluating how to make them as

consistent as possible. We also

recognize that the demand for

implementation of prospective payment

systems for post-acute services is

sufficiently immediate so that there may

not be time for the broad study, data

collection, and research needed to

develop a ‘‘unified’’ system using

similar resource grouping principles.

Most of the current legislative

proposals, including the

Administration’s proposals, would

require implementation dates within the

next several years. It may not be feasible

to develop a ‘‘unified’’ system within

the time frames contemplated by the

current legislative proposals. Trade-offs

may be required between continuation

of the interim payment systems versus
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27487

the full-blown prospective payment

systems on one hand, and the separate

versus ‘‘unified’’ prospective payment

systems on the other hand.

P. Case-Mix Measures for PostAcute

Services (Recommendation 21)

Recommendation: Reliable case-mix

measurement is important in

prospective payment systems to account

for resource use and to analyze

treatment patterns and costs across sites.

The Secretary should coordinate casemix research across postacute care

settings, using consistent methods for

measuring patient acuity and resource

use.

Response: We are attempting to

coordinate our work on case-mix

adjustment for home health care, longterm and SNF care, and rehabilitative

services. To develop a case-mix

adjustment system for SNF care, time

studies were conducted in order to

measure resource utilization. Similarly,

as noted above in response to

Recommendation 20, we plan to fund

research to identify a home health casemix adjuster.

In addition, in the case-mix work to

date for both home health care and SNF

care, dependence in activities of daily

living is the biggest predictor of

resource utilization. Some of the other

predictors differ across SNF care and

home health care due to differences in

the treatment settings and the

availability of information for a

classification system.

As also noted above in the preceding

response, researchers at the University

of Pennsylvania have developed a

classification system based on FIMs

called Function Related Groups (FIM–

FRGs). This system appears promising

for use in a case-mix adjusted

prospective payment system for

rehabilitation and long-term care

facilities, and we are working with the

Rand Corporation on a research project

to evaluate the suitability of FIM–FRGs

for this purpose.

We agree that a compatible crossprovider measure of resource use would

be the best multiplier in any universal

postacute system. We also believe that

such measures do not now exist and to

produce them would require the

program to incur significant costs and

impose significant data reporting and

collection requirements on providers.

We would prefer to obtain explicit

legislative direction before we incur

these costs and impose these burdens.

Even so, we believe several years would

be required to gather the data and

develop the case-mix measures. For

these reasons, we believe that interim

prospective payment systems of the

types contained in the President’s FY

1997 budget should be put in place.

Q. Interim Fee-for-Service Payment

Method for Skilled Nursing Facility

Services (Recommendation 22)

Recommendation: An interim

payment method should be

implemented to control the growth in

Medicare payments for SNF services

until a comprehensive prospective

payment system is established. A

system based on historical data and

facility-specific limits, however, may

not allow facilities to respond

appropriately to changes in a dynamic

environment.

Response: We agree with ProPAC’s

recommendation that an interim

payment system should be developed

until a permanent system is established.

Both the interim and permanent

payment systems could better promote

the goals of quality care, maximum

access to care, and cost containment. A

payment system that incorporates these

goals is essential as the nursing home

industry evolves toward a more eclectic

mix of care levels and delivery models.

In addition, the need exists for a

payment system that is simpler to

administer for both providers and

HCFA. In order to maximize these goals,

a permanent prospective payment

system for SNFs should include

payment for all costs (that is, routine

operating, ancillary, and capital costs)

and take into account actual facility case

mix. However, thecase-mix and

ancillary cost data necessary to

accomplish this goal are not yet

available.

In the interim, based on current data

resources, a prospective payment

system could be implemented. It would

apply solely to routine costs (including

routine capital costs) and utilize facilityspecific payment rates subject to cost

limits. We are studying various cost

limit designs, such as regional limits

versus national limits, to account for

geographical cost differences. In

addition, methodologies to ease the

transition from the current payment

system would be incorporated into an

interim prospective payment system.

While there is agreement that a need

exists to implement an interim

prospective payment system for SNFs,

the Commission believes that a system

based on historical data and facilityspecific limits may not allow facilities

to respond appropriately to changes in

a dynamic environment. However, we

believe that a facility-specific interim

prospective payment system would

provide a number of advantages over the

current system, and could be

constructed to accommodate changes in

a facility’s case mix. The system would

provide for greater cost containment and

administrative simplicity, through

predetermined pricing. In addition, the

potential to earn a profit under the

interim system, by holding down costs,

would provide an incentive for nursing

homes to participate in Medicare, or

certify more beds if already

participating. This would provide

greater access for beneficiaries. This

same incentive would produce greater

efficiency in nursing home operations

and would support the provision of

quality care. When compared to a flat

rate system, a facility-specific system

would maintain an appropriate

distribution of payments, since the basis

of payments under the system is the

nursing homes’ own cost history. As a

nursing home case-mix classification

system is finalized and tested, and

further analysis is completed on

ancillary payment, these elements

would be incorporated into the payment

system.

In addition, we are analyzing some

features of an interim system that would

result in savings for the Medicare

program. Specifically, in developing

providers’ facility-specific payment

rates for routine services, the system

would incorporate one set of cost limits

based on freestanding costs only. The

current system provides for separate

(higher) limits for hospital-based

facilities. Consequently, savings would

result from holding down payments to

these hospital-based SNFs. In addition,

savings would result through the

elimination of routine cost limit

exemptions granted to new providers of

skilled nursing services. The current

system of cost limit exceptions for

‘‘atypical nursing services’’ would be

eliminated as well. Finally, the

Medicare Part B carrier fee schedules

could be utilized for Part A SNF

services as a limit on the reasonable

costs of certain ancillary services.

Currently, there are no limits or

reasonable cost guidelines for many of

these services.

We support the ProPAC view that a

per-episode payment system be

developed. We have noted above,

however, that there are great obstacles to

developing both (1) prospective

payment systems that are consistent

across provider types with respect to the

method of measuring resource use, and

(2) classifications systems for episodes

of postacute care (either by provider

type or in general) that account for a

sufficient degree of the variability

among different types of patients. Thus,

our inclination would be to pursue our

current plans for the prospective

payment systems with the thought that
27488 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

further refinements could be made

when data are available.

R. Interim Fee-for-Service Payment

Method for Home Health Care

(Recommendation 23)

Recommendation: Until a fully

prospective payment system for home

health care is developed, the

Commission supports adopting episodebased payment limits. In addition,

beneficiary copayments, subject to an

annual limit, should be introduced.

Response: There is agreement

between ProPAC and HCFA that an

interim cost control mechanism should

be established prior to implementing a

prospective payment system for home

health care. We would like to highlight

significant differences between the

prospective payment systems proposed

by the Congress and the Administration.

The congressional proposal would

limit payment to 120 days of service

with certain exceptions for up to 165

days of care. This provision has the

potential of serious financial impact on

some agencies, as well as reduced

access to services for some patients with

the greatest needs. The proposal also

assumes the availability of data and

systems to categorize and assign

patients to one of the 18 ‘‘case-mix

categories’’ established in Phase II of

HCFA’s HHA prospective payment

system demonstration. Neither the data

nor the systems are currently in

existence, and the implementation of

such a system would entail a major

increase in the reporting burden on

agencies. Were we able to implement

such a system, we estimate that the

system would be able to explain less

than 10 percent of the variation in cost

per episode, at best.

The Administration’s interim

proposal entails no increased reporting

burden, as it uses data currently

reported by agencies. Although that

budget proposal does not provide for

per-episode payments, its aggregate

payment caps effectively create a perepisode cap on costs. Given the

uncertainty about the resource

composition of individual types of

episodes, the use of an aggregate cap

gives agencies an incentive to provide

services in a cost effective manner by

sharing savings with agencies whose

costs are below their per beneficiary

limitation. We note that ProPAC was

also concerned that the interim proposal

utilizes regional cost experience, which

the Commission feels may not be

appropriate. The President’s FY 1997

budget includes a provision to use

average national or regional cost

experience in constructing the per

beneficiary limitation. We agree with

ProPAC that, should we find unjustified

differences in regional cost experience,

we would support a move to national

cost experience as the basis for the per

beneficiary limit.

It may be necessary to use regional

rates to move individual HHAs toward

a national norm over time. This would

avoid major displacements. We are

considering both regional and national

blending.

We do not agree with the ProPAC

recommendation that beneficiary

copayments be introduced. Our

proposed interim system of limits

should adequately control the growth in

service use. We do not agree with

shifting costs to beneficiaries, however

limited, as a method of controlling the

growth in utilization.

As HCFA moves forward in designing

a prospective payment system for home

health care, we will consider ProPAC’s

recommendations to look at more

uniformly defined units of services.

S. Update to the Composite Rate for

Dialysis Services (Recommendation 24)

Recommendation: The Secretary

should develop methods to control total

Medicare per capita expenditures for

end stage renal disease (ESRD)

beneficiaries. In the meantime, the

composite rate should be updated by 2.7

percent for hospital-based dialysis

facilities and by 2.0 percent for

freestanding facilities for fiscal year

1997. The Secretary should also develop

reliable measures of patient severity and

outcomes to analyze the relationships

among treatment processes, patient

outcomes, and costs. These factors

should be considered in evaluating the

need for and the level of future payment

updates.

Response: One of ProPAC’s

suggestions is that HCFA consider

opening enrollment for ESRD

beneficiaries to participate in Medicare

risk programs. The reason for this

recommendation is the rapid growth in

total Medicare spending for ESRD

beneficiaries. A large part of this

increase is attributable to the expanding

ESRD population, especially older

patients who require more services.

These beneficiaries are using more acute

inpatient, skilled nursing and other

dialysis-related services than ever

before. ProPAC suggests that to control

these expenditures, Medicare examine

the possibility of adopting a capitation

payment system for ESRD services,

since capitation rates have been

successful in controlling expenditure

growth for other populations. At a

minimum, they are recommending that

utilization review or other managed care

techniques be used to control the total

volume of services provided to ESRD

beneficiaries across all sites of care.

Section 1876(d) of the Act currently

prevents an individual with ESRD from

enrolling in an HMO or a competitive

medical plan. However, an individual

who is enrolled in a prepaid health plan

when he or she is determined to have

ESRD may continue enrollment in that

plan. A prepaid health plan may only

disenroll a beneficiary as provided by

regulations at 417.460.

Congress addressed the issue of

paying for ESRD services in a capitation

setting in legislation. Section 13567(b)

of the Omnibus Budget Reconciliation

Act of 1993 (Public Law 103–66)

(August 10, 1993) amended section 2355

of Public Law 98–369 by requiring the

Secretary to include the integration of

acute and chronic care management for

patients with ESRD through expanded

community care case management

services in a social health maintenance

organization (SHMO). Initial legislation

required the Secretary to grant

demonstration waivers for SHMOs that

provide for the integration of health and

social services at a fixed annual prepaid

capitation rate. In the January 26, 1996

Federal Register, we published a notice

informing interested parties of the

opportunity to apply for funds for a

cooperative agreement to operate an

ESRD Managed Care Demonstration (61

FR 2516). Two of the demonstration’s

purposes would be to test whether

ESRD beneficiaries can and should be

given access to HMOs during open

enrollment and whether the statewide

capitation rate can and should be

adjusted. The demonstration would

adjust rates for treatment status (such as

dialysis, transplant, or a functioning

graft), age groups and the cause of renal

failure (for example, diabetes). As the

legislation requires, rates would be

based on 100 percent of the adjusted

average per capita costs (AAPCC);

additional non-Medicare-covered

benefits would be offered by the

provider to justify the additional 5

percent beyond the 95 percent of the

AAPCC paid to Medicare riskcontracting HMOs on behalf of ESRD

enrollees. Based on the results of this

demonstration, we would make

recommendations to Congress

concerning the appropriateness of

paying for dialysis services in a

capitation setting.

To improve the quality of care ESRD

patients are receiving, we are in the

process of developing proposed rules for

ESRD conditions for coverage. The

essence of the regulation is patientcentered and outcome-oriented. The

proposed conditions for coverage will

focus on facilities achieving an optimal
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27489

level of health and well-being for all

dialysis patients. The proposed rules

will be published in Spring 1996 with

expected implementation in late fiscal

year 1997.

While we share ProPAC’s concern

that payment rates be sufficient to

assure quality care for ESRD patients,

we do not believe there is sufficient

evidence at this point to conclude that

more money is needed to provide

appropriate care. Currently, the

University of Michigan, as part of a

National Institute of Health grant, is

examining the relationship between

facilities’ costs and the level of KT/V.

Also the National Institute of Diabetes

and Digestive and Kidney Diseases is

sponsoring a study on the impact of

increasing dialysis as measured by KT/

V and the use of high-flux-dialysis on

ESRD patients. The results of these

studies should help us analyze the

relationship between patient outcomes

and costs, and thus provide us with a

basis for recommending an appropriate

payment rate increase.

While we acknowledge that an

increase in the composite rate may be

appropriate in the next few years, we

believe that any rate increase should be

linked to implementation of the revised

conditions for coverage. Moreover, any

ESRD rate increase must be considered

within the context of Medicare

budgetary concerns and should have a

direct link to improved patient

outcomes. We will continue to monitor

ESRD facility costs, and, if appropriate,

we may recommend an update to the

ESRD composite rate for FY 1998.

We note that ProPAC’s

recommendation provides for an acrossthe-board rate increase for all renal

facilities. However, data show that high

volume independent facilities (over

6,000 treatments per year) account for

about 85 percent of independent

dialysis treatments. These high volume

facilities report margins between

Medicare payments and costs that are

higher than average. Therefore, in

proposing a future rate increase, we

would want to examine the need to

adjust payment increases for volume. In

addition, we believe that any update to

the composite rate should include an

update to the wage index currently used

to adjust the labor portion of the rate.

We are currently using an outdated

wage index which is a blend of 1980

Bureau of Labor Statistics (BLS) and

1984 prospective payment system wage

data and does not reflect the MSA

revisions resulting from the 1990

census.

The Commission’s final

recommendation is that the Secretary

closely monitor treatment patterns and

patient outcomes to ensure that facilities

use the payment increase to improve

quality of care. The proposed ESRD

conditions for coverage should address

this issue. We expect the proposed rule

to be published in the Federal Register

before Summer 1996. Between the

publication of the proposed and final

rules, HCFA is planning to meet with

the renal community to develop

complete clinical data sets to monitor

patient outcomes and medical

conditions. These data will then be used

to evaluate the quality of dialysis

services furnished by individual

facilities. Of course, this is a long-term

project. In the short term, we are

exploring the possibility of collecting

limited patient outcome data such as

KT/V and URR.

T. Prospective Payment for Hospital

Outpatient Services (Recommendation

25)

Recommendation: A comprehensive

prospective payment system should be

developed for hospital outpatient

services. Such a system should include

a strategy for controlling the volume of

ambulatory services.

Response: We agree with the need to

implement a comprehensive prospective

payment system for outpatient services.

While we await legislative authority, we

continue to develop and refine the

Medicare-specific factors of the

Ambulatory Patient Group (APG) system

that we recommend using. We plan to

analyze the payments that would be

made across sites, for example in

Ambulatory Surgical Centers (ASCs) or

physician radiology practices, to ensure

that we have not created unwarranted

incentives to perform procedures in a

given setting for financial reasons.

We are concerned as well about the

potential for increases in the volume of

services provided, both in outpatient

departments and in other settings. We

are examining approaches to volume

measurement and control, including the

level of packaging for ancillary services

and monitoring of patterns of care. For

example, we could track whether

Medicare beneficiaries received more

clinic visits per patient under APGs

than they did under cost-based

reimbursement. If so, we could take

corrective action either systemically or

on a hospital-specific basis. This issue

clearly requires study. We welcome

suggestions in this area.

U. Beneficiary Liability for Hospital

Outpatient Services (Recommendation

26)

Recommendation: The growing

financial burden for Medicare enrollees

who receive services in hospital

outpatient departments should be

alleviated immediately. Beneficiary

coinsurance for these services should be

limited to 20 percent of the Medicareallowed payment, as it is in other

settings. For services not paid on a

prospective basis, the Secretary should

establish a new method for determining

beneficiary copayments based on

estimated allowed payments since they

cannot be calculated precisely when

services are delivered.

Response: We agree that the issue of

beneficiary coinsurance should be

addressed. In the context of the monies

available to the Medicare program, we

doubt that Congress would authorize

that Medicare immediately assume the

full cost of paying 80 percent of the cost

of outpatient services. Among the

approaches that could be used are: (1)

Applying the savings achieved by

eliminating the formula-driven

overpayment to offset the beneficiaries’

responsibility; (2) requiring copayments

in other areas of the program, such as

for home health services or laboratory

services; and/or (3) moving gradually to

reduce the ratio of copayments to total

payments. One issue that must be

considered at the same time is the rise

in the Part B premium that would

accompany any significant increase in

program payments. This would have the

effect of distributing costs over the

entire range of beneficiaries, rather than

having it focused only on those patients

who actually use outpatient services, as

it is now. We are eager to have this issue

addressed and resolved, but know that

it must be examined in light of broader

budget decisions.

IX. Other Required Information

A. Paperwork Reduction Act

The Paperwork Reduction Act of 1995

provides for notice and comment when

a collection of information requirement

is submitted to the Office of

Management and Budget (OMB) for

review and approval. In order to fairly

evaluate whether an information

collection should be approved by OMB,

section 3506(c)(2)(A) of the Paperwork

Reduction Act of 1995 requires that we

solicit comment on the following issues:

• Whether the information collection

is necessary and useful to carry out the

proper functions of the agency;

• The accuracy of the agency’s

estimate of the information collection

burden;

• The quality, utility, and clarity of

the information to be collected; and

• Recommendations to minimize the

information collection burden on the

affected public, including automated

collection techniques.
27490 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

Therefore, we are soliciting public

comment on each of these issues for the

information collection requirement

discussed below.

The only information collection or

paperwork burden item contained in

this proposed rule involves the

requirement under § 489.27 that a

hospital furnish each Medicare

beneficiary with a notice of discharge

rights supplied by HCFA, that is, ‘An

Important Message from Medicare.’

As discussed in section V.F of this

preamble, we are revising the current

requirement that a hospital must

distribute the ‘Important Message’ to

each Medicare beneficiary at or about

the time of admission. In order to permit

hospitals more flexibility, but still

ensure that benficiaries are aware of

their discharge rights, we are proposing

to revise § 489.27 to specify that a

hospital must provide the notice of

discharge rights ‘during the course of

the hospital stay.’ We estimate that the

paperwork burden associated with the

requirement that hospital personnel

distribute the ‘Important Message’ to

each Medicare beneficiary is

approximately 1 minute per admission.

Based on our most recent available data

(1995 Data Compendium, HCFA Pub.

No. 03364), there are roughly 11 million

Medicare beneficiaries admitted to

hospitals each year, resulting in an

annual burden of approximately

183,000 hours.

This paperwork burden is not

effective until it has been approved by

OMB. A notice will be published in the

Federal Register when approval is

obtained. Organizations and individuals

desiring to comment on this paperwork

burden requirement should submit

comments by July 30, 1996 to the Office

of Management and Budget, Human

Resources and Housing Branch, Room

10235, New Executive Office Building,

Washington, D.C., 20503, Attention:

Allison Herron Eydt, HCFA Desk

Officer.

B. Requests for Data from the Public

In order to respond promptly to

public requests for data related to the

prospective payment system, we have

set up a process under which

commenters can gain access to the raw

data on an expedited basis. Generally,

the data are available in computer tape

format or cartridges; however, some files

are available on diskette, and on the

internet at HTTP://WWW.HCFA.GOV/

STATS/PUBFILES.HTML. Data files are

listed below with the cost of each.

Anyone wishing to purchase data tapes,

cartridges, or diskettes should submit a

written request along with a company

check or money order (payable to

HCFA–PUF) to cover the cost, to the

following address: Health Care

Financing Administration, Public Use

Files, Accounting Division, P.O. Box

7520, Baltimore, Maryland 21207–0520,

(410) 786–3691. Files on the internet

may be downloaded without charge.

1. Expanded Modified 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 which means

discharges occurring October 1 through

September 30.)The records are stripped

of most data elements that will permit

identification of beneficiaries. The

hospital is identified by the 6-position

Medicare billing number. The file is

available to persons qualifying under

the terms of the Notice of Proposed New

Routine Uses for an Existing System of

Records published in the Federal

Register on December 24, 1984 (49 FR

49941), and amended by the July 2,

1985 notice (50 FR 27361). The national

file consists of approximately 11 million

records. Under the requirements of

these notices, a data release agreement

must be signed by the purchaser before

release of these data. For all files

requiring a signed data release

agreement, please write or call to obtain

a blank agreement form before placing

an order. Two versions of this file are

created each year. They support the

following:

• Notice of Proposed Rulemaking

(NPRM) published in the Federal

Register, usually available by the end of

May. This file is derived from the

MedPAR file with a cutoff of 3 months

after the end of the fiscal year

(December file).

• Final Rule published in the Federal

Register, usually available by the first

week of September. This file is derived

from the MedPAR file with a cutoff of

9 months after the end of the fiscal year

(June file).

Media: Tape/Cartridge

File Cost: $3,415.00 per fiscal year

Periods Available: FY 1988 through FY

1995

2. Expanded Modified 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, a data

release must be signed by the purchaser

before release of these data. Two

versions of this file are created each

year. They support the following:

• NPRM published in the Federal

Register, usually available by the end of

May. This file is derived from the

MedPAR file with a cutoff of 3 months

after the end of the fiscal year

(December file).

• Final Rule published in the Federal

Register, usually available by the first

week of September. This file is derived

from the MedPAR file with a cutoff of

9 months after the end of the fiscal year

(June file).

Media: Tape/Cartridge

File Cost: $1,050.00 per State per year

Periods Available: FY 1988 through FY

1995

3. HCFA Hospital Wage Index Data File

This file is composed of four separate

diskettes. Included are: (1) The hospital

hours and salaries for FY 1993 used to

create the proposed FY 1997

prospective payment system wage

indexes; (2) a history of all wage indexes

used since October 1, 1983; (3) a list of

State and county codes used by SSA

and FIPS (Federal Information

Processing Standards), county name,

and Metropolitan Statistical Area

(MSA); and (4) a file of hospitals that

were reclassified for the purpose of the

FY 1997 wage index. Two versions of

these files are created each year. They

support the following:

• NPRM published in the Federal

Register, usually by the end of May.

• Final Rule published in the Federal

Register, usually by the first week of

September.

Media: Diskette/Internet

File Cost: $500.00

Periods Available: FY 1997 PPS Update

We note that the files also are

available individually as indicated

below.

(1) HCFA Hospital Wage Index Survey

Only (usually available by the end of

March for the NPRM and the middle of

August for the final rule.)

(2) Urban and Rural Wage Indices

Only

(3) PPS SSA/FIPS MSA State and

County Crosswalk Only (usually

available by the end of March)
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27491

(4) Reclassified Hospitals by Provider

Only

Media: Diskette/Internet

File cost: $145.00 per file

4. PPS–IV to PPS–XII Minimum Data

Sets

The Minimum Data Set contains cost,

statistical, financial, and other

information from the Medicare hospital

cost report. The data set includes only

the most current cost report (as

submitted, final settled or reopened)

submitted for a Medicare participating

hospital by the Medicare Fiscal

Intermediary to HCFA. This data set is

updated at the end of each calendar

quarter and is available on the last day

of the following month.

Media: Tape/Cartridge

Periods beginning on 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 XII Minimum Data Set covering 1995 will not be available until July 31,

1996.)

File Cost: $715.00 per year

5. PPS-IX to PPS-XII Capital Data Set

The Capital Data Set contains selected

data for capital-related costs, interest

expense and related information and

complete balance sheet data from the

Medicare hospital cost report. The data

set includes only the most current cost

report (as submitted, final settled or

reopened) submitted for a Medicare

certified hospital by the Medicare fiscal

intermediary to HCFA. This data set is

updated at the end of each calendar

quarter and is available on the last day

of the following month.

Media: Tape/Cartridge

Periods beginning on 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 XII Capital Data Set covering 1994 will not be available until July 31,

1996.)

File Cost: $715.00 per year

6. Provider-Specific File

This file is a component of the

PRICER program used in the fiscal

intermediary’s system to compute DRG

payments for individual bills. The file

contains records for all prospective

payment system eligible hospitals,

including hospitals in waiver States,

and data elements used in the

prospective payment system

recalibration processes and related

activities. Beginning with December

1988, the individual records were

enlarged to include pass-through per

diems and other elements.

Media: Tape/Cartridge

File Cost: $500.00 per file

Periods Available: FY 1987 through FY

1996 (December updates)

Media: Diskette/Internet

File Cost: $265.00

Periods Available: FY 1996 PPS Update

7. HCFA Medicare Case-Mix Index File

This file contains the Medicare 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.

• Final rule published in the Federal

Register, usually by the first week of

September.

Media: Diskette/Internet

Price: $145.00 per year

Periods Available: FY 1985 through FY

1995 (Internet—FY 1995)

8. Table 5 DRG File

This file contains a listing of DRGs,

DRG narrative description, relative

weight, geometric mean, length of stay,

and day outlier trim points as published

in the Federal Register. The hardcopy

image has been copied to diskette. There

are two versions of this file as published

in the Federal Register:

a. NPRM, usually published by the

end of May.

b. Final rule, usually published by the

first week of September.

Media: Diskette/Internet

File Cost: $145.00

Periods Available: FY 1997 PPS Update

9. PPS Payment Impact File

This file contains data used to

estimate payments under Medicare’s

hospital inpatient prospective payment

systems for operating and capital-related

costs. The data are taken from various

sources, including the Provider-Specific

File, Minimum Data Sets, and prior

impact files. The data set is abstracted

from an internal file used for the impact

analysis of the changes to the

prospective payment systems published

in the Federal Register. This file is

available for release 1 month after the

proposed and final rules are published

in the Federal Register.

Media: Diskette/Internet

File Cost: $145.00

Periods Available: FY 1997 PPS Update

10. AOR/BOR Tables

This file contains data used to

develop the DRG relative weights. It

contains mean, maximum, minimum,

standard deviation and coefficient of

variation statistics by DRG for length of

stay and standardized charges. The BOR

tables are ‘‘Before Outliers Removed’’

and the AOR is ‘‘After Outliers

Removed.’’ (Outliers refers to statistical

outliers, not payment outliers.) Two

versions of this file are created each

year. They support the following:

• NPRM published in the Federal

Register, usually by the end of May.

• Final rule published in the Federal

Register, usually by the first week of

September.

Media: Diskette/Internet

File Cost: $145.00

Periods Available: FY 1997 PPS Update

11. HCFA FY 1992 Capital-Related Tax

File

This file contains data used to

develop a special property tax

adjustment to the capital prospective

payment system for capital-related

costs. The data set includes a

preliminary hospital-specific add-on

amount for all PPS hospitals. The data

set also contains the information used to

propose an adjustment to the Federal

rate so that the tax add-on is budget

neutral. The proposed property tax

adjustment provides special treatment

to qualified hospitals who pay capitalrelated property taxes. The add-on was

10. determined using base year tax costs

per discharge attributable to Medicare.

The data are taken from the FY 1992

Medicare hospital cost report and a

special request for validation by the

fiscal intermediaries.

Media: Diskette

File cost: $145.00

Period available: FY 1992

For further information concerning

these data tapes, contact Mary R. White

at (410) 786–0168.

Commenters interested in obtaining or

discussing any other data used in

constructing this rule should contact

Stephen Phillips at (410) 786–4548.
27492 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

C. Public Comments

Because of the large number of items

of correspondence we normally receive

on a proposed rule, we are not able to

acknowledge or respond to them

individually. However, in preparing the

final rule, we will consider all

comments concerning the provisions of

this proposed rule that we receive by

the date and time specified in the

‘‘Dates’’ section of this preamble and

respond to those comments in the

preamble to that rule. We emphasize

that, given the statutory requirement

under section 1886(e)(5) of the Act that

our final rule for FY 1997 be published

by September 1, 1996, we will consider

only those comments that deal

specifically with the matters discussed

in this proposed rule.

List of Subjects

42 CFR Part 412

Administrative practice and

procedure, Health facilities, Medicare,

Puerto Rico, Reporting and

recordkeeping requirements.

42 CFR Part 413

Health facilities, Kidney diseases,

Medicare, Puerto Rico, Reporting and

recordkeeping requirements.

42 CFR Part 489

Health facilities, Medicare.

42 CFR chapter IV would be amended

as set forth below:

A. Part 412 would be amended as

follows:

PART 412—PROSPECTIVE PAYMENT

SYSTEMS FOR INPATIENT HOSPITAL

SERVICES

1. The authority citation for part 412

continues to read as follows:

Authority: Secs. 1102 and 1871 of the

Social Security Act (42 U.S.C. 1302 and

1395hh).

Subpart D—Basic Methodology for

Determining Prospective Payment

Federal Rates for Inpatient Operating

Costs

2. In § 412.63(s)(1), a new sentence is

added at the end to read as follows:

§ 412.63 Federal rates for inpatient

operating costs for fiscal years after

Federal fiscal year 1984.

* * * * *

(s) * * *

(1) * * * The wage index is updated

annually.

* * * * *

Subpart L—The Medicare Geographic

Classification Review Board

3. In 412.246, paragraph (b) is revised

to read as follows:

§ 412.246 MGCRB members.

* * * * *

(b) Term of office. The term of office

for an MGCRB member may not exceed

3 years. A member may serve more than

one term. The Secretary may terminate

a member’s tenure prior to its full term.

Subpart M—Prospective Payment

System for Inpatient Hospital Capital

Costs

4. In § 412.302, a new paragraph (d)(4)

is added to read as follows:

§ 412.302 Introduction to capital costs.

* * * * *

(d) * * *

(4) Hospitals may elect the simplified

cost allocation methodology under the

terms and conditions provided in the

instructions for HCFA Form 2552.

B. Part 413 would be amended as

follows:

PART 413—PRINCIPLES OF

REASONABLE COST

REIMBURSEMENT; PAYMENT FOR

END-STAGE RENAL DISEASE

SERVICES; OPTIONAL

PROSPECTIVELY DETERMINED

PAYMENT RATES FOR SKILLED

NURSING FACILITIES

1. The authority citation for part 413

continues to read as follows:

Authority: Secs. 1102, 1861(v)(1)(A), and

1871 of the Social Security Act (42 U.S.C.

1302, 1395x(v)(1)(A), and 1395hh).

Subpart C—Limits on Cost

Reimbursement

2. In § 413.40, paragraph (d)(3) is

revised to read as follows:

§ 413.40 Ceiling on the rate of increase in

hospital inpatient costs.

* * * * *

(d) * * *

(3) Net inpatient operating costs are

greater than the ceiling. For cost

reporting periods beginning on or after

October 1, 1991, if a hospital’s allowable

net inpatient operating costs exceed the

hospital’s ceiling (or the adjusted

ceiling, if applicable), payment will be

based on the lower of the—

(i) Ceiling (or the adjusted ceiling, if

applicable) plus 50 percent of the

allowable net inpatient operating costs

in excess of the ceiling (or the adjusted

ceiling, if applicable); or

(ii) One hundred-ten percent of the

ceiling (or the adjusted ceiling, if

applicable).

* * * * *

Subpart F—Specific Categories of

Costs

3. In § 413.86, a new sentence is

added at the end of paragraph (g)(1)

introductory text to read as follows:

§ 413.86 Direct graduate medical

education payments.

* * * * *

(g) * * *

(1) * * * For combined residency

programs, an inital residency period is

defined as the time required for

individual certification in the longer of

the two programs.

* * * * *

C. Part 489 would be amended as

follows:

PART 489—PROVIDER AGREEMENTS

AND SUPPLIER APPROVAL

1. The authority citation for part 489

continues to read as follows:

Authority: Secs. 1102, and 1871 of the

Social Security Act (42 U.S.C. 1302, and

1395hh).

Subpart B—Essentials of Provider

Agreements

2. Section 489.27 is revised to read as

follows:

§ 489.27 Beneficiary notice of discharge

rights.

A hospital that participates in the

Medicare program must furnish each

Medicare beneficiary, or an individual

acting on his or her behalf, the notice of

discharge rights HCFA supplies to the

hospital to implement section

1886(a)(1)(M) of the Act. The hospital

must provide timely notice during the

course of the hospital stay. For purposes

of this paragraph, the course of the

hospital stay may begin with the

provision of a package of information

regarding scheduled preadmission

testing and registration for a planned

hospital admission. The hospital must

be able to demonstrate compliance with

this requirement.

(Catalog of Federal Domestic Assistance

Program No. 93.773, Medicare—Hospital

Insurance; and Program No. 93.774,

Medicare—Supplementary Medical

Insurance Program)
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27493

Dated: May 13, 1996.

Bruce C. Vladeck,

Administrator, Health Care Financing

Administration.

Dated: May 24, 1996.

Donna E. Shalala,

Secretary.

[Editorial Note: The following addendum

and appendixes will not appear in the Code

of Federal Regulations.]

Addendum—Proposed Schedule of

Standardized Amounts Effective With

Discharges on or After October 1, 1996

and Update Factors and Rate-ofIncrease Percentages Effective With

Cost Reporting Periods Beginning on

or After October 1, 1996

I. Summary and Background

In this addendum, we are setting forth

the proposed amounts and factors for

determining prospective payment rates

for Medicare inpatient operating costs

and Medicare inpatient capital-related

costs. We are also setting forth proposed

rate-of-increase percentages for updating

the target amounts for hospitals and

hospital units excluded from the

prospective payment system.

For discharges occurring on or after

October 1, 1996, except for sole

community hospitals and hospitals

located in Puerto Rico, each hospital’s

payment per discharge under the

prospective payment system will be

based on 100 percent of the Federal

national rate.

Sole community hospitals are paid

based on whichever of the following

rates yields the greatest aggregate

payment: the Federal national rate, the

updated hospital-specific rate based on

FY 1982 cost per discharge, or the

updated hospital-specific rate based on

FY 1987 cost per discharge. For

hospitals in Puerto Rico, the payment

per discharge is based on the sum of 75

percent of a Puerto Rico rate and 25

percent of a national rate (section

1886(d)(9)(A) of the Act).

As discussed below in section II, we

are proposing to make changes in the

determination of the prospective

payment rates for Medicare inpatient

operating costs. The changes, to be

applied prospectively, would affect the

calculation of the Federal rates. In

section III, we discuss our proposed

changes for determining the prospective

payment rates for Medicare inpatient

capital-related costs. Section IV sets

forth our proposed changes for

determining the rate-of-increase limits

for hospitals excluded from the

prospective payment system. The tables

to which we refer in the preamble to the

proposed rule are presented at the end

of this addendum in section V.

II. Proposed Changes to Prospective

Payment rates For Inpatient Operating

Costs for FY 1997

The basic methodology for

determining prospective payment rates

for inpatient operating costs is set forth

at § 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 manner

in which we are changing some of the

factors used for determining the

prospective payment rates. The Federal

and Puerto Rico rate changes, once

issued as final, will be effective with

discharges occurring on or after October

1, 1996. As required by section

1886(d)(4)(C) of the Act, we must also

adjust the DRG classifications and

weighting factors for discharges in FY

1997.

In summary, the proposed

standardized amounts set forth in

Tables 1a and 1c of section V of this

addendum reflect—

• Updates of 2.2 percent for all areas

(that is, the market basket percentage

increase of 2.7 percent minus 0.5

percentage points);

• An adjustment to ensure budget

neutrality as provided for in sections

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

Act by applying new budget neutrality

adjustment factors to the large urban

and other standardized amounts;

• An adjustment to ensure budget

neutrality as provided for in section

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

FY 1996 budget neutrality factor and

applying a revised factor; and

• An adjustment to apply the revised

outlier offset by removing the FY 1996

outlier offsets and applying a new offset.

A. Calculation of Adjusted

Standardized Amounts

1. Standardization of Base-Year Costs or

Target Amounts

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

required the establishment of base-year

cost data containing allowable operating

costs per discharge of inpatient hospital

services for each hospital. The preamble

to the September 1, 1983 interim final

rule (48 FR 39763) contains a detailed

explanation of how base-year cost data

were established in the initial

development of standardized amounts

for the prospective payment system and

how they are used in computing the

Federal rates.

Section 1886(d)(9)(B)(i) of the Act

required that Medicare target amounts

be determined for each hospital located

in Puerto Rico for its cost reporting

period beginning in FY 1987. The

September 1, 1987 final rule contains a

detailed explanation of how the target

amounts were determined and how they

are used in computing the Puerto Rico

rates (52 FR 33043, 33066).

The standardized amounts are based

on per discharge averages of adjusted

hospital costs from a base period or, for

Puerto Rico, adjusted target amounts

from a base period, updated and

otherwise adjusted in accordance with

the provisions of section 1886(d) of the

Act. Sections 1886 (d)(2)(C) and

(d)(9)(B)(ii) of the Act required that the

updated base-year per discharge costs

and, for Puerto Rico, the updated target

amounts, respectively, be standardized

in order to remove from the cost data

the effects of certain sources of variation

in cost among hospitals. These include

case mix, differences in area wage

levels, cost of living adjustments for

Alaska and Hawaii, indirect medical

education costs, and payments to

hospitals serving a disproportionate

share of low-income patients.

Since the standardized amounts have

already been adjusted for differences in

case mix, wages, cost-of-living, indirect

medical education costs, and payments

to hospitals serving a disproportionate

share of low-income patients, no

additional adjustments for these factors

for FY 1997 were made. That is, the

standardization adjustments reflected in

the FY 1997 standardized amounts are

the same as those reflected in the FY

1996 standardized amounts.

Under sections 1886 (d)(2)(H) and

(d)(3)(E) of the Act, in making payments

under the prospective payment system,

the Secretary estimates from time to

time the proportion of costs that are

wages and wage-related costs. Since

October 1, 1990, when the market basket

was last rebased, we have considered

71.4 percent of costs to be labor-related

for purposes of the prospective payment

system. As discussed in section IV of

the preamble, we are proposing to use

a rebased market basket effective for FY

1997. Based on the proposed rebased

market basket, we are revising the labor

and nonlabor proportions of the

standardized amounts. Effective with

discharges occurring on or after October

1, 1996, we are proposing a labor-related

proportion of 71.2 percent and a

nonlabor-related proportion of 28.8

percent. The standardized amounts in

Table 1a of section V of this addendum

have been recomputed to reflect the

revised labor-related and nonlaborrelated proportions. (We are revising the

Puerto Rico standardized amounts by

the average labor share in Puerto Rico of

82.8 percent. We are revising the

discharged-weighted national
27494 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

standardized amount to reflect the

proportion of discharges in large urban

and other areas from the FY 1995

MedPAR file.)

2. Computing Large Urban and Other

Averages Within Geographic Areas

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

the Secretary to compute two average

standardized amounts for discharges

occurring in a fiscal year: one for

hospitals located in large urban areas

and one for hospitals located in other

areas. In addition, under sections

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

the average standardized amount per

discharge must be determined for

hospitals located in urban and other

areas in Puerto Rico. Hospitals in Puerto

Rico are paid a blend of 75 percent of

the applicable Puerto Rico standardized

amount and 25 percent of a national

standardized payment amount.

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

defines ‘‘urban areas’’ as those areas

within a Metropolitan Statistical Area

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

as an urban area with a population of

more than 1,000,000. In addition,

section 4009(i) of Public Law 100–203

provides that a New England County

Metropolitan Area (NECMA) with a

population of more than 970,000 is

classified as a large urban area. As

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

Act, population size is determined by

the Secretary based on the latest

population data published by the

Bureau of the Census. Urban areas that

do not meet the definition of a ‘‘large

urban area’’ are referred to as ‘‘other

urban areas.’’ Areas that are not

included in MSAs are considered ‘‘rural

areas’’ under section 1886(d)(2)(D).

Payment for discharges from hospitals

located in large urban areas will be

based on the large urban standardized

amount. Payment for discharges from

hospitals located in other urban and

rural areas will be based on the other

standardized amount.

Based on 1995 population estimates

published by the Bureau of the Census,

56 areas meet the criteria to be defined

as large urban areas for FY 1997. These

areas are identified by an asterisk in

Table 4a.

Table 1a contains the two national

standardized amounts that we are

proposing be applicable to all hospitals,

except for sole community hospitals and

hospitals in Puerto Rico. For a number

of years, Table 1b had been used to set

forth the 18 regional standardized

amounts applicable for hospitals located

in census areas subject to the regional

floor. However, as provided in section

1886(d)(1)(A)(iii)(II) of the Act, the

regional floor expires effective with

discharges occurring on or after October

1, 1996. Therefore, all hospitals (except

sole community hospitals and hospitals

in Puerto Rico) will be paid solely on

the basis of the national standardized

amounts. Under section

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

standardized payment amount

applicable to hospitals in Puerto Rico

consists of the discharge-weighted

average of the national large urban

standardized amount and the national

other standardized amount (as set forth

in Table 1a). The national average

standardized amount for Puerto Rico is

now set forth in Table 1b. This table

also includes the two standardized

amounts that would be applicable to

most hospitals in Puerto Rico.

3. Updating the Average Standardized

Amounts

In accordance with section

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

proposing to update the large urban and

the other areas average standardized

amounts for FY 1997 using the

applicable percentage increases

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

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

the Act specifies that, for hospitals in all

areas, the update factor for the

standardized amounts for FY 1997 is the

market basket percentage increase

minus 0.5 percentage points.

The percentage change in the market

basket reflects the average change in the

price of goods and services purchased

by hospitals to furnish inpatient care.

The most recent forecast of the proposed

rebased hospital market basket increase

for FY 1997 is 2.7 percent. For FY 1997,

this yields an update to the average

standardized amounts of 2.2 percent

(2.7 percent minus 0.5 percent). (See

section IV of this preamble of this

proposed rule for a discussion of the

market basket rebasing.)

As in the past, we are adjusting the

FY 1996 standardized amounts to

remove the effects of the FY 1996

geographic reclassifications and outlier

payments before applying the FY 1997

updates. That is, we are increasing the

standardized amounts to restore the

reductions that were made for the

effects of geographic reclassification and

outliers. After including offsets to the

standardized amounts for outliers and

geographic reclassification, we estimate

that there will be an actual increase of

2.3 percent to the large urban and other

area standardized amounts.

Although the update factor for FY

1997 is set by law, we are required by

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

to Congress on our initial

recommendation of update factors for

FY 1997 for both prospective payment

hospitals and hospitals excluded from

the prospective payment system. For

general information purposes, we have

included the report to Congress as

Appendix D to this proposed rule. Our

proposed recommendation on the

update factors (which is required by

sections 1886 (e)(4)(A) and (e)(5)(A) of

the Act), as well as our responses to

ProPAC’s recommendation concerning

the update factor, are set forth as

Appendix E to this proposed rule.

4. Other Adjustments to the Average

Standardized Amounts

a. Recalibration of DRG Weights and

Updated Wage Index—Budget

Neutrality Adjustment. Section

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

that beginning in FY 1991, the annual

DRG reclassification and recalibration of

the relative weights must be made in a

manner that ensures that aggregate

payments to hospitals are not affected.

As discussed in section II of the

preamble, we normalized the

recalibrated DRG weights by an

adjustment factor, so that the average

case weight after recalibration is equal

to the average case weight prior to

recalibration.

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

specifies that the hospital wage index

must be updated on an annual basis

beginning October 1, 1993. This

provision also requires that any updates

or adjustments to the wage index must

be made in a manner that ensures that

aggregate payments to hospitals are not

affected by the change in the wage

index.

To comply with the requirement of

section 1886(d)(4)(C)(iii) of the Act that

DRG reclassification and recalibration of

the relative weights be budget neutral,

and the requirement in section

1886(d)(3)(E) of the Act that the updated

wage index be budget neutral, we

compared aggregate payments using the

FY 1996 relative weights and wage

index to aggregate payments using the

proposed FY 1997 relative weights and

wage index. The same methodology was

used for the FY 1996 budget neutrality

adjustment. (See the discussion in the

September 1, 1992 final rule (57 FR

39832).) Based on this comparison, we

computed a budget neutrality

adjustment factor equal to 0.998509.

This budget neutrality adjustment factor

is applied to the standardized amounts

without removing the effects of the FY

1996 budget neutrality adjustment. We

do not remove the prior budget

neutrality adjustment because estimated

aggregate payments after the changes in

the DRG relative weights and wage

index should equal estimated aggregate

payments prior to the changes. If we
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removed the prior year adjustment, we

would not satisfy this condition.

In addition, we are proposing to

continue to apply the same FY 1997

adjustment factor to the hospitalspecific rates that are effective for cost

reporting periods beginning on or after

October 1, 1996, in order to ensure that

we meet the statutory requirement that

aggregate payments neither increase nor

decrease as a result of the

implementation of the FY 1997 DRG

weights and updated wage index. (See

the discussion in the September 4, 1990

final rule (55 FR 36073).)

b. Reclassified Hospitals—Budget

Neutrality Adjustment. Section

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

certain rural hospitals are deemed urban

effective with discharges occurring on

or after October 1, 1988. In addition,

section 1886(d)(10) of the Act provides

for the reclassification of hospitals

based on determinations by the

Medicare Geographic Classification

Review Board (MGCRB). Under section

1886(d)(10) of the Act, a hospital may be

reclassified for purposes of the

standardized amount or the wage index,

or both.

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

Act, the Secretary is required to adjust

the standardized amounts so as to

ensure that total aggregate payments

under the prospective payment system

after implementation of the provisions

of sections 1886(d)(8) (B) and (C) and

1886(d)(10) of the Act are equal to the

aggregate prospective payments that

would have been made absent these

provisions. To calculate this budget

neutrality factor, we used historical

discharge data to simulate payments,

and compared total prospective

payments (including IME and DSH

payments) prior to any reclassifications

to total prospective payments after

reclassifications. We are applying an

adjustment factor of 0.994059 to ensure

that the effects of reclassification are

budget neutral.

The adjustment factor is applied to

the standardized amounts after

removing the effects of the FY 1996

budget neutrality adjustment factor. We

note that the proposed FY 1997

adjustment reflects wage index and

standardized amount reclassifications

approved by the MGCRB or the

Administrator as of March 14, 1996. The

effects of any additional reclassification

changes resulting from appeals and

reviews of the MGCRB decisions for FY

1997 or from a hospital’s request for the

withdrawal of a reclassification request

will be reflected in the final budget

neutrality adjustment required under

section 1886(d)(8)(D) of the Act and

published in the final rule for FY 1997.

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

the Act provides for payments in

addition to the basic prospective

payments for ‘‘outlier’’ cases, cases

involving extraordinarily high costs

(cost outliers) or long lengths of stay

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

the Act requires the Secretary to adjust

both the large urban and other area

national standardized amounts by the

same factor to account for the estimated

proportion of total DRG payments made

to outlier cases. Similarly, section

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

Secretary to adjust the large urban and

other standardized amounts applicable

to hospitals in Puerto Rico by the same

factor to account for the estimated

proportion of total DRG payments made

to outlier cases. Furthermore, under

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

outlier payments for any year must be

projected to be not less than 5 percent

nor more than 6 percent of total

payments based on DRG prospective

payment rates.

Beginning with FY 1995, section

1886(d)(5)(A) of the Act requires the

Secretary to phase out payments for day

outliers (correspondingly, payments for

cost outliers would increase). Under the

requirements of section

1886(d)(5)(A)(v), the proportion of day

outlier payments to total outlier

payments is reduced from FY 1994

levels as follows: 75 percent of FY 1994

levels in FY 1995, 50 percent of FY 1994

levels in FY 1996, and 25 percent of FY

1994 levels in FY 1997. We estimated

the FY 1994 proportion of day outlier

payments to total outlier payments at

31.3 percent in our September 1, 1993

final rule (58 FR 46348). Thus, the

proportion of day outlier payments to

total outlier payments in FY 1997 will

be approximately 8 percent (25 percent

of 31.3 percent). For discharges

occurring after September 30, 1997, the

Secretary will no longer pay for day

outliers under the provisions of section

1886(d)(5)(A)(i) of the Act.

i. Proposed FY 1997 Outlier Payment

Policies, Including Outlier Thresholds.

For FY 1996, the day outlier threshold

is the geometric mean length of stay for

each DRG plus the lesser of 23 days or

3.0 standard deviations. The marginal

cost factor for day outliers (the percent

of Medicare’s average per diem payment

paid for each outlier day) is 44 percent

for FY 1996. The fixed loss cost outlier

threshold is equal to the prospective

payment for the DRG plus $15,150

($13,800 for hospitals that have not yet

entered the prospective payment system

for capital-related costs). The marginal

cost factor for cost outliers (the percent

of costs paid after costs for the case

exceed the threshold) is 80 percent. We

applied an outlier adjustment to the FY

1996 standardized amounts of 0.949054

for the large urban and other areas rates

and 0.9526 for the capital Federal rate.

For FY 1997, we propose to set the

day outlier threshold at the geometric

mean length of stay for each DRG plus

the lesser of 24 days or 3.0 standard

deviations. Section 1886(d)(5)(A)(iii) of

the Act, as amended by section

13501(c)(3) of Public Law 103–66,

provides that additional payments for

day outlier cases may be reduced below

the marginal cost of care to meet the

requirements of section 1886(d)(5)(A)(v)

of the Act. We are proposing to reduce

the marginal cost factor for each outlier

day from 44 percent to 35 percent in FY

1997. We estimate that our proposed

policies will reduce the proportion of

outlier payments paid as day outliers in

FY 1997 to approximately 8 percent, in

accordance with section 1886(d)(5)(A)

of the Act.

We are also proposing a fixed loss

cost outlier threshold in FY 1997 equal

to the prospective payment rate for the

DRG plus $11,050 ($10,075 for hospitals

that have not yet entered the

prospective payment system for 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 1997 standardized amounts by the

same percentage to account for the

projected proportion of payments paid

to outliers.

As stated in the September 1, 1993

final rule (58 FR 46348), we establish

outlier thresholds that are applicable to

both inpatient operating costs and

inpatient capital-related costs. When we

modeled the combined operating and

capital outlier payments, we found that

using a common set of thresholds

resulted in a higher percentage of outlier

payments for capital-related costs than

for operating costs. We project that the

proposed thresholds for FY 1997 will

result in outlier payments equal to 5.1

percent of operating DRG payments and

5.2 percent of capital payments based

on the Federal rate.

Thus, the proposed outlier adjustment

factors applied to the standardized

amounts and the capital Federal rate for

FY 1997 are as follows:
27496 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

Operating Standardized Amounts

Capital

Federal

Rate

0.948968 ....................................... 0.9476

We would apply the proposed outlier

adjustment factors after removing the

effects of the FY 1996 outlier adjustment

factors on the standardized amounts and

the capital Federal rate.

ii. Other Changes Concerning

Outliers. Table 5 of section V of this

addendum contains the DRG relative

weights, geometric and arithmetic mean

lengths of stay, as well as the day outlier

threshold for each DRG. When we

recalibrate DRG weights, we set a

threshold of 10 cases as the minimum

number of cases required to compute a

reasonable weight and geometric mean

length of stay. DRGs that do not have at

least 10 cases are considered to be low

volume DRGs. For the low volume

DRGs, we use the original geometric

mean lengths of stay, because no

arithmetic mean length of stay was

calculated based on the original data.

Table 8a in section V of this

addendum contains the updated

Statewide average operating cost-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 September 1, 1995

final rule (60 FR 45922), effective

October 1, 1996. Table 8b contains

comparable Statewide average capital

cost-to-charge ratios. These average

ratios would be used to calculate cost

outlier payments for those hospitals for

which the intermediary computes

operating cost-to-charge ratios lower

than 0.24345 or greater than 1.30392

and capital cost-to-charge ratios lower

than 0.013297 or greater than 0.19968.

This range represents 3.0 standard

deviations (plus or minus) from the

mean of the log distribution of cost-tocharge ratios for all hospitals. We note

that the cost-to-charge ratios in Tables

8a and 8b would be used for all cost

reports settled during FY 1997

(regardless of the actual cost reporting

period) when hospital-specific cost-tocharge ratios are either not available or

outside the three standard deviations

range.

iii. FY 1995 and FY 1996 Outlier

Payments. In the September 1, 1995

final rule (59 FR 45408), we stated that,

based on available data, we estimated

that actual FY 1995 outlier payments

would be approximately 4.0 percent of

actual total DRG payments. This

percentage was computed by simulating

payments using actual FY 1994 bill data

available at the time. That is, the

estimate of actual outlier payments did

not reflect actual FY 1995 bills but

instead reflected the application of FY

1995 rates and policies to available FY

1994 bills. Our current estimate, using

available FY 1995 bills, is that actual

outlier payments for FY 1995 were

approximately 3.7 percent of actual total

DRG payments (lower than the 5.1

percent we projected in setting outlier

policies for FY 1995). We note that the

MedPAR file for FY 1995 discharges

continues to be updated.

We currently estimate that actual

outlier payments for FY 1996 will be

approximately 4.2 percent of actual total

DRG payments (lower than the 5.1

percent we projected in setting outlier

policies for FY 1996). This estimate is

based on simulations using the

December 1995 update of the providerspecific file and the December 1995

update of the FY 1995 MedPAR file

(discharge data for FY 1995 bills). We

used these data to calculate an estimate

of the actual outlier percentage for FY

1996 by applying FY 1996 rates and

policies to available FY 1995 bills.

The following discussion addresses

the methodology we use to set outlier

thresholds for an upcoming fiscal year

and also addresses possible

explanations for the difference between

projected and actual outlier payment

percentages in recent years.

iv. Methodology for Setting Outlier

Thresholds. In previous rulemaking

documents, we have discussed the

methodology for setting outlier

thresholds as well as our periodic

refinements to that methodology. In this

document, we once again describe our

methodology and analyze it to suggest

some possible explanations for the

recent differences between projected

and actual outlier percentages. We

invite comments and suggestions for

further refinements to the methodology.

In General. In accordance with

section 1886(d)(5)(A)(iv) of the Act, we

set outlier thresholds so that outlier

payments are expected (projected) to

equal 5.1 percent of total payments

based on DRG prospective payment

rates. The databases used to calculate

thresholds for an upcoming fiscal year

include data on discharges from a

previous fiscal year as well as hospitalspecific data. We update the data every

year. In setting the proposed FY 1997

outlier thresholds, we used the

December 1995 update of the FY 1995

MedPAR file, which contains data on

FY 1995 hospital inpatient discharges,

and the December 1995 update of the

provider-specific file, which contains

information on hospital-specific

payment parameters (such as cost-tocharge ratios).

The methodology for setting outlier

thresholds for an upcoming fiscal year

involves analyzing the set of hospital

inpatient cases in the MedPAR file and

simulating payments for those cases by

using the payment rates and policies

that would apply in the upcoming fiscal

year. For example, in calculating the

proposed thresholds for FY 1997, we

used the proposed payment rates and

policies for FY 1997 and simulated

payments for the set of cases in the FY

1995 MedPAR file.

The computer simulation calculates

‘‘payments’’—outlier payments and total

payments—for all discharges for a given

set of outlier thresholds. In order to

achieve established objectives (for

example, the projected percentage of

outlier payments relative to total DRG

payments is 5.1 percent, and the

projected percentage of outlier

payments attributable to day outliers is

8 percent for FY 1997), the methodology

involves an iterative process, that is,

numerous successive simulations using

alternative sets of outlier thresholds. In

short, then, the outlier estimation

methodology involves analyzing

historical discharge data, simulating

payments for the discharges in the

database by using the payment rates that

would apply in the upcoming fiscal

year, and testing alternative sets of

outlier thresholds until the simulations

are consistent with established

objectives.

Cost Inflation Factors. In setting

outlier thresholds for an upcoming

fiscal year, we need to calculate the

‘‘costs’’ for each case in our database. In

the payment simulations, this ‘‘cost’’ for

each case is used to determine, for a

given cost outlier threshold, whether a

case qualifies for additional outlier

payments and the amount of any such

payments. (As explained above, we test

alternative sets of thresholds.)

The MedPAR file includes data on

billed charges, and as part of the

estimation methodology, we make

adjustments to convert the charges to

costs, including adjusting the data for

inflation. In setting the proposed outlier

thresholds for FY 1997, we analyzed

data for FY 1995 discharges.

As we explained in the September 1,

1993 final rule (58 FR 46347), prior to

FY 1994, we used a charge inflation

factor to adjust charges to costs; for

example, in setting outlier thresholds

for FY 1993, we adjusted the FY 1991

MedPAR file charge data by a charge

inflation factor for 2 years in order to

estimate FY 1993 charges and then

applied the applicable cost-to-charge
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27497

ratio. Beginning with FY 1994, we have

used a cost inflation factor to estimate

‘‘costs’’; that is, we adjust the charges by

the cost-to-charge ratio and then adjust

the resulting costs for 2 years of cost

inflation. This adjustment automatically

accounts for any changes in the cost-tocharge ratios that may occur, since the

relevant variable is the estimated

‘‘costs’’ for a given case.

In setting the final outlier thresholds

for recent years immediately prior to FY

1995, we determined cost inflation

factors by analyzing cost report

information to calculate moving

averages of cost inflation for prior

periods. (For example, in setting the FY

1994 outlier thresholds, we analyzed

cost reports for cost reporting periods

beginning in FY 1988 through FY 1991

to calculate a cost inflation factor, that

is, the average annual increase in cost

per case, of 8.3 percent.) In doing so, we

made an audit adjustment for any cost

report that had not been settled, based

on the average ratio of submitted to final

cost report data. In setting the final

outlier thresholds for FYs 1995 and

1996, we determined cost inflation

factors by analyzing cost report

information and calculating the change

in cost per case for one year, rather than

the average change in cost per case over

more than one year.

In setting the proposed FY 1997

outlier thresholds, we used a cost

inflation factor of 0.0 percent, because it

is unclear whether FY 1997 ‘‘costs’’ will

be higher or lower than costs reflected

in the FY 1995 MedPAR file. Analysis

of recent cost report information shows

that cost per case increased slightly for

cost reporting periods beginning in FY

1993 relative to those beginning in FY

1992, but decreased slightly in the

following year (that is, for cost reporting

periods beginning in FY 1994 relative to

those beginning in FY 1993). We will

reevaluate this factor when we develop

the final rule for FY 1997. At that time,

more recent data should be available for

analysis, specifically, cost report data

for cost reporting periods beginning in

FY 1995.

Differences Between Projected and

Actual Outlier Percentages. As

explained above, the cost inflation

factor is an important aspect of the

methodology for setting outlier

thresholds, and we believe the cost

inflation factor is a major reason that in

recent years the actual outlier

percentages (the proportion of actual

outlier payments to actual total DRG

payments) have been lower than

projected.

In determining the cost inflation

factor, we analyze historical hospital

cost report information, and there is

necessarily a time lag of 2 to 3 years

between the cost reporting period itself

and the time when data for that cost

reporting period become available. For

example, in setting the FY 1994 outlier

thresholds, we used a cost inflation

factor of 8.3 percent, derived from cost

reports for cost reporting periods

beginning in FY 1988 through FY 1991.

We adjusted the charges from the FY

1992 MedPAR bills by the cost-to-charge

ratio and then adjusted the resulting FY

1992 costs for 2 years of cost inflation

(costs multiplied by 1.083 multiplied by

1.083) to estimate ‘‘FY 1994 costs.’’

However, analysis of more recent cost

report information shows that cost per

case increased at a much lower rate of

0.97 percent in cost reporting periods

between FY 1992 and FY 1993 and

actually decreased 1.77 percent in cost

reporting periods between FY 1993 and

FY 1994. In effect, we ‘‘overestimated’’

costs by approximately 15.4 percent.

Since costs did not increase at nearly

the rate we expected, actual costs in FY

1994 proved to be lower than those

reflected in the simulations used to set

the thresholds for FY 1994; accordingly,

the proportion of outlier payments was

lower than expected.

Another aspect of the outlier

methodology that may have contributed

to the difference between projected and

actual outlier percentages concerns the

payment adjustments for indirect

medical education (IME) and

disproportionate share hospitals (DSH).

As indicated in previous rulemaking

documents, for purposes of determining

outlier payments, we standardize a

hospital’s costs for IME and DSH

adjustments; that is, we reduce the

hospital’s costs for a given discharge to

account for IME and DSH payments.

The ‘‘standardized’’≥ cost for a

discharge is calculated by taking total

costs for the discharge and dividing it

by the sum of one plus the hospital’s

DSH factor plus the hospital’s IME

factor. Therefore, the higher the IME

and DSH factors, the more costs are

reduced by standardization.

The factors used for purposes of

setting thresholds are taken from the

most recent provider-specific file. In

setting the proposed FY 1997 outlier

thresholds, we used information from

the December 1995 update of the

provider-specific file. We standardized

the costs for each discharge in our

database to account for IME and DSH

adjustments. The proposed outlier

thresholds reflect these standardized

costs.

While we use the latest, most up-todate sources of information, the

‘‘projected’’ IME and DSH factors (the

factors used to set thresholds for a fiscal

year) may differ from the actual IME and

DSH factors used to make payments in

that fiscal year. If the ‘‘projected’’ factors

used to standardize costs for a given

discharge are ‘‘too low,’’ then

standardization does not ‘‘sufficiently’’

reduce the costs for that discharge and

the resulting standardized cost is ‘‘too

high.’’ If the standardized costs for the

discharges analyzed to set outlier

thresholds are generally ‘‘too high,’’

then in turn the thresholds would be too

high; consequently, this might result in

a lower than expected proportion of

outlier payments. Analysis shows that,

for FY 1994 for example, the

‘‘projected’’ IME and DSH factors were

on average lower than the actual factors.

Conclusion. As we have done since

the inception of the prospective

payment system, we determine outlier

thresholds based on estimates before the

beginning of each fiscal year. The

methodology we use involves analysis

of the best data available at the time

thresholds are established; however, by

their nature, projections are imprecise

and may differ from actual payment

data for any number of reasons. We

discussed above some of the numerous

factors that affect payment and why

these particular factors may have

contributed to the difference between

projected and actual outlier payments in

recent years. (See also, for example, the

discussion in the September 1, 1995

final rule (60 FR 45855).) We note that

any difference between projected and

actual outlier payment percentages in a

given year does not affect standardized

amounts in future years.

We continue to explore refinements to

the methodology for setting outlier

thresholds. We welcome comments and

suggestions regarding these issues.

B. Adjustments for Area Wage Levels

and Cost of Living

The adjusted standardized amounts

are divided into labor and nonlabor

portions. Tables 1a and 1c, as set forth

in this addendum, contain the actual

labor-related and nonlabor-related

shares that will be used to calculate the

prospective payment rates for hospitals

located in the 50 States, the District of

Columbia, and Puerto Rico. This section

addresses two types of adjustments to

the standardized amounts that are made

in determining the prospective payment

rates as described in this addendum.

1. Adjustment for Area Wage Levels

Sections 1886(d)(3)(E) and

1886(d)(9)(C)(iv) of the Act require that

an adjustment be made to the laborrelated portion of the prospective

payment rates to account for area

differences in hospital wage levels. This
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adjustment is made by multiplying the

labor-related portion of the adjusted

standardized amounts by the

appropriate wage index for the area in

which the hospital is located. In section

III of the preamble, we discuss certain

revisions we are making to the wage

index. This index is set forth in Tables

4a through 4e of this addendum.

2. Adjustment for Cost of Living in

Alaska and Hawaii

Section 1886(d)(5)(H) of the Act

authorizes an adjustment to take into

account the unique circumstances of

hospitals in Alaska and Hawaii. Higher

labor-related costs for these two States

are taken into account in the adjustment

for area wages described above. For FY

1997, we propose to adjust the

payments for hospitals in Alaska and

Hawaii by multiplying the nonlabor

portion of the standardized amounts by

the appropriate adjustment factor

contained in the table below. If the

Office of Personnel Management

releases revised cost-of-living

adjustment factors before August 1,

1996, we will publish them in the final

rule and use them in determining FY

1997 payments.

TABLE OF COST-OF-LIVING ADJUSTMENT

FACTORS, ALASKA AND HAWAII HOSPITALS

Alaska—All areas .......................................... 1.25

Hawaii:

County of Honolulu .................................... 1.225

County of Hawaii ....................................... 1.15

County of Kauai ......................................... 1.20

County of Maui .......................................... 1.225

County of Kalawao .................................... 1.225

(The above factors are based on data obtained from the U.S. Office of Personnel Management.)

C. DRG Relative Weights

As discussed in section II of the

preamble, we have developed a

classification system for all hospital

discharges, assigning them into DRGs,

and have developed relative weights for

each DRG that reflect the resource

utilization of cases in each DRG relative

to Medicare cases in other DRGs. Table

5 of section V of this addendum

contains the relative weights that we

propose to use for discharges occurring

in FY 1997. These factors have been

recalibrated as explained in section II of

the preamble.

D. Calculation of Prospective Payment

Rates for FY 1997

General Formula for Calculation of

Prospective Payment Rates for FY 1997

Prospective payment rate for all

hospitals located outside Puerto Rico

except sole community hospitals =

Federal rate.

Prospective payment rate for sole

community hospitals = Whichever of

the following rates yields the greatest

aggregate payment: 100 percent of the

Federal rate, 100 percent of the updated

FY 1982 hospital-specific rate, or 100

percent of the updated FY 1987

hospital-specific rate. Prospective

payment rate for Puerto Rico = 75

percent of the Puerto Rico rate + 25

percent of a discharge-weighted average

of the national large urban standardized

amount and the national other

standardized amount.

1. Federal Rate

For discharges occurring on or after

October 1, 1996 and before October 1,

1997, except for sole community

hospitals and hospitals in Puerto Rico,

the hospital’s payment is based

exclusively on the Federal national rate.

Section 1866(d)(1)(A)(iii) of the Act

provides that the Federal rate is

comprised of 100 percent of the Federal

national rate.

The payment amount is determined as

follows:

Step 1—Select the appropriate

national standardized amount

considering the type of hospital and

designation of the hospital as large

urban or other (see Tables 1a, section V

of this addendum).

Step 2—Multiply the labor-related

portion of the standardized amount by

the applicable wage index for the

geographic area in which the hospital is

located (see Tables 4a, 4b, and 4c,

section V of this addendum).

Step 3—For hospitals in Alaska and

Hawaii, multiply the nonlabor-related

portion of the standardized amount by

the appropriate cost-of-living

adjustment factor. Step 4—Add the amount from Step 2

and the nonlabor-related portion of the

standardized amount (adjusted if

appropriate under Step 3).

Step 5—Multiply the final amount

from Step 4 by the relative weight

corresponding to the appropriate DRG

(see Table 5, section V of this

addendum).

2. Hospital-Specific Rate (Applicable

Only to Sole Community Hospitals)

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

of the Act provide that sole community

hospitals are paid based on whichever

of the following rates yields the greatest

aggregate payment: the Federal rate, the

updated hospital-specific rate based on

FY 1982 cost per discharge, or the

updated hospital-specific rate based on

FY 1987 cost per discharge. Hospital-specific rates have been

determined for each of these hospitals

based on both the FY 1982 cost per

discharge and the FY 1987 cost per

discharge. For a more detailed

discussion of the calculation of the FY

1982 hospital-specific rate and the FY

1987 hospital-specific rate, we refer the

reader to the September 1, 1983 interim

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

1990 final rule with comment (55 FR

15150); and the September 4, 1990 final

rule (55 FR 35994).

a. Updating the FY 1982 and FY 1987

Hospital-Specific Rates for FY 1997. We

are proposing to increase the hospitalspecific rates by 2.2 percent (the

hospital market basket percentage

increase minus 0.5 percentage points)

for sole community hospitals located in

all areas in FY 1997. Section

1886(b)(3)(C)(ii) of the Act provides that

the update factor applicable to the

hospital-specific rates for sole

community hospitals equals the update

factor provided under section

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

FY 1997, is the market basket rate of

increase minus 0.5 percentage points. b. Calculation of Hospital-Specific

Rate. For sole community hospitals, the

applicable FY 1997 hospital-specific

rate would be calculated by multiplying

a hospital’s hospital-specific rate for the

preceding fiscal year by the applicable

update factor (2.2 percent), which is the

same as the update for all prospective

payment hospitals. In addition, the

hospital-specific rate would be adjusted

by the budget neutrality adjustment

factor (that is, 0.998509) as discussed in

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

resulting rate would be used in

determining under which rate a sole

community hospital is paid for its

discharges beginning on or after October

1, 1996, based on the formula set forth

above.

3. General Formula for Calculation of

Prospective Payment Rates for Hospitals

Located in Puerto Rico Beginning On or

After October 1, 1996 and Before

October 1, 1997.

a. Puerto Rico Rate. The Puerto Rico

prospective payment rate is determined

as follows:

Step 1—Select the appropriate

adjusted average standardized amount

considering the large urban or other

designation of the hospital (see Table

1b, section V of the addendum).

Step 2—Multiply the labor-related

portion of the standardized amount by

the appropriate wage index (see Tables

4a and 4b, section V of the addendum).

Step 3—Add the amount from Step 2

and the nonlabor-related portion of the

standardized amount.

Step 4—Multiply the result in Step 3

by 75 percent. Step 5—Multiply the amount from

Step 4 by the appropriate DRG relative

weight (see Table 5, section V of the

addendum).
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27499

b. National Rate. The national

prospective payment rate is determined

as follows:

Step 1—Multiply the labor-related

portion of the national average

standardized amount (see Table 1b,

section V of the addendum) by the

appropriate wage index.

Step 2—Add the amount from Step 1

and the nonlabor-related portion of the

national average standardized amount.

Step 3—Multiply the result in Step 2

by 25 percent.

Step 4—Multiply the amount from

Step 3 by the appropriate DRG relative

weight (see Table 5, section V of the

addendum).

The sum of the Puerto Rico rate and

the national rate computed above equals

the prospective payment for a given

discharge for a hospital located in

Puerto Rico.

III. Proposed Changes to Payment Rates

for Inpatient Capital-Related Costs for

FY 1997

The prospective payment system for

hospital inpatient capital-related costs

was implemented for cost reporting

periods beginning on or after October 1,

1991. Effective with that cost reporting

period and during a 10-year transition

period extending through FY 2001,

hospital inpatient capital-related costs

are paid on the basis of an increasing

proportion of the capital prospective

payment system Federal rate and a

decreasing proportion of a hospital’s

historical costs for capital.

The basic methodology for

determining Federal capital prospective

rates is set forth at §§ 412.308 through

412.352. Below we discuss the factors

that we used to determine the proposed

Federal rate and the hospital-specific

rates for FY 1997. The rates will be

effective for discharges occurring on or

after October 1, 1996.

For FY 1992, we computed the

standard Federal payment rate for

capital-related costs under the

prospective payment system by

updating the FY 1989 Medicare

inpatient capital cost per case by an

actuarial estimate of the increase in

Medicare inpatient capital costs per

case. Each year after FY 1992 we update

the standard Federal rate, as provided in

§ 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. Section 412.308(c)(3)

further requires that the Federal rate be

reduced by an adjustment factor equal

to the estimated proportion of payments

for exceptions under § 412.348, and

§ 412.308(c)(4)(ii) requires that the

Federal rate be adjusted so that the

annual DRG reclassification and the

recalibration of DRG weights and

changes in the geographic adjustment

factor are budget neutral. For FY 1992

through FY 1995, § 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 capitalrelated costs on a reasonable cost basis

during the fiscal year. That provision

expired in FY 1996.

The hospital-specific rate for each

hospital was calculated by dividing the

hospital’s Medicare inpatient capitalrelated costs for a specified base year by

its Medicare discharges (adjusted for

transfers), and dividing the result by the

hospital’s case mix index (also adjusted

for transfers). The resulting case-mix

adjusted average cost per discharge was

then updated to FY 1992 based on the

national average increase in Medicare’s

inpatient capital cost per discharge and

adjusted by the exceptions payment

adjustment factor and the budget

neutrality adjustment factor to yield the

FY 1992 hospital-specific rate. The

hospital-specific rate is updated each

year after FY 1992 for inflation and for

changes in the exceptions payment

adjustment factor. For FY 1992 through

FY 1995, the hospital-specific rate was

also adjusted by a budget neutrality

adjustment factor.

To determine the appropriate budget

neutrality adjustment factors and the

exceptions payment adjustment factor,

we developed a dynamic model of

Medicare inpatient capital-related costs,

that is, a model that projects changes in

Medicare inpatient capital-related costs

over time. With the expiration of the

budget neutrality provision, the model

is still used to estimate the exceptions

payment adjustment and other factors.

The model and its application are

described more fully in Appendix B.

In accordance with section

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

prospective payment system for

inpatient operating costs, hospitals

located in Puerto Rico are paid for

operating costs under a special payment

formula. These hospitals are paid a

blended rate that is comprised of 75

percent of the applicable standardized

amount specific to Puerto Rico hospitals

and 25 percent of the applicable

national average standardized amount.

Section 412.374 provides for the use of

this blended payment system for

payments to Puerto Rico hospitals under

the prospective payment system for

inpatient capital-related costs.

Accordingly, for capital-related costs we

compute a separate payment rate

specific to Puerto Rico hospitals using

the same methodology used to compute

the national Federal rate for capital.

Hospitals in Puerto Rico are paid based

on 75 percent of the Puerto Rico rate

and 25 percent of the Federal rate.

A. Determination of Federal Inpatient

Capital-Related Prospective Payment

Rate Update

For FY 1996, the Federal rate is

$461.96. With the changes we are

proposing to the factors used to

establish the Federal rate, the proposed

FY 1997 Federal rate is $441.84.

In the discussion that follows, we

explain the factors that were used to

determine the proposed FY 1997

Federal rate. In particular, we explain

why the FY 1997 Federal rate has

decreased 4.36 percent compared to the

FY 1996 Federal rate. Nevertheless, as

explained in section VII of Appendix A,

capital payments per case are estimated

to increase 4.45 percent. Taking into

account the effects of increases in

projected discharges, we also estimate

that aggregate capital payments will

increase 7.28 percent.

The major factor contributing to the

decrease in the proposed FY 1997 rate

in comparison to the FY 1996 rate is the

change in the exceptions reduction

factor. We have expected the number

and amount of exceptions payments

generally to increase throughout the

transition period.

Total payments to hospitals under the

prospective payment system are

relatively insensitive to changes in the

capital prospective payments. Since

capital payments constitute about 10

percent of hospital payments, a 1

percent change in the capital Federal

rate yields only about 0.1 percent

change in actual payments to hospitals.

Aggregate payments under the capital

prospective payment transition system

are estimated to increase in FY 1997

compared to FY 1996. Specifically, we

estimate that aggregate payments in FY

1997 will be 7.28 percent higher than

they were in FY 1996. Changes in

aggregate payments include changes in

capital payments per discharge and

changes in the number of discharges.

Under the prospective payment system

for capital-related costs, payments per

discharge (or case) are estimated to

increase 4.45 percent in FY 1997

compared to FY 1996.

1. Standard Federal Rate Update

Section 412.308(c)(1) has provided

that the standard Federal rate is updated

on the basis of an analytical framework
27500 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

that takes into account changes in a

capital input price index and other

factors. The update framework consists

of a capital input price index (CIPI) and

several policy adjustment factors.

Specifically, we have adjusted the

projected CIPI rate of increase as

appropriate each year for case-mix

index related changes, for intensity, and

for errors in previous CIPI forecasts. The

proposed update factor for FY 1997

under that framework is 1.0 percent.

This proposal is based on a projected

1.0 percent increase in the CIPI, and on

policy adjustment factors of zero. We

explain the basis for the FY 1997 CIPI

projection in section IV.B of the

preamble to this proposed rule. Here we

describe the policy adjustments that

have been applied.

The case-mix index (CMI) is the

measure of the average DRG weight for

cases paid under the prospective

payment system. Because the DRG

weight determines the prospective

payment for each case, any percentage

increase in the CMI corresponds to an

equal percentage increase in hospital

payments.

The CMI can change for any of several

reasons: because the average resource

use of Medicare patients changes (‘‘real’’

case-mix change); because changes in

hospital coding of patient records result

in higher weight DRG assignments

(‘‘coding effects’’); and because the

annual DRG reclassification and

recalibration changes may not be budget

neutral (‘‘reclassification effect’’). We

define real case-mix change as actual

changes in the mix (and resource

requirements) of Medicare patients as

opposed to changes in coding behavior

that result in assignment of cases to

higher-weighted DRGs but do not reflect

higher resource requirements. In the

update framework for the prospective

payment system for operating costs, we

adjust the update upwards to allow for

real case-mix change, but remove the

effects of coding changes on the CMI.

We also remove the effect on total

payments of prior changes to the DRG

classifications and relative weights, in

order to retain budget neutrality for all

CMI-related changes other than patient

severity. (For example, we adjusted for

the effects of the FY 1992 DRG

reclassification and recalibration as part

of our FY 1994 update

recommendation.) The operating

adjustment consists of a reduction for

total observed case-mix change, an

increase for the portion of case-mix

change that we determine is due to real

case-mix change rather than coding

modifications, and an adjustment for the

effect of prior DRG reclassification and

recalibration changes. We have adopted

this CMI adjustment in the capital

update framework as well.

For FY 1997, we are projecting a 1.6

percent increase in the case-mix index.

We estimate that real case-mix increase

will equal projected case-mix increase

in FY 1997. We do not anticipate any

changes in coding behavior in our

projected case-mix change. We explain

the basis for this determination in

Appendix D to this proposed rule. The

proposed net adjustment for case-mix

change in FY 1997 is therefore 0.0

percentage points.

We estimate that DRG reclassification

and recalibration resulted in a 0.0

percent change in the case mix when

compared with the case-mix index that

would have resulted if we had not made

the reclassification and recalibration

changes to the DRGs.

The current operating update

framework contains an adjustment for

forecast error. The input price index

forecast is based on historical trends

and relationships ascertainable at the

time the update factor is established for

the upcoming year. In any given year

there may be unanticipated price

fluctuations that may result in

differences between the actual increase

in prices faced by hospitals and the

forecast used in calculating the update

factors. In setting a prospective payment

rate under the proposed framework, we

make an adjustment for forecast error

only if our estimate of the capital input

price index rate of increase for any year

is off by 0.25 percentage points or more.

There is a 2-year lag between the

forecast and the measurement of the

forecast error. Thus, for example, we

would adjust for a forecast error made

in FY 1996 through an adjustment to the

FY 1998 update. Because we only

introduced this analytical framework in

FY 1996, FY 1998 is the first year in

which a forecast error adjustment could

be required.

Under the capital prospective

payment system framework, we also

make an adjustment for changes in

intensity. We calculate this adjustment

using the same methodology and data as

in the framework for the operating

prospective payment system. The

intensity factor for the operating update

framework reflects how hospital

services are utilized to produce the final

product, that is, the discharge. This

component accounts for changes in the

use of quality-enhancing services,

changes in within-DRG severity, and

expected modification of practice

patterns to remove cost-ineffective

services.

We calculate case-mix constant

intensity as the change in total charges

per admission, adjusted for price level

changes (the CPI hospital component)

and changes in real case mix. The use

of total charges in the calculation of the

proposed intensity factor makes it a

total intensity factor, that is, charges for

capital services are already built into the

calculation of the factor. We have

therefore incorporated the intensity

adjustment from the operating update

framework into the capital update

framework. In the absence of reliable

estimates of the proportions of the

overall annual intensity increases that

are due, respectively, to ineffective

practice patterns and to the combination

of quality-enhancing new technologies

and within-DRG complexity, we

assume, as in the revised operating

update framework, that one-half of the

annual increase is due to each of these

factors. The capital update framework

thus provides an add-on to the input

price index rate of increase of one-half

of the estimated annual increase in

intensity to allow for within-DRG

severity increases and the adoption of

quality-enhancing technology.

For FY 1997, we have developed a

Medicare-specific intensity measure

based on a five-year average using FY

1991-1995. In determining case-mix

constant intensity, we found that

observed case-mix increase was 2.8

percent in FY 1991, 1.8 percent in FY

1992, 0.9 percent in FY 1993, 0.8

percent in FY 1994, and 1.6 percent in

FY 1995. For FY 1991 and FY 1992, we

estimate that real case-mix increase was

1.0 to 1.4 percent each year. The

estimate for those years is supported by

past studies of case-mix change by the

RAND Corporation. The most recent

study was ‘‘Has DRG Creep Crept Up?

Decomposing the Case Mix Index

Change Between 1987 and 1988’’ by

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

Relles, R-4098-HCFA/ProPAC (1991).

The study suggested that real case-mix

change was not dependent on total

change, but was rather a fairly steady

1.0 to 1.5 percent per year. We use 1.4

percent as the upper bound because the

RAND study did not take into account

that hospitals may have induced doctors

to document medical records more

completely in order to improve

payment. Following that study, we

consider up to 1.4 percent of observed

case-mix change as real for FY 1991

through FY 1994. As discussed above,

we have determined that all of the

observed case-mix increase for FY 1995

is real.

Given estimates of real case-mix

increase of 1.0 percent for FY 1991 and

FY 1992, 0.9 percent for FY 1993, 0.8

percent for FY 1994, and 1.6 percent for

FY 1995, we estimate that case-mix

constant intensity declined by an
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27501

average 1.1 percent during FY 1991

through FY 1995, for a cumulative

decrease of 5.6 percent. If we assume

that real case-mix increase was 1.4

percent for FY 1991 and FY 1992, 0.9

percent for FY 1993, 0.8 percent for FY

1994, and 1.6 percent for FY 1995, we

estimate that case-mix constant

intensity declined by an average 1.2

percent during FY 1991 through FY

1995, for a cumulative decrease of 5.9

percent. Since we estimate that intensity

has declined during that period, we are

recommending a 0.0 percent intensity

adjustment for FY 1997.

2. Outlier Payment Adjustment Factor

Section 412.312(c) establishes a

unified outlier methodology for

inpatient operating and inpatient

capital-related costs. A single set of

thresholds is used to identify outlier

cases for both inpatient operating and

inpatient capital-related payments.

Outlier payments are made only on the

portion of the Federal rate that is used

to calculate the hospital’s inpatient

capital-related payments (for example,

60 percent for cost reporting periods

beginning in FY 1997 for hospitals paid

under the fully prospective

methodology). Section 412.308(c)(2)

provides that the standard Federal rate

for inpatient capital-related costs be

reduced by an adjustment factor equal

to the estimated proportion of outlier

payments under the Federal rate to total

inpatient capital-related payments

under the Federal rate. The outlier

thresholds are set so that operating

outlier payments are projected to be 5.1

percent of total operating DRG

payments. The inpatient capital-related

outlier reduction factor reflects the

inpatient capital-related outlier

payments that would be made if all

hospitals were paid according to 100

percent of the Federal rate. For purposes

of calculating the outlier thresholds and

the outlier reduction factor, we model

all hospitals as if paid 100 percent of the

Federal rate because, as explained

above, outlier payments are made only

on the portion of the Federal rate that

is included in the hospital’s inpatient

capital-related payments.

In the September 1, 1995 final rule,

we estimated that outlier payments for

capital in FY 1996 would equal 4.64

percent of inpatient capital-related

payments based on the Federal rate.

Accordingly, we applied an outlier

adjustment factor of 0.9536 to the

Federal rate. Based on the thresholds as

set forth in section II.A.4.d of this

Addendum, we estimate that outlier

payments for capital will equal 5.24

percent of inpatient capital-related

payments based on the Federal rate in

FY 1997. We are, therefore, proposing

an outlier adjustment factor of 0.9476 to

the Federal rate. Thus, estimated capital

outlier payments for FY 1997 represent

a higher percentage of total capital

standard payments than in FY 1996.

The outlier reduction factors are not

built permanently into the rates; that is,

they are not applied cumulatively in

determining the Federal rate. Therefore,

the proposed net change in the outlier

adjustment to the Federal rate for FY

1997 is 0.9937 (0.9476/0.9536). Thus,

the outlier adjustment decreases the FY

1997 Federal rate by 0.63 percent

(0.9937 - 1) compared with the FY 1996

outlier adjustment.

3. Budget Neutrality Adjustment Factor

for Changes in DRG Classifications and

Weights and the Geographic Adjustment

Factor

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

the Federal rate be adjusted so that

aggregate payments for the fiscal year

based on the Federal rate after any

changes resulting from the annual DRG

reclassification and recalibration and

changes in the geographic adjustment

factor are projected to equal aggregate

payments that would have been made

on the basis of the Federal rate without

such changes. We use the actuarial

model described in Appendix B to

estimate the aggregate payments that

would have been made on the basis of

the Federal rate without changes in the

DRG classifications and weights and in

the geographic adjustment factor. We

also use the model to estimate aggregate

payments that would be made on the

basis of the Federal rate as a result of

those changes. We then use these figures

to compute the adjustment required to

maintain budget neutrality for changes

in DRG weights and in the geographic

adjustment factor.

For FY 1996, we calculated a GAF/

DRG budget neutrality factor of 0.9994.

For FY 1997, we are proposing a GAF/

DRG budget neutrality factor of 0.9992.

The GAF/DRG budget neutrality factors

are built permanently into the rates; that

is, they are applied cumulatively in

determining the Federal rate. This

follows from the requirement that

estimated aggregate payments each year

be no more than they would have been

in the absence of the annual DRG

reclassification and recalibration and

changes in the geographic adjustment

factor. The proposed incremental

change in the adjustment from FY 1996

to FY 1997 is 0.9992. The proposed

cumulative change in the rate due to

this adjustment is 1.0017 (the product of

the incremental factors for FY 1993, FY

1994, FY 1995, FY 1996 and the

proposed incremental factor for FY

1997:

0.9980×1.0053×0.9998×0.9994×0.9992 =

1.0017).

This factor accounts for DRG

reclassifications and recalibration and

for changes in the geographic

adjustment factor. It also incorporates

the effects on the geographic adjustment

factor of FY 1997 geographic

reclassification decisions made by the

MGCRB compared to FY 1996 decisions.

However, it does not account for

changes in payments due to changes in

the disproportionate share and indirect

medical education adjustment factors or

in the large urban add-on.

4. Exceptions Payment Adjustment

Factor

Section 412.308(c)(3) requires that the

standard Federal rate for inpatient

capital-related costs be reduced by an

adjustment factor equal to the estimated

proportion of additional payments for

exceptions under § 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

exceptions payment adjustment factor.

We describe that model in Appendix B

to this proposed rule.

For FY 1996, we estimated that

exceptions payments would equal 1.51

percent of aggregate payments based on

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

exceptions reduction factor of 0.9849

(1–0.0151) in determining the Federal

rate. For this proposed rule, we estimate

that exceptions payments for FY 1997

will equal 6.07 percent of aggregate

payments based on the Federal rate and

the hospital-specific rate. We are,

therefore, proposing an exceptions

payment reduction factor of 0.9393 to

the Federal rate for FY 1997.

The proposed exceptions reduction

factor for FY 1997 is thus 4.63 percent

lower than the factor for FY 1996. We

have expected the number and amount

of exceptions payments generally to

increase throughout the transition

period.

The exceptions reduction factors are

not built permanently into the rates; that

is, the factors are not applied

cumulatively in determining the Federal

rate. Therefore, the proposed net

adjustment to the FY 1997 Federal rate

is 0.9393/0.9849, or 0.9537.

5. Standard Capital Federal Rate for FY

1997

For FY 1996, the capital Federal rate

was $461.96. With the changes we are

proposing to the factors used to

establish the Federal rate, the FY 1997
27502 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

Federal rate would be $441.84. The

proposed Federal rate for FY 1997 was

calculated as follows:

• The proposed FY 1997 update

factor is 1.0100, that is, the proposed

update is 1.00 percent.

• The proposed FY 1997 budget

neutrality adjustment factor that is

applied to the standard Federal payment

rate for changes in the DRG relative

weights and in the geographic

adjustment factor is 0.9992.

• The proposed FY 1997 outlier

adjustment factor is 0.9476.

• The proposed FY 1997 exceptions

payments adjustment factor is 0.9393.

Since the Federal rate has already

been adjusted for differences in case

mix, wages, cost of living, indirect

medical education costs, and payments

to hospitals serving a disproportionate

share of low-income patients, we

propose to make no additional

adjustments in the standard Federal rate

for these factors other than the budget

neutrality factor for changes in the DRG

relative weights and the geographic

adjustment factor.

We are providing a chart that shows

how each of the factors and adjustments

for FY 1997 affected the computation of

the proposed FY 1997 Federal rate in

comparison to the FY 1996 Federal rate.

The proposed FY 1997 update factor has

the effect of increasing the Federal rate

by 1.00 percent compared to the rate in

FY 1996, while the proposed geographic

and DRG budget neutrality factor has

the effect of decreasing the Federal rate

by 0.08 percent. The proposed FY 1997

outlier adjustment factor has the effect

of decreasing the Federal rate by 0.63

percent compared to FY 1996. The

proposed FY 1997 exceptions reduction

factor has the effect of decreasing the

Federal rate by 4.63 percent compared

to the exceptions reduction for FY 1996.

The combined effect of all the proposed

changes is to decrease the proposed

Federal rate by 4.36 percent compared

to the Federal rate for FY 1996.

COMPARISON OF FACTORS AND ADJUSTMENTS: FY 1996 FEDERAL RATE AND PROPOSED FY 1997 FEDERAL RATE

Change Percent

change

Update factor: 1

FY 1996 ......................................................................................................................................................... 1.0120 ................ ................

Proposed FY 1997 ........................................................................................................................................ 1.0100 1.0100 1.00

GAF/DRG adjustment factor 1 ................

FY 1996 ......................................................................................................................................................... 0.9994 ................ ................

Proposed FY 1997 ........................................................................................................................................ 0.9992 0.9992 ¥0.08

Outlier adjustment factor: 2

FY 1996 ......................................................................................................................................................... 0.9536 ................ ................

Proposed FY 1997 ........................................................................................................................................ 0.9476 0.9937 ¥0.63

Exceptions adjustment factor: 2

FY 1996 ......................................................................................................................................................... 0.9849 ................ ................

Proposed FY 1997 ........................................................................................................................................ 0.9393 0.9537 ¥4.63

Federal Rate:

FY 1996 ......................................................................................................................................................... $461.96 ................ ................

Proposed FY 1997 ........................................................................................................................................ $441.84 0.9564 ¥4.36

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

from FY 1996 to FY 1997 resulting from the application of the 0.9992 GAF/DRG budget neutrality factor for FY 1997 is 0.9992. 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 1997 exceptions reduction factor

is 0.9393/0.9849, or 0.9537.

6. Special Rate for Puerto Rico Hospitals

For FY 1996, the special rate for

Puerto Rico hospitals was $355.35. With

the changes we are proposing to the

factors used to determine the rate, the

proposed FY 1997 special rate for

Puerto Rico would be $339.87.

B. Determination of Hospital-Specific

Rate Update

Section 412.328(e) of the regulations

provides that the hospital-specific rate

for FY 1997 be determined by adjusting

the FY 1996 hospital-specific rate by the

following factors:

1. Hospital-Specific Rate Update Factor

The hospital-specific rate is updated

in accordance with the update factor for

the standard Federal rate determined

under § 412.308(c)(1). For FY 1997, we

are proposing that the hospital-specific

rate be updated by a factor of 1.0100.

2. Exceptions Payment Adjustment

Factor

For FY 1992 through FY 2001, the

updated hospital-specific rate is

multiplied by an adjustment factor to

account for estimated exceptions

payments for capital-related costs under

§ 412.348, determined as a proportion of

the total amount of payments under the

hospital-specific rate and the Federal

rate. For FY 1997, we estimate that

exceptions payments will be 6.07

percent of aggregate payments based on

the Federal rate and the hospitalspecific rate. We therefore propose that

the updated hospital-specific rate be

reduced by a factor of 0.9393. The

exceptions reduction factors are not

built permanently into the rates; that is,

the factors are not applied cumulatively

in determining the hospital-specific

rate. Therefore, the proposed net

adjustment to the FY 1997 hospitalspecific rate is 0.9393/0.9849, or 0.9537.

3. Net Change to Hospital-Specific Rate

We are providing a chart to show the

net change to the hospital-specific rate.

The chart shows the factors for FY 1996

and FY 1997 and the net adjustment for

each factor. It also shows that the

proposed cumulative net adjustment

from FY 1996 to FY 1997 is 0.9632,

which represents a proposed decrease of

3.68 percent to the hospital-specific

rate. The proposed FY 1997 hospitalspecific rate for each hospital is

determined by multiplying the FY 1996

hospital-specific rate by the cumulative

net adjustment of 0.9632.
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27503

PROPOSED FY 1997 UPDATE AND ADJUSTMENTS TO HOSPITAL-SPECIFIC RATES

Net adjustmentPercent

change

Update factor:

FY 1996 ......................................................................................................................................................... 1.0120 ................ ................

Proposed FY 1997 ........................................................................................................................................ 1.0100 1.0100 1.00

Exceptions payment adjustment factor:

FY 1996 ......................................................................................................................................................... 0.9849 ................ ................

Proposed FY 1997 ........................................................................................................................................ 0.9393 0.9537 ¥4.63

Cumulative adjustments:

FY 1996 ......................................................................................................................................................... 0.9967 ................ ................

Proposed FY 1997 ........................................................................................................................................ 0.9601 0.9632 ¥3.68

Note: The update factor for the hospital-specific rate is applied cumulatively in determining the rates. Thus, the incremental increase in the update factor from FY 1996 to FY 1997 is 1.0100. In contrast, the exceptions payment adjustment factor is not applied cumulatively. Thus, for example, the incremental increase in the exceptions reduction factor from FY 1996 to FY 1997 is 0.9393/0.9849, or 0.9537.

C. Calculation of Inpatient CapitalRelated Prospective Payments for FY

1997

During the capital prospective

payment system transition period, a

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

alternative payment methodologies: the

fully prospective payment methodology

or the hold-harmless methodology. The

payment methodology applicable to a

particular hospital is determined when

a hospital comes under the prospective

payment system for capital-related costs

by comparing its hospital-specific rate

to the Federal rate applicable to the

hospital’s first cost reporting period

under the prospective payment system.

The applicable Federal rate was

determined by making adjustments as

follows:

• For outliers by dividing the

standard Federal rate by the outlier

reduction factor for that fiscal year; and,

• For the payment adjustment factors

applicable to the hospital (that is, the

hospital’s geographic adjustment factor,

the disproportionate share adjustment

factor, and the indirect medical

education adjustment factor, when

appropriate).

If the hospital-specific rate is above

the applicable Federal rate, the hospital

is paid under the hold-harmless

methodology. If the hospital-specific

rate is below the applicable Federal rate,

the hospital is paid under the fully

prospective methodology.

For purposes of calculating payments

for each discharge under both the holdharmless payment methodology and the

fully prospective payment methodology,

the standard Federal rate is adjusted as

follows: (Standard Federal Rate)×(DRG

weight)×(Geographic Adjustment

Factor)×(Large Urban Add-on, if

applicable)×(COLA adjustment for

hospitals located in Alaska and

Hawaii)×(1+Disproportionate Share

Adjustment Factor+Indirect Medical

Education Adjustment Factor, if

applicable). The result is termed the

adjusted Federal rate.

Payments under the hold-harmless

methodology are determined under one

of two formulas. A hold-harmless

hospital is paid the higher of:

• 100 percent of the adjusted Federal

rate for each discharge; or

• An old capital payment equal to 85

percent (100 percent for sole community

hospitals) of the hospital’s allowable

Medicare inpatient old capital costs per

discharge for the cost reporting period

plus a new capital payment based on a

percentage of the adjusted Federal rate

for each discharge. The percentage of

the adjusted Federal rate equals the ratio

of the hospital’s allowable Medicare

new capital costs to its total Medicare

inpatient capital-related costs in the cost

reporting period.

Once a hospital receives payment

based on 100 percent of the adjusted

Federal rate in a cost reporting period

beginning on or after October 1, 1994 (or

the first cost reporting period after

obligated capital that is recognized as

old capital under § 412.302(c) is put in

use for patient care, if later), the hospital

continues to receive capital prospective

payment system payments on that basis

for the remainder of the transition

period.

Payment for each discharge under the

fully prospective methodology is the

sum of:

• The hospital-specific rate

multiplied by the DRG relative weight

for the discharge and by the applicable

hospital-specific transition blend

percentage for the cost reporting period;

and

• The adjusted Federal rate

multiplied by the Federal transition

blend percentage.

The blend percentages for cost

reporting periods beginning in FY 1997

are 60 percent of the adjusted Federal

rate and 40 percent of the 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 60 percent of the Federal rate for

discharges occurring in cost reporting

periods beginning during FY 1997.

Thus, a fully prospective hospital will

receive 60 percent of the capital-related

outlier payment calculated for the case

for discharges occurring in cost

reporting periods beginning in FY 1997.

For hold-harmless hospitals paid 85

percent of their reasonable costs for old

inpatient capital, the portion of the

Federal rate that is included in the

hospital’s outlier payments is based on

the hospital’s ratio of Medicare

inpatient costs for new capital to total

Medicare inpatient capital costs. For

hold-harmless hospitals that are paid

100 percent of the Federal rate, 100

percent of the Federal rate is included

in the hospital’s outlier payments.

The proposed outlier thresholds for

FY 1997 are published in section

II.A.4.c of this Addendum. For FY 1997,

a case qualifies as a cost outlier if the

cost for the case (after standardization

for the indirect teaching adjustment and

disproportionate share adjustment) is

greater than the prospective payment

rate for the DRG plus $11,050. A case

qualifies as a day outlier for FY 1997 if

the length of stay is greater than the

geometric mean length of stay for the

DRG plus the lesser of 24 days or three

standard deviations of the length of stay.

During the capital prospective

payment system transition period, a

hospital may also receive an additional

payment under an exceptions process if

its total inpatient capital-related
27504 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

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 1997 are:

• Sole community hospitals (located

in either an urban or rural area), 90

percent;

• Urban hospitals with at least 100

beds and a disproportionate share

patient percentage of at least 20.2

percent and urban hospitals with at

least 100 beds that qualify for

disproportionate share payments under

§ 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.

V. Tables

This section contains the tables

referred to throughout the preamble to

this proposed rule and in this

Addendum. For purposes of this

proposed rule, and to avoid confusion,

we have retained the designations of

Tables 1 through 5 that were first used

in the September 1, 1983 initial

prospective payment final rule (48 FR

39844). Tables 1a, 1c, 1d, 3C, 4a, 4b, 4c,

4d, 4e, 5, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H,

7A, 7B, 8A, and 8B are presented below.

The tables presented below are as

follows:

Table 1a—National Adjusted Operating

Standardized Amounts, Labor/Nonlabor

Table 1c—Adjusted Operating Standardized

Amounts for Puerto Rico, Labor/

Nonlabor

Table 1d—Capital Standard Federal Payment

Rate

Table 3C—Hospital Case Mix Indexes for

Discharges Occurring in Federal Fiscal

Year 1995 and Hospital Average Hourly

Wage for Federal Fiscal Year 1997 Wage

Index

Table 4a—Wage Index and Capital

Geographic Adjustment Factor (GAF) for

Urban Areas

Table 4b—Wage Index and Capital

Geographic Adjustment Factor (GAF) for

Rural Areas

Table 4c—Wage Index and Capital

Geographic Adjustment Factor (GAF) for

Hospitals That Are Reclassified

Table 4d—Average Hourly Wage for Urban

Areas

Table 4e—Average Hourly Wage for Rural

Areas

Table 5—List of Diagnosis Related Groups

(DRGs), Relative Weighting Factors,

Geometric Mean Length of Stay, and

Length of Stay Outlier Cutoff Points

Used in the Prospective Payment System

Table 6A—New Diagnosis Codes

Table 6B—New Procedure Codes

Table 6C—Invalid Diagnosis Codes

Table 6D—Invalid Procedure Codes

Table 6E—Revised Diagnosis Code Titles

Table 6F—Revised Procedure Code Titles

Table 6G—Additions to the CC Exclusions

List

Table 6H—Deletions to the CC Exclusions

List

Table 7A—Medicare Prospective Payment

System Selected Percentile Lengths of

Stay FY 95 MEDPAR Update 12/95

GROUPER V13.0

Table 7B—Medicare Prospective Payment

System Selected Percentile Lengths of

Stay FY 95 MEDPAR Update 12/95

GROUPER V14.0

Table 8A—Statewide Average Operating

Cost-to-Charge Ratios for Urban and

Rural Hospitals (Case Weighted) April

1996

Table 8B—Statewide Average Capital Cost-toCharge Ratios (Case Weighted) April

1996

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

Large urban areas Other areas

Labor-related Non-labor

related Labor-related Non-labor related

2796.66 1131.23 2752.39 1113.33

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

Large urban areas Other areas

LaborrelatedNon-labor

related

LaborrelatedNon-labor

related

National ............................................................................................................................. $2772.89 $1121.62 $2772.89 $1121.62

Puerto Rico ....................................................................................................................... 2501.07 521.22 2461.47 512.97

TABLE 1D.—CAPITAL STANDARD FEDERAL PAYMENT RATE

Rate

National ........................................................................................................................................................................................................ $441.84

Puerto Rico .................................................................................................................................................................................................. 339.87
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27505

TABLE 3C.—HOSPITAL CASE MIX INDEXES FOR DISCHARGES OCCURRING IN FEDERAL FISCAL YEAR 1995

PAGE 1 OF 16

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 ..... 01.4400 14.82 010095 ..... 00.9230 11.25 030004 ..... 00.9824 13.49 040004 ..... 01.4485 14.83 040107 ..... 01.1923 14.95

010004 ..... 00.9600 11.10 010097 ..... 00.9405 15.20 030006 ..... 01.5576 17.52 040005 ..... 01.0380 11.59 040109 ..... 01.1692 12.69

010005 ..... 01.1609 15.40 010098 ..... 01.1941 11.02 030007 ..... 01.3158 16.41 040007 ..... 01.8761 18.12 040114 ..... 01.8513 16.64

010006 ..... 01.4752 15.23 010099 ..... 01.1210 15.49 030008 ..... 02.1095 20.42 040008 ..... 01.0325 10.77 040116 ..... 01.3895 19.25

010007 ..... 01.0986 13.12 010100 ..... 01.1688 14.77 030009 ..... 01.2993 15.58 040010 ..... 01.2298 13.78 040118 ..... 01.1313 14.29

010008 ..... 01.1366 09.54 010101 ..... 01.1127 14.21 030010 ..... 01.4160 17.75 040011 ..... 00.9298 10.75 040119 ..... 01.0914 14.34

010009 ..... 01.1377 14.82 010102 ..... 00.9529 13.63 030011 ..... 01.4747 17.66 040014 ..... 01.1929 16.07 040124 ..... 01.2238 14.30

010010 ..... 01.1330 14.33 010103 ..... 01.7534 17.01 030012 ..... 01.2246 15.81 040015 ..... 01.1944 12.12 040126 ..... 00.9617 11.74

010011 ..... 01.6185 18.94 010104 ..... 01.6892 17.87 030013 ..... 01.2459 18.99 040016 ..... 01.7330 16.43 050002 ..... 01.5554 25.91

010012 ..... 01.2666 16.27 010108 ..... 01.1189 13.68 030014 ..... 01.4394 17.86 040017 ..... 01.2569 11.68 050006 ..... 01.3983 19.15

010015 ..... 01.0512 15.63 010109 ..... 01.0527 11.48 030016 ..... 01.2462 17.09 040018 ..... 01.1686 16.66 050007 ..... 01.5848 25.29

010016 ..... 01.2643 16.76 010110 ..... 01.0168 13.44 030017 ..... 01.4929 18.98 040019 ..... 01.1618 13.52 050008 ..... 01.4998 25.48

010018 ..... 00.9017 16.19 010112 ..... 01.1253 14.09 030018 ..... 01.7989 19.57 040020 ..... 01.5987 14.08 050009 ..... 01.7211 31.63

010019 ..... 01.2868 14.99 010113 ..... 01.6374 13.69 030019 ..... 01.1962 19.31 040021 ..... 01.2277 14.69 050013 ..... 01.8099 22.05

010021 ..... 01.2388 12.20 010114 ..... 01.3174 15.37 030022 ..... 01.5055 17.41 040022 ..... 01.6951 14.73 050014 ..... 01.1741 22.55

010022 ..... 01.0109 16.89 010115 ..... 00.8385 11.98 030023 ..... 01.2640 17.64 040024 ..... 01.1709 12.16 050015 ..... 01.3882 22.18

010023 ..... 01.4760 14.71 010117 ..... 00.7880 13.54 030024 ..... 01.7809 21.04 040025 ..... 00.9214 11.81 050016 ..... 01.1598 18.51

010024 ..... 01.4014 15.62 010118 ..... 01.2475 15.07 030025 ..... 01.1633 12.76 040026 ..... 01.5547 16.35 050017 ..... 02.0618 24.39

010025 ..... 01.4390 13.16 010119 ..... 01.5429 16.36 030027 ..... 01.0875 14.69 040027 ..... 01.2889 12.56 050018 ..... 01.3434 18.49

010027 ..... 00.8352 13.55 010120 ..... 00.9668 14.32 030030 ..... 01.6651 18.19 040028 ..... 01.0903 11.40 050021 ..... 01.4146 23.75

010029 ..... 01.4957 14.84 010121 ..... 01.2269 12.92 030033 ..... 01.2475 16.40 040029 ..... 01.2557 14.12 050022 ..... 01.4601 22.63

010031 ..... 01.1808 14.58 010123 ..... 01.2421 17.47 030034 ..... 01.0430 15.89 040030 ..... 00.8925 11.09 050024 ..... 01.3952 21.31

010032 ..... 00.9478 12.45 010124 ..... 01.2927 16.15 030035 ..... 01.3403 20.77 040032 ..... 01.0056 11.18 050025 ..... 01.8000 22.00

010033 ..... 01.9143 17.61 010125 ..... 01.0247 12.86 030036 ..... 01.1393 18.23 040035 ..... 01.0240 10.24 050026 ..... 01.4525 21.79

010034 ..... 01.0751 13.48 010126 ..... 01.1770 13.13 030037 ..... 02.0161 19.60 040036 ..... 01.4976 16.45 050028 ..... 01.4395 15.33

010035 ..... 01.2397 15.13 010127 ..... 01.2999 16.29 030038 ..... 01.6125 18.82 040037 ..... 01.1101 11.55 050029 ..... 01.3830 25.55

010036 ..... 01.1252 15.34 010128 ..... 00.9565 12.34 030040 ..... 01.1885 15.88 040039 ..... 01.2411 12.23 050030 ..... 01.3324 19.24

010038 ..... 01.3397 16.48 010129 ..... 01.0795 13.29 030041 ..... 00.9963 13.68 040040 ..... 00.9953 15.73 050032 ..... 01.2735 22.76

010039 ..... 01.7029 16.14 010130 ..... 01.0352 15.28 030043 ..... 01.1937 18.25 040041 ..... 01.3946 13.95 050033 ..... 01.4136 25.47

010040 ..... 01.5335 18.21 010131 ..... 01.3636 17.75 030044 ..... 01.0291 13.19 040042 ..... 01.2978 12.03 050036 ..... 01.6162 18.61

010043 ..... 01.1036 10.35 010134 ..... 00.9206 13.36 030046 ..... 00.9134 16.38 040044 ..... 00.9622 10.04 050038 ..... 01.4553 29.05

010044 ..... 01.0919 11.01 010137 ..... 01.2516 16.36 030047 ..... 00.9471 19.91 040045 ..... 01.0301 14.28 050039 ..... 01.6127 21.04

010045 ..... 01.2121 10.79 010138 ..... 00.9485 09.85 030049 ..... 00.9741 17.30 040047 ..... 01.0939 14.78 050040 ..... 01.0842 22.92

010046 ..... 01.5291 15.51 010139 ..... 01.6592 19.67 030054 ..... 00.8723 12.63 040048 ..... 01.2149 13.48 050041 ..... 02.8656 22.21

010047 ..... 01.0243 10.05 010143 ..... 01.1921 15.83 030055 ..... 01.2014 16.85 040050 ..... 01.1013 11.66 050042 ..... 01.3081 20.20

010049 ..... 01.1121 15.66 010144 ..... 01.3104 18.42 030059 ..... 01.2776 19.95 040051 ..... 01.0923 12.64 050043 ..... 01.5723 30.15

010050 ..... 01.0635 13.48 010145 ..... 01.3376 14.59 030060 ..... 01.2095 13.90 040053 ..... 01.1093 11.67 050045 ..... 01.2649 17.11

010051 ..... 00.8549 10.24 010146 ..... 01.1772 15.59 030061 ..... 01.6462 16.75 040054 ..... 01.0301 12.44 050046 ..... 01.1888 23.81

010052 ..... 00.9858 12.78 010148 ..... 00.9969 12.83 030062 ..... 01.2267 15.56 040055 ..... 01.4506 14.51 050047 ..... 01.6388 29.15

010053 ..... 01.0653 12.67 010149 ..... 01.3527 17.75 030064 ..... 01.6191 16.92 040058 ..... 01.0617 13.61 050051 ..... 01.1104 16.63

010054 ..... 01.1726 16.17 010150 ..... 01.0473 16.29 030065 ..... 01.6407 18.87 040060 ..... 00.9896 09.85 050054 ..... 01.1961 20.55

010055 ..... 01.4846 16.35 010152 ..... 01.4762 16.29 030067 ..... 01.0515 15.92 040062 ..... 01.6181 16.66 050055 ..... 01.3742 27.54

010056 ..... 01.3970 17.99 010155 ..... 00.9996 09.42 030068 ..... 00.9514 14.04 040063 ..... 01.4673 15.67 050056 ..... 01.3374 25.23

010058 ..... 01.0881 12.96 020001 ..... 01.4712 25.53 030069 ..... 01.3354 19.11 040064 ..... 01.0523 10.49 050057 ..... 01.4835 20.22

010059 ..... 01.0165 14.17 020002 ..... 01.0281 24.16 030071 ..... 00.9488 .......... 040066 ..... 01.1537 14.63 050058 ..... 01.4664 22.78

010061 ..... 01.0127 14.70 020004 ..... 01.1028 25.46 030072 ..... 00.9090 .......... 040067 ..... 01.0801 11.34 050060 ..... 01.5897 24.25

010062 ..... 01.0042 13.45 020005 ..... 00.9029 28.36 030073 ..... 00.9752 .......... 040069 ..... 01.1090 14.90 050061 ..... 01.4258 22.12

010064 ..... 01.7890 17.85 020006 ..... 01.1418 23.19 030074 ..... 00.8587 .......... 040070 ..... 00.9433 14.98 050063 ..... 01.4029 21.44

010065 ..... 01.3668 14.30 020007 ..... 00.8909 21.82 030075 ..... 00.8660 .......... 040071 ..... 01.5932 15.42 050065 ..... 01.6064 22.37

010066 ..... 00.9789 10.87 020008 ..... 01.1006 26.45 030076 ..... 00.9802 .......... 040072 ..... 01.0871 13.40 050066 ..... 01.2689 24.33

010068 ..... 01.2370 18.82 020009 ..... 00.9255 21.29 030077 ..... 00.8761 .......... 040074 ..... 01.2566 14.51 050067 ..... 01.3777 21.09

010069 ..... 01.1589 13.06 020010 ..... 00.9141 22.13 030078 ..... 01.1027 .......... 040075 ..... 01.0668 11.57 050068 ..... 01.0839 19.05

010072 ..... 01.2161 12.72 020011 ..... 01.0488 22.27 030079 ..... 00.7787 .......... 040076 ..... 01.0273 14.71 050069 ..... 01.6183 23.15

010073 ..... 00.9701 09.66 020012 ..... 01.3062 23.99 030080 ..... 01.6564 20.82 040077 ..... 00.9196 10.72 050070 ..... 01.2901 30.80

010078 ..... 01.1795 15.04 020013 ..... 01.0055 24.03 030083 ..... 01.3106 21.70 040078 ..... 01.4945 17.29 050071 ..... 01.3159 30.70

010079 ..... 01.2807 12.53 020014 ..... 01.0769 24.52 030084 ..... 00.9358 .......... 040080 ..... 01.0752 15.45 050072 ..... 01.3053 31.00

010080 ..... 01.0389 12.99 020017 ..... 01.5181 26.83 030085 ..... 01.5045 20.21 040081 ..... 00.9285 09.91 050073 ..... 01.3239 31.41

010081 ..... 01.9832 16.16 020018 ..... 00.8963 .......... 030086 ..... 01.3209 18.76 040082 ..... 01.2156 13.69 050074 ..... 01.2314 32.96

010083 ..... 01.0377 13.25 020019 ..... 00.8718 .......... 030087 ..... 01.6153 18.77 040084 ..... 01.0963 14.83 050075 ..... 01.4037 30.72

010084 ..... 01.4816 16.61 020020 ..... 00.8398 .......... 030088 ..... 01.3513 19.90 040085 ..... 01.2493 15.18 050076 ..... 01.7756 29.65

010085 ..... 01.3233 17.11 020021 ..... 00.8478 .......... 030089 ..... 01.5736 18.66 040088 ..... 01.3091 13.73 050077 ..... 01.6152 22.83

010086 ..... 01.0507 13.54 020024 ..... 01.0693 22.64 030092 ..... 01.5590 20.62 040090 ..... 00.8983 13.78 050078 ..... 01.3591 24.44

010087 ..... 01.6243 16.88 020025 ..... 01.0046 24.44 030093 ..... 01.3791 18.08 040091 ..... 01.2930 18.25 050079 ..... 01.5938 28.30

010089 ..... 01.1934 14.91 020026 ..... 01.3340 .......... 030094 ..... 01.2494 18.57 040093 ..... 00.9598 10.98 050080 ..... 01.2183 22.05

010090 ..... 01.5725 16.40 020027 ..... 00.9975 .......... 030095 ..... 01.2183 13.09 040095 ..... 00.9069 10.56 050081 ..... 01.6564 24.01

010091 ..... 00.9195 13.43 030001 ..... 01.3076 19.28 040001 ..... 01.1308 12.37 040100 ..... 01.2465 12.81 050082 ..... 01.4989 21.34

010092 ..... 01.4209 15.17 030002 ..... 01.7918 20.25 040002 ..... 01.1644 13.07 040105 ..... 01.0068 11.90 050084 ..... 01.5611 22.33

010094 ..... 01.1410 16.76 030003 ..... 01.8923 21.05 040003 ..... 01.0704 13.19 040106 ..... 01.2448 12.84 050088 ..... 01.1538 21.94
27506 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

PAGE 2 OF 16

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

050089 ..... 01.3485 19.92 050189 ..... 00.9777 21.50 050296 ..... 01.2071 22.69 050420 ..... 01.4424 25.15 050545 ..... 00.8420 20.39

050090 ..... 01.2755 21.75 050191 ..... 01.5032 20.64 050298 ..... 01.3081 20.18 050421 ..... 01.4112 24.62 050546 ..... 00.7212 21.10

050091 ..... 01.1984 24.42 050192 ..... 01.1071 18.74 050299 ..... 01.3607 22.49 050423 ..... 00.9821 19.25 050547 ..... 00.9602 20.65

050092 ..... 00.8504 16.19 050193 ..... 01.3631 22.56 050300 ..... 01.3100 18.87 050424 ..... 01.8316 22.16 050549 ..... 01.7182 25.86

050093 ..... 01.5917 22.35 050194 ..... 01.2409 25.03 050301 ..... 01.3825 21.54 050425 ..... 01.2719 30.41 050550 ..... 02.3168 23.34

050096 ..... 01.1244 12.95 050195 ..... 01.5876 31.29 050302 ..... 01.4049 24.31 050426 ..... 01.3055 23.89 050551 ..... 01.3473 24.20

050097 ..... 01.5025 18.40 050196 ..... 01.4205 16.40 050305 ..... 01.5824 29.82 050430 ..... 00.9919 15.94 050552 ..... 01.1633 22.44

050099 ..... 01.4660 22.91 050197 ..... 01.8278 29.07 050307 ..... 01.4439 20.51 050431 ..... 01.0836 22.58 050557 ..... 01.4928 21.08

050100 ..... 01.6910 29.38 050199 ..... 00.8980 19.48 050308 ..... 01.5797 29.77 050432 ..... 01.5774 23.69 050559 ..... 01.3672 24.18

050101 ..... 01.3999 25.12 050204 ..... 01.4910 23.12 050309 ..... 01.3306 23.63 050433 ..... 01.0327 17.37 050560 ..... 01.1894 ..........

050102 ..... 01.4714 22.34 050205 ..... 01.3876 19.99 050310 ..... 01.2239 22.24 050434 ..... 01.1491 18.08 050561 ..... 01.2110 30.34

050103 ..... 01.6097 26.74 050207 ..... 01.2860 20.58 050312 ..... 01.9820 23.66 050435 ..... 01.2411 18.98 050564 ..... 01.2109 24.02

050104 ..... 01.3906 21.73 050208 ..... 00.9572 27.63 050313 ..... 01.1891 20.90 050436 ..... 01.0099 15.77 050565 ..... 01.1456 21.26

050107 ..... 01.4355 22.92 050211 ..... 01.3142 29.60 050315 ..... 01.1826 20.75 050438 ..... 01.6261 23.33 050566 ..... 00.8791 19.75

050108 ..... 01.5819 22.78 050213 ..... 01.3924 21.12 050317 ..... 01.3583 20.90 050440 ..... 01.4107 19.93 050567 ..... 01.6543 23.01

050109 ..... 02.3436 24.68 050214 ..... 01.4409 21.76 050320 ..... 01.3185 27.27 050441 ..... 01.9214 28.10 050568 ..... 01.4314 18.28

050110 ..... 01.2436 18.72 050215 ..... 01.5216 27.75 050324 ..... 01.8339 25.93 050443 ..... 00.9533 15.95 050569 ..... 01.3545 22.93

050111 ..... 01.3786 18.81 050217 ..... 01.3730 18.44 050325 ..... 01.2554 20.87 050444 ..... 01.3479 22.19 050570 ..... 01.7026 24.91

050112 ..... 01.5234 22.15 050219 ..... 01.3115 20.37 050327 ..... 01.5839 21.00 050446 ..... 00.8936 17.25 050571 ..... 01.4016 22.37

050113 ..... 01.2749 28.23 050222 ..... 01.5916 24.56 050328 ..... 01.4584 32.92 050447 ..... 01.0883 18.59 050573 ..... 01.6412 23.66

050114 ..... 01.3978 21.65 050224 ..... 01.5471 22.17 050329 ..... 01.3142 20.34 050448 ..... 01.1113 19.82 050575 ..... 01.2303 ..........

050115 ..... 01.6146 21.11 050225 ..... 01.3284 20.67 050331 ..... 01.4090 27.22 050449 ..... 01.3527 21.99 050577 ..... 01.3652 20.32

050116 ..... 01.4542 22.73 050226 ..... 01.3349 22.58 050333 ..... 00.9767 18.66 050454 ..... 01.8309 26.10 050578 ..... 01.1731 23.70

050117 ..... 01.2871 20.93 050228 ..... 01.3665 29.90 050334 ..... 01.7683 28.22 050455 ..... 01.9292 22.89 050579 ..... 01.5656 26.94

050118 ..... 01.2840 23.24 050230 ..... 01.2972 26.22 050335 ..... 01.2505 19.62 050456 ..... 01.1314 20.24 050580 ..... 01.3595 23.47

050121 ..... 01.4060 19.96 050231 ..... 01.6364 24.14 050336 ..... 01.3398 21.04 050457 ..... 01.9435 28.66 050581 ..... 01.4162 24.63

050122 ..... 01.7066 22.90 050232 ..... 01.7628 24.17 050337 ..... 01.1726 23.87 050459 ..... 01.1929 28.20 050583 ..... 01.5880 23.08

050124 ..... 01.2730 19.72 050233 ..... 01.2974 30.88 050342 ..... 01.3686 17.55 050464 ..... 01.8776 22.62 050584 ..... 01.2006 22.39

050125 ..... 01.3140 25.98 050234 ..... 01.3251 22.00 050343 ..... 01.0325 18.56 050468 ..... 01.4046 16.26 050585 ..... 01.2357 23.70

050126 ..... 01.4704 23.23 050235 ..... 01.5105 25.00 050348 ..... 01.6030 22.83 050469 ..... 01.0879 17.33 050586 ..... 01.3647 21.76

050127 ..... 01.2952 22.89 050236 ..... 01.6626 24.28 050349 ..... 00.8988 14.28 050470 ..... 01.1148 21.29 050588 ..... 01.3703 26.55

050128 ..... 01.5405 20.97 050238 ..... 01.4959 22.95 050350 ..... 01.3856 22.68 050471 ..... 01.7202 24.07 050589 ..... 01.3124 25.37

050129 ..... 01.5583 22.11 050239 ..... 01.5085 21.24 050351 ..... 01.4774 24.81 050476 ..... 01.3437 19.12 050590 ..... 01.4086 23.00

050131 ..... 01.2652 27.83 050240 ..... 01.3951 22.82 050352 ..... 01.2941 23.35 050477 ..... 01.5136 24.50 050591 ..... 01.2861 27.01

050132 ..... 01.4397 24.55 050241 ..... 01.2374 25.78 050353 ..... 01.5622 21.45 050478 ..... 00.9225 21.73 050592 ..... 01.3408 20.34

050133 ..... 01.3513 20.16 050242 ..... 01.4698 27.10 050355 ..... 00.9696 15.53 050481 ..... 01.4166 24.85 050593 ..... 01.5583 24.40

050135 ..... 01.3794 26.86 050243 ..... 01.5323 21.58 050357 ..... 01.7247 23.17 050482 ..... 00.9451 14.55 050594 ..... 02.0151 23.81

050136 ..... 01.3772 22.75 050245 ..... 01.3837 21.74 050359 ..... 01.2172 18.78 050483 ..... 01.1666 23.89 050597 ..... 01.2786 21.91

050137 ..... 01.3802 31.46 050248 ..... 01.2124 24.50 050360 ..... 01.4656 30.15 050485 ..... 01.6275 22.34 050598 ..... 01.3940 26.87

050138 ..... 01.8728 32.07 050251 ..... 01.0753 17.68 050366 ..... 01.3174 20.47 050486 ..... 01.4180 24.94 050599 ..... 01.6829 22.70

050139 ..... 01.3396 31.14 050253 ..... 00.7232 18.87 050367 ..... 01.2881 27.02 050488 ..... 01.3879 30.41 050601 ..... 01.3075 29.03

050140 ..... 01.4139 30.76 050254 ..... 01.1940 22.13 050369 ..... 01.3323 23.30 050489 ..... 00.9718 27.10 050603 ..... 01.4252 23.50

050144 ..... 01.5835 26.03 050256 ..... 01.7700 19.70 050373 ..... 01.3964 23.83 050491 ..... 01.2797 23.76 050604 ..... 01.5933 29.56

050145 ..... 01.3571 27.67 050257 ..... 01.0715 20.65 050376 ..... 01.3932 25.86 050492 ..... 01.2458 23.05 050607 ..... 01.3006 21.79

050146 ..... 01.3245 .......... 050260 ..... 01.0965 21.96 050377 ..... 00.9012 15.01 050494 ..... 01.1674 24.95 050608 ..... 01.3067 15.23

050147 ..... 00.6896 20.55 050261 ..... 01.1927 17.91 050378 ..... 01.0814 22.45 050496 ..... 01.7959 31.60 050609 ..... 01.4365 31.39

050148 ..... 01.1273 19.62 050262 ..... 01.9179 26.89 050379 ..... 01.0921 19.04 050497 ..... 00.7948 .......... 050613 ..... 01.1496 22.70

050149 ..... 01.4339 19.87 050263 ..... 01.2879 24.24 050380 ..... 01.6703 28.31 050498 ..... 01.2636 22.42 050615 ..... 01.6939 23.31

050150 ..... 01.2565 23.23 050264 ..... 01.3732 26.01 050382 ..... 01.4511 20.97 050502 ..... 01.6551 23.61 050616 ..... 01.2953 20.68

050152 ..... 01.4301 24.60 050267 ..... 01.5239 24.88 050385 ..... 01.3960 24.83 050503 ..... 01.2916 23.01 050618 ..... 01.0619 19.36

050153 ..... 01.6384 30.53 050270 ..... 01.2432 23.60 050388 ..... 00.9028 14.19 050506 ..... 01.4122 25.57 050623 ..... 01.1349 24.40

050155 ..... 01.1043 23.60 050272 ..... 01.3296 19.69 050390 ..... 01.2211 20.80 050510 ..... 01.3632 30.59 050624 ..... 01.3670 25.95

050158 ..... 01.6805 27.88 050274 ..... 00.9624 18.36 050391 ..... 01.2785 21.61 050512 ..... 01.4686 31.38 050625 ..... 01.6096 24.00

050159 ..... 01.2651 22.01 050276 ..... 01.2223 26.99 050392 ..... 00.9426 17.56 050515 ..... 01.3589 30.78 050630 ..... 01.3621 21.26

050167 ..... 01.4551 21.67 050277 ..... 01.3817 21.30 050393 ..... 01.4157 21.56 050516 ..... 01.6670 24.33 050633 ..... 01.2959 21.76

050168 ..... 01.6003 24.83 050278 ..... 01.5174 23.01 050394 ..... 01.5428 20.71 050517 ..... 01.2879 19.15 050635 ..... 01.4145 31.17

050169 ..... 01.5891 24.53 050279 ..... 01.2461 20.58 050396 ..... 01.6157 21.89 050522 ..... 01.3128 30.40 050636 ..... 01.4311 20.28

050170 ..... 01.5175 21.58 050280 ..... 01.6551 22.80 050397 ..... 01.0118 19.97 050523 ..... 01.2703 27.65 050638 ..... 01.1002 24.28

050172 ..... 01.2609 19.96 050281 ..... 01.4519 22.74 050401 ..... 01.1174 19.09 050526 ..... 01.3687 24.28 050641 ..... 01.2473 12.26

050173 ..... 01.2203 23.70 050282 ..... 01.3433 21.42 050404 ..... 01.1443 16.51 050528 ..... 01.3542 16.46 050643 ..... 00.7832 ..........

050174 ..... 01.6873 27.89 050283 ..... 01.1267 27.59 050406 ..... 01.1263 15.29 050531 ..... 01.3012 23.60 050644 ..... 00.9053 26.86

050175 ..... 01.3926 21.97 050286 ..... 01.0350 17.99 050407 ..... 01.3254 27.06 050534 ..... 01.3853 23.83 050660 ..... 01.3428 ..........

050177 ..... 01.2994 18.76 050289 ..... 01.7845 27.38 050410 ..... 01.0706 17.45 050535 ..... 01.3827 22.46 050661 ..... 00.8831 20.21

050179 ..... 01.2600 17.29 050290 ..... 01.6330 32.31 050411 ..... 01.4042 29.35 050537 ..... 01.2622 21.30 050662 ..... 00.8549 21.17

050180 ..... 01.5539 30.12 050291 ..... 01.2553 24.46 050414 ..... 01.2846 24.32 050539 ..... 01.2184 21.90 050663 ..... 01.0604 23.51

050183 ..... 01.1940 19.09 050292 ..... 01.0963 21.20 050417 ..... 01.3037 19.65 050541 ..... 01.5870 31.06 050666 ..... 00.7423 23.76

050186 ..... 01.2694 24.12 050293 ..... 01.1312 19.93 050418 ..... 01.4191 24.24 050542 ..... 01.2270 13.79 050667 ..... 01.0672 24.88

050188 ..... 01.3467 25.25 050295 ..... 01.4144 20.86 050419 ..... 01.3136 18.88 050543 ..... 00.9214 21.68 050668 ..... 01.1532 28.20
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27507

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050670 ..... 00.7582 20.12 060046 ..... 01.1205 16.56 080005 ..... 01.3363 16.82 100071 ..... 01.3024 16.98 100167 ..... 01.3944 20.55

050672 ..... 00.6267 23.77 060047 ..... 00.9606 11.40 080006 ..... 01.3822 20.49 100072 ..... 01.2515 17.24 100168 ..... 01.3799 19.35

050674 ..... 01.2111 29.18 060049 ..... 01.3511 17.47 080007 ..... 01.3620 17.99 100073 ..... 01.7938 20.61 100169 ..... 01.8590 18.29

050675 ..... 01.7056 16.32 060050 ..... 01.1719 14.62 090001 ..... 01.4216 19.65 100075 ..... 01.6403 17.85 100170 ..... 01.4917 16.50

050676 ..... 00.9864 13.83 060052 ..... 01.0999 18.38 090002 ..... 01.3022 20.51 100076 ..... 01.3869 17.15 100172 ..... 01.3694 13.38

050677 ..... 01.4253 32.99 060053 ..... 00.9988 13.73 090003 ..... 01.3041 24.74 100077 ..... 01.3153 16.78 100173 ..... 01.6691 16.33

050678 ..... 01.0713 24.07 060054 ..... 01.3361 16.74 090004 ..... 01.7168 23.49 100078 ..... 01.1683 15.14 100174 ..... 01.5295 18.20

050680 ..... 01.2114 26.13 060056 ..... 00.9577 13.37 090005 ..... 01.3431 27.07 100079 ..... 01.7501 16.01 100175 ..... 01.2130 16.18

050682 ..... 00.8558 14.98 060057 ..... 01.0356 21.11 090006 ..... 01.3749 19.52 100080 ..... 01.6306 19.40 100176 ..... 02.0431 21.95

050684 ..... 01.2074 21.30 060058 ..... 00.9237 12.54 090007 ..... 01.3832 19.58 100081 ..... 01.1202 13.33 100177 ..... 01.3403 18.55

050685 ..... 01.2219 26.94 060060 ..... 00.9651 12.21 090008 ..... 01.5276 24.06 100082 ..... 01.5459 17.93 100179 ..... 01.6520 19.03

050686 ..... 01.3503 30.96 060062 ..... 00.9518 15.85 090010 ..... 01.0013 21.70 100083 ..... 01.3240 17.30 100180 ..... 01.4188 17.49

050688 ..... 01.2730 27.89 060063 ..... 01.0264 11.12 090011 ..... 01.9804 24.77 100084 ..... 01.5314 16.53 100181 ..... 01.2846 17.59

050689 ..... 01.3988 29.12 060064 ..... 01.4325 20.21 090015 ..... 01.3306 .......... 100085 ..... 01.4349 19.50 100183 ..... 01.3710 19.18

050690 ..... 01.4363 30.39 060065 ..... 01.3463 19.98 100001 ..... 01.5247 18.83 100086 ..... 01.3328 21.32 100186 ..... 01.4758 16.70

050693 ..... 01.9152 28.80 060066 ..... 00.9950 13.10 100002 ..... 01.4789 19.71 100087 ..... 01.8071 20.71 100187 ..... 01.4501 18.35

050694 ..... 01.3678 21.20 060068 ..... 01.2760 14.00 100004 ..... 01.0274 11.81 100088 ..... 01.6730 17.32 100189 ..... 01.3707 23.13

050695 ..... 01.1808 24.30 060070 ..... 01.0357 14.99 100005 ..... 01.0178 16.26 100090 ..... 01.4256 16.07 100191 ..... 01.3315 19.19

050696 ..... 02.0076 27.85 060071 ..... 01.2259 14.69 100006 ..... 01.5531 18.99 100092 ..... 01.4411 16.20 100199 ..... 01.4473 21.29

050697 ..... 01.1093 17.93 060073 ..... 01.0017 14.32 100007 ..... 01.8477 19.61 100093 ..... 01.5156 14.28 100200 ..... 01.3972 21.35

050698 ..... 01.1189 22.83 060075 ..... 01.3472 20.27 100008 ..... 01.7361 19.80 100098 ..... 01.1482 17.43 100203 ..... 01.2603 19.34

050699 ..... 00.5855 23.13 060076 ..... 01.3675 15.97 100009 ..... 01.5641 17.89 100099 ..... 01.2518 13.09 100204 ..... 01.6232 19.95

050700 ..... 01.4412 32.46 060085 ..... 00.9819 10.94 100010 ..... 01.5475 20.58 100102 ..... 01.1033 16.44 100206 ..... 01.3458 19.47

050701 ..... 01.3170 27.13 060087 ..... 01.6558 18.67 100012 ..... 01.6776 16.91 100103 ..... 01.1730 14.46 100207 ..... 01.4710 19.86

050702 ..... 00.8637 16.98 060088 ..... 01.0388 15.38 100014 ..... 01.4272 18.57 100105 ..... 01.4697 18.08 100208 ..... 01.6409 21.14

050704 ..... 01.2140 20.48 060090 ..... 00.9518 14.23 100015 ..... 01.2444 17.60 100106 ..... 01.0395 15.46 100209 ..... 01.6671 ..........

050706 ..... 00.9234 16.16 060096 ..... 00.9724 21.69 100017 ..... 01.6489 17.18 100107 ..... 01.4676 18.26 100210 ..... 01.6647 16.51

050707 ..... 01.2237 25.62 060100 ..... 01.4045 20.95 100018 ..... 01.2869 19.94 100108 ..... 01.1017 15.45 100211 ..... 01.3441 19.17

050708 ..... 00.9493 15.13 060103 ..... 01.2269 21.10 100019 ..... 01.4930 18.81 100109 ..... 01.3522 16.81 100212 ..... 01.6646 18.54

050709 ..... 01.3030 .......... 060104 ..... 01.3213 20.32 100020 ..... 01.3365 18.31 100110 ..... 01.4128 18.91 100213 ..... 01.5438 20.00

050710 ..... 01.4014 .......... 070001 ..... 01.7582 24.78 100022 ..... 01.8009 23.05 100112 ..... 00.9738 10.84 100217 ..... 01.3055 17.06

050711 ..... 02.3868 .......... 070002 ..... 01.8728 24.78 100023 ..... 01.3489 15.88 100113 ..... 02.0848 18.19 100220 ..... 01.9563 19.66

050712 ..... 02.1147 .......... 070003 ..... 01.1239 24.50 100024 ..... 01.3583 19.54 100114 ..... 01.4930 17.73 100221 ..... 01.5644 20.68

060001 ..... 01.5550 18.95 070004 ..... 01.1696 23.70 100025 ..... 01.8825 16.22 100117 ..... 01.3334 18.18 100222 ..... 01.3723 18.80

060003 ..... 01.2961 15.85 070005 ..... 01.3792 25.45 100026 ..... 01.6477 15.52 100118 ..... 01.2737 16.03 100223 ..... 01.4892 18.53

060004 ..... 01.2624 19.46 070006 ..... 01.3529 26.73 100027 ..... 00.9736 11.53 100121 ..... 01.3068 15.44 100224 ..... 01.4648 19.77

060006 ..... 01.1955 16.19 070007 ..... 01.3475 24.08 100028 ..... 01.2678 16.38 100122 ..... 01.4565 16.39 100225 ..... 01.3368 19.52

060007 ..... 01.1900 13.06 070008 ..... 01.3124 23.47 100029 ..... 01.4029 18.94 100124 ..... 01.3643 19.41 100226 ..... 01.3383 16.58

060008 ..... 01.0198 14.31 070009 ..... 01.2830 25.01 100030 ..... 01.2690 18.25 100125 ..... 01.1630 17.77 100228 ..... 01.2947 21.09

060009 ..... 01.4621 19.88 070010 ..... 01.5535 22.46 100032 ..... 01.9188 17.39 100126 ..... 01.4954 18.74 100229 ..... 01.3211 16.27

060010 ..... 01.5276 21.10 070011 ..... 01.3259 22.80 100034 ..... 01.7338 18.34 100127 ..... 01.6870 17.42 100230 ..... 01.5471 18.97

060011 ..... 01.3023 20.75 070012 ..... 01.2576 23.38 100035 ..... 01.6138 16.46 100128 ..... 02.2417 20.13 100231 ..... 01.6613 17.46

060012 ..... 01.3852 15.79 070013 ..... 01.2822 24.01 100038 ..... 01.5951 21.18 100129 ..... 01.2509 17.45 100232 ..... 01.2675 17.64

060013 ..... 01.2654 18.83 070015 ..... 01.3569 23.82 100039 ..... 01.7158 21.15 100130 ..... 01.2008 17.45 100234 ..... 01.5324 19.03

060014 ..... 01.6915 20.52 070016 ..... 01.3194 25.46 100040 ..... 01.6731 16.31 100131 ..... 01.3922 18.44 100235 ..... 01.4827 17.51

060015 ..... 01.5657 19.33 070017 ..... 01.3781 23.54 100043 ..... 01.4570 17.78 100132 ..... 01.4189 15.67 100236 ..... 01.4442 13.79

060016 ..... 01.0954 11.42 070018 ..... 01.3719 27.83 100044 ..... 01.5045 19.01 100134 ..... 01.0741 14.50 100237 ..... 02.1446 22.65

060018 ..... 01.2199 16.36 070019 ..... 01.2169 24.04 100045 ..... 01.4032 17.12 100135 ..... 01.5224 16.11 100238 ..... 01.4858 18.68

060020 ..... 01.5176 16.73 070020 ..... 01.3709 24.32 100046 ..... 01.5110 18.53 100137 ..... 01.3279 18.42 100239 ..... 01.4622 19.34

060022 ..... 01.6695 17.89 070021 ..... 01.2987 25.47 100047 ..... 01.9163 18.62 100138 ..... 00.9478 13.00 100240 ..... 00.8437 15.06

060023 ..... 01.6463 16.65 070022 ..... 01.7641 24.30 100048 ..... 01.0025 11.69 100139 ..... 01.0496 14.54 100241 ..... 00.9433 12.47

060024 ..... 01.8181 22.01 070024 ..... 01.3541 23.81 100049 ..... 01.3263 18.03 100140 ..... 01.2518 16.87 100242 ..... 01.4135 16.29

060026 ..... 01.4223 19.44 070025 ..... 01.7842 24.06 100050 ..... 01.2227 15.06 100142 ..... 01.2004 16.68 100243 ..... 01.4119 18.82

060027 ..... 01.6577 19.01 070026 ..... 01.2223 23.07 100051 ..... 01.1532 16.60 100144 ..... 01.1466 13.65 100244 ..... 01.4339 17.32

060028 ..... 01.4947 21.29 070027 ..... 01.2599 24.31 100052 ..... 01.3772 15.60 100145 ..... 01.3481 14.87 100246 ..... 01.3465 20.92

060029 ..... 00.9485 13.93 070028 ..... 01.4783 24.67 100053 ..... 01.2886 17.36 100146 ..... 01.2770 14.27 100248 ..... 01.6989 17.88

060030 ..... 01.3165 20.36 070029 ..... 01.3524 21.65 100054 ..... 01.2923 17.44 100147 ..... 01.0996 13.43 100249 ..... 01.3543 18.87

060031 ..... 01.6115 18.95 070030 ..... 01.2990 24.71 100055 ..... 01.3679 17.47 100150 ..... 01.3759 18.64 100252 ..... 01.2419 19.21

060032 ..... 01.5777 19.35 070031 ..... 01.2706 22.24 100056 ..... 01.4655 19.83 100151 ..... 01.8572 18.63 100253 ..... 01.4755 20.60

060033 ..... 01.1561 11.96 070033 ..... 01.2881 28.25 100057 ..... 01.3455 16.78 100154 ..... 01.5689 17.95 100254 ..... 01.5854 17.50

060034 ..... 01.4958 16.90 070034 ..... 01.3752 24.74 100060 ..... 01.8491 17.71 100156 ..... 01.2204 18.65 100255 ..... 01.3322 19.00

060036 ..... 01.1712 14.37 070035 ..... 01.3469 24.31 100061 ..... 01.5100 20.88 100157 ..... 01.6134 19.31 100256 ..... 01.8955 19.32

060037 ..... 01.0382 13.22 070036 ..... 01.4320 26.98 100062 ..... 01.7185 16.94 100159 ..... 00.9856 12.76 100258 ..... 01.6509 21.12

060038 ..... 01.0192 12.25 070039 ..... 00.9213 .......... 100063 ..... 01.3423 16.12 100160 ..... 01.1059 18.07 100259 ..... 01.4493 16.36

060041 ..... 00.9203 16.53 080001 ..... 01.6101 23.66 100067 ..... 01.4267 16.38 100161 ..... 01.5194 19.76 100260 ..... 01.4016 20.44

060042 ..... 01.0532 18.49 080002 ..... 01.1904 17.32 100068 ..... 01.3880 17.42 100162 ..... 01.3924 14.53 100262 ..... 01.4109 19.32

060043 ..... 00.9506 11.78 080003 ..... 01.3137 19.32 100069 ..... 01.3653 17.29 100165 ..... 01.2958 13.45 100263 ..... 01.3896 15.44

060044 ..... 01.2631 17.32 080004 ..... 01.2871 17.59 100070 ..... 01.4420 17.56 100166 ..... 01.4618 20.31 100264 ..... 01.3958 18.24
27508 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

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100265 ..... 01.3686 17.47 110063 ..... 01.0768 11.44 110156 ..... 01.0003 12.68 130011 ..... 01.2386 16.74 140045 ..... 01.0555 14.21

100266 ..... 01.2337 15.64 110064 ..... 01.2883 15.87 110161 ..... 01.3328 20.79 130012 ..... 01.0233 18.53 140046 ..... 01.3023 14.83

100267 ..... 01.3092 16.39 110065 ..... 01.0143 12.00 110162 ..... 00.8588 .......... 130013 ..... 01.2416 17.21 140047 ..... 01.1406 13.20

100268 ..... 01.1990 22.00 110066 ..... 01.4374 16.30 110163 ..... 01.4549 18.52 130014 ..... 01.3094 16.43 140048 ..... 01.2744 21.50

100269 ..... 01.3605 19.07 110069 ..... 01.1706 15.22 110164 ..... 01.4190 19.63 130015 ..... 00.8608 12.43 140049 ..... 01.5796 19.35

100270 ..... 00.8185 12.95 110070 ..... 01.1733 11.37 110165 ..... 01.3107 17.47 130016 ..... 00.9300 16.18 140051 ..... 01.4912 19.14

100271 ..... 01.6614 19.27 110071 ..... 01.0308 10.29 110166 ..... 01.4995 16.67 130017 ..... 01.3710 13.03 140052 ..... 01.3150 16.77

100273 ..... 00.5356 19.72 110072 ..... 01.0243 11.53 110168 ..... 01.6538 19.22 130018 ..... 01.7015 17.60 140053 ..... 01.8914 17.88

100275 ..... 01.4206 21.96 110073 ..... 01.2050 12.67 110169 ..... 00.7308 19.70 130019 ..... 01.1172 13.74 140054 ..... 01.3616 26.25

100276 ..... 01.3027 21.94 110074 ..... 01.4803 18.11 110171 ..... 01.4451 21.21 130021 ..... 01.0324 11.96 140055 ..... 00.9382 13.00

100277 ..... 01.0093 12.71 110075 ..... 01.2149 15.29 110172 ..... 01.3290 22.83 130022 ..... 01.1917 15.44 140058 ..... 01.2318 15.26

100279 ..... 01.3786 18.35 110076 ..... 01.3902 18.01 110174 ..... 01.0473 17.57 130024 ..... 01.0580 15.25 140059 ..... 01.1334 13.52

100280 ..... 01.3831 16.93 110078 ..... 01.6637 20.46 110176 ..... 01.1251 19.42 130025 ..... 01.1537 15.21 140061 ..... 01.0878 13.80

100281 ..... 01.2517 20.85 110079 ..... 01.3869 21.08 110177 ..... 01.4857 19.21 130026 ..... 01.1747 17.89 140062 ..... 01.2451 23.10

100282 ..... 01.0482 16.99 110080 ..... 01.1544 16.86 110178 ..... 01.3702 16.78 130027 ..... 00.9528 17.18 140063 ..... 01.3960 22.48

100283 ..... 01.5478 .......... 110082 ..... 02.0163 20.36 110179 ..... 01.2381 21.56 130028 ..... 01.2515 16.08 140064 ..... 01.2951 16.15

110001 ..... 01.2914 17.40 110083 ..... 01.7255 20.66 110181 ..... 00.9860 12.59 130029 ..... 01.0268 17.07 140065 ..... 01.4926 23.68

110002 ..... 01.2397 14.83 110086 ..... 01.2253 13.74 110183 ..... 01.3704 19.70 130030 ..... 01.0243 16.20 140066 ..... 01.3711 13.39

110003 ..... 01.3129 15.41 110087 ..... 01.3386 19.17 110184 ..... 01.1715 17.58 130031 ..... 01.0201 13.26 140067 ..... 01.8194 18.24

110004 ..... 01.3118 16.17 110088 ..... 00.9740 11.17 110185 ..... 01.0833 12.23 130034 ..... 01.0393 16.38 140068 ..... 01.3583 19.00

110005 ..... 01.1872 21.40 110089 ..... 01.2146 15.37 110186 ..... 01.3060 15.97 130035 ..... 01.0736 15.37 140069 ..... 01.0029 14.23

110006 ..... 01.3597 18.00 110091 ..... 01.3449 19.15 110187 ..... 01.2469 17.19 130036 ..... 01.2609 12.50 140070 ..... 01.2830 16.18

110007 ..... 01.4425 15.69 110092 ..... 01.1821 12.55 110188 ..... 01.4186 18.00 130037 ..... 01.2616 14.58 140074 ..... 00.9704 14.60

110008 ..... 01.2405 15.47 110093 ..... 01.0096 09.81 110189 ..... 01.1327 19.78 130043 ..... 00.9469 14.61 140075 ..... 01.4685 21.53

110009 ..... 01.0377 15.71 110094 ..... 00.9542 12.06 110190 ..... 01.0859 14.41 130044 ..... 01.1660 12.37 140077 ..... 01.1503 17.05

110010 ..... 02.1503 21.39 110095 ..... 01.2750 13.86 110191 ..... 01.3482 18.06 130045 ..... 01.0284 12.15 140079 ..... 01.2410 20.90

110011 ..... 01.2868 16.01 110096 ..... 01.1414 14.30 110192 ..... 01.3977 22.17 130048 ..... 01.0663 11.90 140080 ..... 01.5779 19.60

110013 ..... 01.1312 14.36 110097 ..... 01.0166 15.58 110193 ..... 01.2300 16.16 130049 ..... 01.2960 17.55 140081 ..... 01.0821 13.92

110014 ..... 01.0340 14.48 110098 ..... 01.0881 11.76 110194 ..... 00.9644 11.77 130054 ..... 00.9683 17.12 140082 ..... 01.5059 22.10

110015 ..... 01.3622 16.52 110100 ..... 01.0968 12.27 110195 ..... 01.0844 10.50 130056 ..... 00.8652 09.45 140083 ..... 01.2600 16.51

110016 ..... 01.2991 14.21 110101 ..... 01.1035 09.24 110198 ..... 01.3316 22.58 130058 ..... 01.0150 12.87 140084 ..... 01.2248 17.94

110017 ..... 00.8897 11.01 110103 ..... 00.9630 10.35 110200 ..... 01.9437 15.79 130060 ..... 01.1458 18.38 140086 ..... 01.1464 13.93

110018 ..... 01.1357 17.20 110104 ..... 01.1073 13.28 110201 ..... 01.4531 16.13 130061 ..... 00.9513 .......... 140087 ..... 01.3852 17.10

110020 ..... 01.2352 17.30 110105 ..... 01.1304 15.17 110203 ..... 00.9692 14.94 140001 ..... 01.2958 14.63 140088 ..... 01.6480 23.33

110023 ..... 01.2361 17.53 110107 ..... 01.8146 17.59 110204 ..... 00.7960 13.48 140002 ..... 01.2776 17.04 140089 ..... 01.2253 15.85

110024 ..... 01.4802 18.74 110108 ..... 00.9720 11.27 110205 ..... 01.1080 11.84 140003 ..... 01.0184 13.14 140090 ..... 01.5101 23.62

110025 ..... 01.4157 16.85 110109 ..... 01.1115 12.14 110207 ..... 01.1008 15.59 140004 ..... 01.0799 13.75 140091 ..... 01.8655 17.70

110026 ..... 01.1891 13.87 110111 ..... 01.1934 14.70 110208 ..... 00.9734 14.94 140005 ..... 00.9511 09.98 140093 ..... 01.1961 17.17

110027 ..... 01.1013 14.56 110112 ..... 01.1522 15.06 110209 ..... 00.8222 .......... 140007 ..... 01.4675 20.56 140094 ..... 01.2905 18.81

110028 ..... 01.5984 17.75 110113 ..... 01.1384 12.86 120001 ..... 01.7331 24.22 140008 ..... 01.4859 20.57 140095 ..... 01.3991 ..........

110029 ..... 01.3374 17.71 110114 ..... 01.0749 13.75 120002 ..... 01.1971 21.46 140010 ..... 01.3888 22.14 140097 ..... 00.9102 14.15

110030 ..... 01.2807 16.60 110115 ..... 01.6188 21.82 120003 ..... 01.1450 21.82 140011 ..... 01.1465 15.31 140100 ..... 01.2229 17.62

110031 ..... 01.3367 19.58 110118 ..... 01.0422 13.18 120004 ..... 01.2653 20.56 140012 ..... 01.2840 17.59 140101 ..... 01.2108 18.04

110032 ..... 01.2298 15.31 110120 ..... 01.0800 13.35 120005 ..... 01.2656 18.34 140013 ..... 01.6579 16.49 140102 ..... 01.0422 14.09

110033 ..... 01.5204 20.32 110121 ..... 01.1802 11.84 120006 ..... 01.2116 22.75 140014 ..... 01.0745 16.31 140103 ..... 01.3357 16.66

110034 ..... 01.5019 16.64 110122 ..... 01.3550 16.03 120007 ..... 01.6278 20.27 140015 ..... 01.2937 13.45 140105 ..... 01.3085 18.25

110035 ..... 01.3991 18.53 110124 ..... 01.0703 15.32 120009 ..... 01.0061 18.05 140016 ..... 00.9317 11.59 140107 ..... 01.0869 11.63

110036 ..... 01.6840 22.81 110125 ..... 01.2217 15.97 120010 ..... 01.8369 22.11 140018 ..... 01.4564 18.85 140108 ..... 01.3663 20.00

110037 ..... 01.0904 10.18 110127 ..... 00.9066 14.43 120011 ..... 01.2382 30.31 140019 ..... 00.9926 11.80 140109 ..... 01.1410 12.95

110038 ..... 01.4674 15.04 110128 ..... 01.1920 17.54 120012 ..... 01.0209 20.30 140024 ..... 01.0178 13.59 140110 ..... 01.2359 14.51

110039 ..... 01.3709 17.93 110129 ..... 01.6749 13.01 120014 ..... 01.3556 21.25 140025 ..... 01.0795 15.88 140112 ..... 01.0953 13.55

110040 ..... 01.0270 16.26 110130 ..... 01.0721 10.57 120015 ..... 00.8375 21.01 140026 ..... 01.1409 15.58 140113 ..... 01.4647 19.21

110041 ..... 01.2250 16.43 110132 ..... 01.1433 12.87 120016 ..... 00.8558 21.94 140027 ..... 01.3182 15.96 140114 ..... 01.3202 18.95

110042 ..... 01.2103 14.63 110134 ..... 00.8944 11.65 120018 ..... 01.0071 21.16 140029 ..... 01.3782 19.62 140115 ..... 01.2339 19.32

110043 ..... 01.7167 15.17 110135 ..... 01.1981 13.83 120019 ..... 01.1834 19.48 140030 ..... 01.6711 21.46 140116 ..... 01.2862 19.68

110044 ..... 01.0960 14.31 110136 ..... 01.1213 13.57 120021 ..... 00.9888 19.68 140031 ..... 01.1749 13.02 140117 ..... 01.4895 17.63

110045 ..... 01.2388 22.04 110140 ..... 00.8182 15.03 120022 ..... 01.7240 17.83 140032 ..... 01.2531 16.44 140118 ..... 01.6767 22.66

110046 ..... 01.1993 15.07 110141 ..... 00.9067 11.65 120026 ..... 01.2802 22.30 140033 ..... 01.2640 19.10 140119 ..... 01.6872 19.58

110048 ..... 01.3128 12.97 110142 ..... 00.9806 11.15 120027 ..... 01.5395 21.16 140034 ..... 01.1800 16.74 140120 ..... 01.5073 14.72

110049 ..... 01.0704 13.71 110143 ..... 01.3994 20.07 130001 ..... 01.0424 17.21 140035 ..... 01.0305 10.70 140121 ..... 01.5215 10.91

110050 ..... 01.0669 14.00 110144 ..... 01.1678 16.44 130002 ..... 01.3774 14.66 140036 ..... 01.2388 15.03 140122 ..... 01.5566 21.02

110051 ..... 00.9865 16.35 110146 ..... 01.0299 09.43 130003 ..... 01.3112 18.11 140037 ..... 00.9794 12.24 140124 ..... 01.1139 23.06

110052 ..... 00.9774 09.11 110149 ..... 01.1319 12.17 130005 ..... 01.4396 18.19 140038 ..... 01.1510 15.00 140125 ..... 01.3450 15.60

110054 ..... 01.2816 16.57 110150 ..... 01.3658 16.56 130006 ..... 01.8983 18.19 140039 ..... 00.9224 11.51 140127 ..... 01.3522 16.83

110056 ..... 00.9765 12.61 110152 ..... 01.1295 13.06 130007 ..... 01.6434 18.60 140040 ..... 01.3093 14.34 140128 ..... 01.0595 16.10

110059 ..... 01.2900 14.39 110153 ..... 01.0212 15.33 130008 ..... 00.9857 10.28 140041 ..... 01.2320 15.01 140129 ..... 01.0555 13.18

110061 ..... 01.0143 10.61 110154 ..... 00.8337 12.68 130009 ..... 00.9627 14.78 140042 ..... 01.0524 13.30 140130 ..... 01.2738 21.67

110062 ..... 00.9181 09.73 110155 ..... 01.2376 12.27 130010 ..... 00.9403 15.04 140043 ..... 01.1790 16.37 140132 ..... 01.4146 18.58
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27509

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140133 ..... 01.3730 19.77 140230 ..... 00.9439 15.48 150043 ..... 01.0625 16.58 150127 ..... 01.0419 14.34 160069 ..... 01.4042 16.05

140135 ..... 01.3146 14.29 140231 ..... 01.6272 19.79 150044 ..... 01.2634 17.63 150128 ..... 01.2340 18.59 160070 ..... 01.0255 13.84

140137 ..... 01.0354 13.61 140233 ..... 01.7471 16.57 150045 ..... 01.0913 15.00 150129 ..... 01.1915 20.35 160072 ..... 01.0688 12.08

140138 ..... 00.9661 12.15 140234 ..... 01.1838 15.82 150046 ..... 01.5896 16.06 150130 ..... 01.1496 15.90 160073 ..... 01.0070 11.50

140139 ..... 01.0792 13.46 140236 ..... 01.0311 12.82 150047 ..... 01.6212 17.74 150132 ..... 01.3365 19.17 160074 ..... 01.1069 12.89

140140 ..... 01.1317 13.05 140239 ..... 01.5856 18.81 150048 ..... 01.1679 16.18 150133 ..... 01.2095 14.96 160075 ..... 01.1112 13.84

140141 ..... 00.8984 13.30 140240 ..... 01.5048 20.90 150049 ..... 01.0776 13.72 150134 ..... 01.2828 16.61 160076 ..... 01.0692 16.28

140143 ..... 01.0643 15.85 140242 ..... 01.5726 22.51 150050 ..... 01.1998 14.50 150136 ..... 00.9472 18.69 160077 ..... 01.1216 10.97

140144 ..... 00.9856 16.57 140245 ..... 01.1273 13.55 150051 ..... 01.3841 16.82 150138 ..... 01.1623 .......... 160079 ..... 01.4245 15.22

140145 ..... 01.2030 14.31 140246 ..... 01.0570 12.03 150052 ..... 01.0743 12.93 150139 ..... 01.4806 .......... 160080 ..... 01.2082 15.41

140146 ..... 00.9666 14.85 140250 ..... 01.3165 21.35 150053 ..... 01.0618 16.69 150141 ..... 01.0859 .......... 160081 ..... 01.0672 14.36

140147 ..... 01.1866 13.37 140251 ..... 01.3066 18.25 150054 ..... 01.1376 12.39 150142 ..... 02.4300 .......... 160082 ..... 01.7545 17.09

140148 ..... 01.8018 16.51 140252 ..... 01.4201 21.25 150056 ..... 01.6228 21.59 150897 ..... 04.9892 .......... 160083 ..... 01.5789 17.49

140150 ..... 01.5561 26.00 140253 ..... 01.4456 .......... 150057 ..... 02.3179 15.06 160001 ..... 01.2719 16.39 160085 ..... 01.0916 12.79

140151 ..... 01.1119 17.61 140258 ..... 01.5345 21.07 150058 ..... 01.6930 18.64 160002 ..... 01.1888 13.13 160086 ..... 01.0283 12.56

140152 ..... 01.0750 22.48 140271 ..... 01.0260 13.54 150059 ..... 01.3218 18.91 160003 ..... 01.0221 11.87 160088 ..... 01.0017 13.10

140155 ..... 01.1854 16.91 140275 ..... 01.2294 18.20 150060 ..... 01.1281 12.79 160005 ..... 01.1072 12.93 160089 ..... 01.1591 14.12

140158 ..... 01.2597 21.41 140276 ..... 01.9589 20.48 150061 ..... 01.2957 15.86 160007 ..... 01.0085 12.02 160090 ..... 01.0066 13.98

140160 ..... 01.2326 15.34 140280 ..... 01.2769 16.16 150062 ..... 01.0670 15.20 160008 ..... 01.1043 13.93 160091 ..... 01.0987 10.56

140161 ..... 01.1373 17.05 140281 ..... 01.6388 20.19 150063 ..... 01.0538 18.88 160009 ..... 01.1577 13.54 160092 ..... 00.9736 12.93

140162 ..... 01.7778 18.38 140285 ..... 01.2063 14.75 150064 ..... 01.2100 16.48 160012 ..... 01.0588 14.05 160093 ..... 01.1351 15.20

140164 ..... 01.2855 16.01 140286 ..... 01.1491 17.59 150065 ..... 01.1505 15.94 160013 ..... 01.2189 16.64 160094 ..... 01.2168 14.79

140165 ..... 01.1085 13.06 140288 ..... 01.7781 22.47 150066 ..... 01.0021 13.75 160014 ..... 01.0459 12.72 160095 ..... 01.0266 12.30

140166 ..... 01.2889 16.62 140289 ..... 01.3089 15.67 150067 ..... 01.1221 14.35 160016 ..... 01.2911 15.68 160097 ..... 01.0785 13.47

140167 ..... 01.1636 14.64 140290 ..... 01.3385 19.21 150069 ..... 01.2347 16.53 160018 ..... 00.9429 13.19 160098 ..... 01.0760 13.90

140168 ..... 01.1840 15.02 140291 ..... 01.2645 22.64 150070 ..... 01.0350 16.16 160020 ..... 01.0963 12.11 160099 ..... 00.9737 12.80

140170 ..... 01.1280 12.39 140292 ..... 01.1678 19.04 150071 ..... 01.1562 12.69 160021 ..... 01.0439 13.85 160101 ..... 01.1220 17.71

140171 ..... 00.9149 12.53 140294 ..... 01.1864 16.10 150072 ..... 01.1914 15.32 160023 ..... 01.1458 13.66 160102 ..... 01.3668 14.31

140172 ..... 01.5065 18.29 140297 ..... 01.2589 21.42 150073 ..... 01.0044 15.49 160024 ..... 01.5710 17.39 160103 ..... 01.0113 12.95

140173 ..... 00.9721 13.11 140300 ..... 01.6785 25.11 150074 ..... 01.5934 19.00 160026 ..... 01.0986 15.21 160104 ..... 01.2335 19.21

140174 ..... 01.4333 18.89 150001 ..... 01.0846 16.95 150075 ..... 01.2247 13.82 160027 ..... 01.1671 13.22 160106 ..... 01.0829 14.18

140176 ..... 01.2617 18.83 150002 ..... 01.4319 19.23 150076 ..... 01.1512 19.89 160028 ..... 01.3407 17.78 160107 ..... 01.1437 13.78

140177 ..... 01.2945 16.44 150003 ..... 01.7075 18.32 150077 ..... 01.2659 16.21 160029 ..... 01.4962 17.46 160108 ..... 01.1602 14.09

140179 ..... 01.3297 19.51 150004 ..... 01.4226 19.99 150078 ..... 01.0834 17.20 160030 ..... 01.2338 16.67 160109 ..... 01.1631 12.01

140180 ..... 01.5189 20.22 150005 ..... 01.1932 17.16 150079 ..... 01.1390 13.01 160031 ..... 01.1797 13.26 160110 ..... 01.4994 17.76

140181 ..... 01.3046 18.82 150006 ..... 01.2074 16.72 150082 ..... 01.4965 18.33 160032 ..... 01.1573 14.66 160111 ..... 01.1019 10.75

140182 ..... 01.3248 19.11 150007 ..... 01.2302 17.95 150084 ..... 01.8737 21.80 160033 ..... 01.7246 15.82 160112 ..... 01.4123 14.45

140184 ..... 01.1967 14.20 150008 ..... 01.3398 18.38 150086 ..... 01.3006 15.72 160034 ..... 01.0681 13.81 160113 ..... 00.9561 11.39

140185 ..... 01.4505 16.35 150009 ..... 01.3365 16.97 150088 ..... 01.1917 16.71 160035 ..... 00.9375 11.91 160114 ..... 01.0697 14.13

140186 ..... 01.3274 18.01 150010 ..... 01.2041 16.10 150089 ..... 01.3985 18.99 160036 ..... 01.0756 12.83 160115 ..... 01.0280 13.87

140187 ..... 01.4861 16.33 150011 ..... 01.2190 16.76 150090 ..... 01.2596 19.34 160037 ..... 01.1621 14.80 160116 ..... 01.1691 15.46

140188 ..... 00.9575 10.54 150012 ..... 01.6875 20.57 150091 ..... 01.0611 15.60 160039 ..... 01.0670 15.23 160117 ..... 01.3337 15.63

140189 ..... 01.1712 15.74 150013 ..... 01.1675 13.09 150092 ..... 01.0673 12.44 160040 ..... 01.3537 16.04 160118 ..... 01.0360 12.42

140190 ..... 01.1195 13.36 150014 ..... 01.4216 18.85 150094 ..... 01.0035 16.65 160041 ..... 01.0646 12.88 160120 ..... 01.0091 09.94

140191 ..... 01.3775 23.16 150015 ..... 01.2264 17.85 150095 ..... 01.1144 15.78 160043 ..... 01.0338 13.38 160122 ..... 01.1669 14.96

140192 ..... 01.1869 16.51 150017 ..... 01.8448 17.26 150096 ..... 01.0971 17.15 160044 ..... 01.1574 13.36 160123 ..... 01.1780 12.18

140193 ..... 01.0112 12.24 150018 ..... 01.2919 17.47 150097 ..... 01.1277 16.53 160045 ..... 01.6987 17.48 160124 ..... 01.2526 15.35

140197 ..... 01.2709 16.05 150019 ..... 01.1266 13.09 150098 ..... 01.1300 11.81 160046 ..... 01.0369 11.92 160126 ..... 01.1504 13.82

140199 ..... 01.0139 15.13 150020 ..... 01.1554 13.19 150099 ..... 01.3115 17.10 160047 ..... 01.3602 15.87 160129 ..... 01.0228 13.07

140200 ..... 01.4295 20.12 150021 ..... 01.6718 18.22 150100 ..... 01.6839 18.15 160048 ..... 01.0179 11.76 160130 ..... 01.1652 13.04

140202 ..... 01.3141 20.09 150022 ..... 01.1381 17.62 150101 ..... 01.0868 14.46 160049 ..... 00.9842 12.04 160131 ..... 01.1087 12.63

140203 ..... 01.1570 19.02 150023 ..... 01.4914 17.81 150102 ..... 01.0903 14.61 160050 ..... 01.0246 14.12 160134 ..... 00.9843 11.37

140205 ..... 00.9221 13.88 150024 ..... 01.4448 16.96 150103 ..... 01.0416 17.63 160051 ..... 00.9907 12.90 160135 ..... 01.0019 13.24

140206 ..... 01.0864 19.58 150025 ..... 01.4616 16.32 150104 ..... 01.1413 15.09 160052 ..... 01.0589 14.80 160138 ..... 01.0588 13.48

140207 ..... 01.3743 26.85 150026 ..... 01.1878 16.69 150105 ..... 01.4085 16.61 160054 ..... 01.0231 10.82 160140 ..... 01.0939 14.86

140208 ..... 01.6111 23.73 150027 ..... 01.0647 16.04 150106 ..... 01.1373 15.58 160055 ..... 01.0477 11.48 160142 ..... 01.0237 13.60

140209 ..... 01.7011 17.46 150029 ..... 01.2733 20.57 150109 ..... 01.4583 16.04 160056 ..... 01.0409 13.16 160143 ..... 01.1324 13.03

140210 ..... 01.0690 12.87 150030 ..... 01.1956 16.20 150110 ..... 00.9896 14.72 160057 ..... 01.3309 15.92 160145 ..... 01.0880 13.74

140211 ..... 01.2233 20.44 150031 ..... 01.0590 15.93 150111 ..... 01.2056 12.88 160058 ..... 01.6642 18.42 160146 ..... 01.4124 15.32

140212 ..... 01.3189 22.65 150032 ..... 01.7894 18.85 150112 ..... 01.2207 16.78 160060 ..... 01.0892 13.82 160147 ..... 01.2670 15.41

140213 ..... 01.2806 20.44 150033 ..... 01.6083 20.07 150113 ..... 01.1860 16.78 160061 ..... 01.0020 14.19 160151 ..... 01.0767 12.75

140215 ..... 01.1642 13.22 150034 ..... 01.3961 18.15 150114 ..... 01.0330 13.44 160062 ..... 00.9619 11.95 160152 ..... 01.0085 13.30

140217 ..... 01.2322 20.90 150035 ..... 01.4087 17.90 150115 ..... 01.3933 17.31 160063 ..... 01.2910 14.24 160153 ..... 01.7014 17.05

140218 ..... 01.0541 13.64 150036 ..... 01.0486 17.35 150122 ..... 01.1412 15.83 160064 ..... 01.6406 16.37 170001 ..... 01.2028 15.90

140220 ..... 01.1056 14.22 150037 ..... 01.2673 17.06 150123 ..... 01.1642 12.81 160065 ..... 01.0735 14.51 170004 ..... 01.0851 13.18

140223 ..... 01.5438 .......... 150038 ..... 01.2744 16.27 150124 ..... 01.1229 15.00 160066 ..... 01.1266 14.06 170006 ..... 01.2031 13.48

140224 ..... 01.3604 22.10 150039 ..... 01.0121 14.51 150125 ..... 01.4243 18.09 160067 ..... 01.3705 16.70 170008 ..... 00.9823 13.35

140228 ..... 01.7003 17.36 150042 ..... 01.2850 15.47 150126 ..... 01.5058 19.24 160068 ..... 01.1116 13.30 170009 ..... 01.1211 16.81
27510 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

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170010 ..... 01.2608 16.38 170090 ..... 01.1085 09.58 180012 ..... 01.3389 17.14 180104 ..... 01.5043 16.55 190064 ..... 01.5583 17.46

170011 ..... 01.4071 14.59 170092 ..... 00.8754 11.45 180013 ..... 01.4998 17.38 180105 ..... 00.9304 12.23 190065 ..... 01.4754 15.75

170012 ..... 01.4843 15.48 170093 ..... 00.9342 11.58 180014 ..... 01.6064 18.86 180106 ..... 00.9106 12.65 190071 ..... 00.8641 11.38

170013 ..... 01.3169 13.27 170094 ..... 01.0452 12.81 180015 ..... 01.2489 14.91 180108 ..... 00.8486 12.49 190077 ..... 00.9246 13.41

170014 ..... 01.0405 15.18 170095 ..... 01.0812 13.80 180016 ..... 01.3171 14.91 180115 ..... 01.0261 13.72 190078 ..... 01.1324 11.21

170015 ..... 00.9820 13.74 170097 ..... 01.0300 13.42 180017 ..... 01.2806 13.52 180116 ..... 01.3689 14.92 190079 ..... 01.2666 14.76

170016 ..... 01.6627 21.80 170098 ..... 01.0817 16.21 180018 ..... 01.2192 15.73 180117 ..... 01.1619 16.14 190081 ..... 00.8838 09.89

170017 ..... 01.1657 14.73 170099 ..... 01.3324 11.00 180019 ..... 01.3403 17.22 180118 ..... 01.0536 11.72 190083 ..... 00.9429 12.45

170018 ..... 01.0727 12.23 170100 ..... 01.0203 14.63 180020 ..... 01.0315 15.37 180120 ..... 01.0378 12.49 190086 ..... 01.3598 14.02

170019 ..... 01.1696 15.13 170101 ..... 00.9101 14.13 180021 ..... 01.1795 13.25 180121 ..... 01.2234 13.09 190088 ..... 01.1892 16.01

170020 ..... 01.3199 14.54 170102 ..... 01.0187 12.78 180023 ..... 00.8295 11.27 180122 ..... 01.0373 14.67 190089 ..... 01.1201 09.60

170022 ..... 01.1704 14.15 170103 ..... 01.2458 15.28 180024 ..... 01.3845 15.69 180123 ..... 01.4607 19.39 190090 ..... 01.0660 15.75

170023 ..... 01.4044 15.57 170104 ..... 01.4205 19.52 180025 ..... 01.1284 16.18 180124 ..... 01.4836 16.00 190092 ..... 01.3355 20.14

170024 ..... 01.1640 12.71 170105 ..... 01.0303 14.45 180026 ..... 01.1086 13.66 180125 ..... 00.9440 16.23 190095 ..... 00.9950 14.04

170025 ..... 01.1596 18.37 170106 ..... 00.8419 12.54 180027 ..... 01.2742 14.17 180126 ..... 01.1707 11.90 190098 ..... 01.5272 17.56

170026 ..... 01.0181 16.38 170108 ..... 00.9468 10.88 180028 ..... 01.0014 16.19 180127 ..... 01.2444 16.63 190099 ..... 01.1506 17.31

170027 ..... 01.3677 15.02 170109 ..... 01.0506 14.67 180029 ..... 01.2273 15.99 180128 ..... 01.1902 15.40 190102 ..... 01.5823 16.15

170030 ..... 01.0391 13.61 170110 ..... 01.0039 13.62 180030 ..... 01.1759 12.89 180129 ..... 01.0293 13.93 190103 ..... 00.8416 09.66

170031 ..... 00.9148 12.36 170112 ..... 00.9127 13.44 180031 ..... 01.0226 12.38 180130 ..... 01.4291 17.87 190106 ..... 01.1367 17.27

170032 ..... 01.1156 14.18 170113 ..... 01.1547 13.43 180032 ..... 00.9954 15.30 180132 ..... 01.2480 15.19 190109 ..... 01.2092 13.68

170033 ..... 01.3483 14.08 170114 ..... 00.9562 12.96 180033 ..... 01.1235 12.57 180133 ..... 01.2433 20.73 190110 ..... 00.9491 11.96

170034 ..... 00.9541 13.74 170115 ..... 00.9903 11.01 180034 ..... 01.0753 13.61 180134 ..... 01.0116 13.71 190111 ..... 01.5215 17.24

170035 ..... 00.9390 12.37 170116 ..... 01.0372 13.94 180035 ..... 01.5699 18.26 180136 ..... 01.5878 16.63 190112 ..... 01.5163 20.35

170036 ..... 00.8720 12.31 170117 ..... 01.0112 12.63 180036 ..... 01.2440 17.36 180137 ..... 01.6535 16.82 190113 ..... 01.3665 17.85

170037 ..... 01.1255 15.02 170119 ..... 00.9561 11.32 180037 ..... 01.2889 20.29 180138 ..... 01.2129 17.02 190114 ..... 01.0055 11.51

170038 ..... 00.9185 10.94 170120 ..... 01.2849 14.66 180038 ..... 01.4243 14.73 180139 ..... 01.0726 16.41 190115 ..... 01.2502 16.88

170039 ..... 01.1367 11.69 170122 ..... 01.8944 19.69 180040 ..... 02.0334 19.04 180140 ..... 01.0095 .......... 190116 ..... 01.3017 14.97

170040 ..... 01.5625 18.21 170123 ..... 01.7747 17.69 180041 ..... 01.0945 13.03 190001 ..... 00.9375 16.35 190118 ..... 01.0495 11.87

170041 ..... 00.9823 11.41 170124 ..... 00.9503 11.92 180042 ..... 01.1163 13.43 190002 ..... 01.6513 16.28 190120 ..... 00.9247 12.89

170043 ..... 00.9081 13.41 170126 ..... 00.9191 11.07 180043 ..... 01.0156 15.31 190003 ..... 01.4519 17.16 190122 ..... 01.2572 13.85

170044 ..... 01.1101 14.73 170128 ..... 01.0769 14.31 180044 ..... 01.0359 14.68 190004 ..... 01.3759 14.75 190124 ..... 01.5739 18.80

170045 ..... 01.0299 10.95 170131 ..... 01.0980 10.54 180045 ..... 01.2057 16.78 190005 ..... 01.6645 14.94 190125 ..... 01.5811 16.74

170049 ..... 01.3313 18.05 170133 ..... 01.1443 14.09 180046 ..... 01.2012 16.81 190006 ..... 01.2072 14.50 190128 ..... 01.2060 17.04

170050 ..... 00.8380 09.63 170134 ..... 00.9114 12.10 180047 ..... 01.0191 13.79 190007 ..... 01.0078 12.79 190130 ..... 00.9913 11.74

170051 ..... 00.9598 13.31 170137 ..... 01.1842 16.81 180048 ..... 01.1403 15.53 190008 ..... 01.6528 17.79 190131 ..... 01.2797 17.33

170052 ..... 01.0682 13.31 170139 ..... 00.9877 11.66 180049 ..... 01.3563 14.47 190009 ..... 01.2058 13.40 190133 ..... 01.0482 15.09

170053 ..... 01.0069 13.09 170140 ..... 01.0533 11.17 180050 ..... 01.2697 15.58 190010 ..... 01.0884 14.69 190134 ..... 00.9967 12.16

170054 ..... 01.0848 12.86 170142 ..... 01.2641 16.10 180051 ..... 01.4187 14.35 190011 ..... 01.1233 14.08 190135 ..... 01.4063 21.99

170055 ..... 01.0698 17.05 170143 ..... 01.1251 12.53 180053 ..... 01.1091 14.22 190013 ..... 01.4220 15.27 190136 ..... 01.1262 10.66

170056 ..... 00.9402 10.99 170144 ..... 01.6112 18.74 180054 ..... 01.1611 14.02 190014 ..... 01.0578 15.36 190138 ..... 00.6897 15.62

170057 ..... 01.0566 13.75 170145 ..... 01.1694 17.02 180055 ..... 01.0370 13.61 190015 ..... 01.2421 16.38 190140 ..... 00.9431 11.60

170058 ..... 01.1738 17.54 170146 ..... 01.4168 17.58 180056 ..... 01.1099 16.68 190017 ..... 01.3736 17.22 190142 ..... 00.9421 12.20

170060 ..... 01.1313 12.73 170147 ..... 01.2245 18.33 180058 ..... 01.0090 12.85 190018 ..... 01.1816 13.78 190144 ..... 01.2097 18.82

170061 ..... 01.1593 12.59 170148 ..... 01.4763 18.35 180059 ..... 00.9670 11.98 190019 ..... 01.5042 17.57 190145 ..... 00.9824 13.77

170062 ..... 00.9501 10.45 170150 ..... 01.0726 13.13 180060 ..... 00.7427 13.48 190020 ..... 01.2002 15.83 190146 ..... 01.5901 18.99

170063 ..... 00.8965 09.30 170151 ..... 01.0012 11.69 180063 ..... 00.9649 10.28 190025 ..... 01.2859 12.36 190147 ..... 00.9911 13.30

170064 ..... 00.9513 11.38 170152 ..... 00.9801 13.27 180064 ..... 01.2906 14.40 190026 ..... 01.4470 15.65 190148 ..... 00.8975 11.81

170066 ..... 00.9908 12.26 170160 ..... 01.0468 11.25 180065 ..... 00.9809 09.05 190027 ..... 01.4852 15.62 190149 ..... 00.9959 11.02

170067 ..... 01.0357 11.05 170164 ..... 01.0426 13.87 180066 ..... 01.2068 16.87 190029 ..... 01.1320 14.09 190151 ..... 01.1518 12.30

170068 ..... 01.3949 14.01 170166 ..... 01.1504 13.49 180067 ..... 01.8783 15.96 190033 ..... 00.9721 09.64 190152 ..... 01.4522 20.50

170069 ..... 01.1769 13.20 170168 ..... 00.9486 09.97 180069 ..... 01.0397 16.08 190034 ..... 01.2434 14.93 190155 ..... 00.9203 10.54

170070 ..... 01.0225 11.83 170171 ..... 01.0889 11.15 180070 ..... 01.0977 14.86 190035 ..... 01.4128 20.27 190156 ..... 00.8945 11.89

170072 ..... 00.9565 11.53 170172 ..... 00.9841 11.07 180072 ..... 01.0513 13.80 190036 ..... 01.6475 18.96 190158 ..... 01.2308 20.36

170073 ..... 01.0984 12.66 170174 ..... 01.0890 11.58 180075 ..... 00.9736 13.08 190037 ..... 00.9653 11.05 190160 ..... 01.2187 15.56

170074 ..... 01.1552 12.86 170175 ..... 01.2928 16.30 180078 ..... 01.1230 17.35 190039 ..... 01.4080 16.41 190161 ..... 01.0441 12.98

170075 ..... 00.8720 10.55 170176 ..... 01.5021 18.40 180079 ..... 01.2486 13.22 190040 ..... 01.3863 19.03 190162 ..... 01.1806 21.04

170076 ..... 01.0770 11.15 170181 ..... 01.1668 .......... 180080 ..... 01.0636 15.16 190041 ..... 01.4973 19.72 190164 ..... 01.2246 16.86

170077 ..... 00.9689 11.12 170182 ..... 00.8647 .......... 180085 ..... 01.2892 17.49 190043 ..... 01.1348 12.38 190166 ..... 01.0758 14.81

170079 ..... 01.0810 11.81 170183 ..... 02.1585 .......... 180087 ..... 01.0887 13.72 190044 ..... 01.1634 18.27 190167 ..... 01.2058 16.09

170080 ..... 00.9459 11.05 180001 ..... 01.2246 16.18 180088 ..... 01.5722 19.42 190045 ..... 01.3672 19.09 190170 ..... 00.9592 12.34

170081 ..... 00.9294 10.42 180002 ..... 01.0070 17.16 180092 ..... 01.0482 14.43 190046 ..... 01.4814 17.16 190173 ..... 01.4578 19.47

170082 ..... 01.0577 10.60 180004 ..... 01.0888 13.51 180093 ..... 01.3617 14.72 190048 ..... 01.0669 14.55 190175 ..... 01.2835 ..........

170084 ..... 00.9862 11.06 180005 ..... 01.0390 17.40 180094 ..... 01.0163 11.93 190049 ..... 00.9644 14.74 190176 ..... 01.7028 18.06

170085 ..... 00.9109 12.01 180006 ..... 00.9063 08.63 180095 ..... 01.1664 12.78 190050 ..... 01.0420 13.90 190177 ..... 01.6125 22.02

170086 ..... 01.7190 18.04 180007 ..... 01.5485 14.17 180099 ..... 01.1988 11.72 190053 ..... 01.0567 11.98 190178 ..... 00.9868 11.20

170087 ..... 01.4582 18.87 180009 ..... 01.3310 17.70 180101 ..... 01.3486 18.84 190054 ..... 01.4052 13.67 190182 ..... 01.1720 20.12

170088 ..... 00.9139 10.59 180010 ..... 01.8382 16.91 180102 ..... 01.5215 15.95 190059 ..... 00.9447 13.58 190183 ..... 01.1294 13.43

170089 ..... 01.0037 14.21 180011 ..... 01.1737 15.71 180103 ..... 02.0850 18.62 190060 ..... 01.4907 16.51 190184 ..... 01.0550 12.13
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27511

PAGE 7 OF 16

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190185 ..... 01.3116 19.03 210004 ..... 01.3245 20.30 220030 ..... 01.0852 16.42 220171 ..... 01.6972 22.55 230103 ..... 01.0124 17.37

190186 ..... 00.9539 11.69 210005 ..... 01.2407 17.70 220031 ..... 01.8518 27.21 220897 ..... 04.8084 .......... 230104 ..... 01.6163 20.32

190187 ..... 00.7801 14.05 210006 ..... 01.1291 16.84 220033 ..... 01.3898 19.40 230001 ..... 01.2015 15.98 230105 ..... 01.6088 19.46

190189 ..... 00.9445 14.54 210007 ..... 01.6215 18.82 220035 ..... 01.2698 19.72 230002 ..... 01.2238 19.28 230106 ..... 01.1784 18.07

190190 ..... 00.9291 18.74 210008 ..... 01.3146 21.21 220036 ..... 01.6218 23.26 230003 ..... 01.0945 18.07 230107 ..... 00.8964 12.56

190191 ..... 01.3068 18.47 210009 ..... 01.7134 18.57 220038 ..... 01.2841 21.85 230004 ..... 01.6105 20.95 230108 ..... 01.2432 16.64

190194 ..... 01.1471 19.16 210010 ..... 01.1960 17.00 220041 ..... 01.2492 20.87 230005 ..... 01.2825 18.02 230110 ..... 01.3309 17.10

190196 ..... 00.9097 16.46 210011 ..... 01.2110 20.12 220042 ..... 01.2078 24.10 230006 ..... 01.1303 16.19 230111 ..... 00.9772 15.13

190197 ..... 01.2655 18.80 210012 ..... 01.4840 21.27 220046 ..... 01.3942 21.48 230007 ..... 01.0869 16.51 230113 ..... 00.9511 17.66

190199 ..... 01.3623 .......... 210013 ..... 01.2780 20.65 220049 ..... 01.2664 21.58 230013 ..... 01.2659 20.70 230114 ..... 00.6368 23.27

190200 ..... 01.5241 21.33 210015 ..... 01.2720 18.48 220050 ..... 01.0888 17.45 230015 ..... 01.1338 18.01 230115 ..... 01.0164 15.14

190201 ..... 01.2315 18.24 210016 ..... 01.7279 20.37 220051 ..... 01.2702 19.70 230017 ..... 01.5125 20.40 230116 ..... 00.9155 15.58

190202 ..... 01.4459 18.34 210017 ..... 01.1256 15.35 220052 ..... 01.2994 22.76 230019 ..... 01.5077 20.50 230117 ..... 01.9674 23.81

190203 ..... 01.6074 19.50 210018 ..... 01.2414 20.93 220053 ..... 01.2564 18.86 230020 ..... 01.7180 21.17 230118 ..... 01.2419 17.25

190204 ..... 01.5314 20.12 210019 ..... 01.4011 17.42 220055 ..... 01.3486 20.61 230021 ..... 01.6010 17.25 230119 ..... 01.3145 21.13

190205 ..... 01.8790 17.63 210022 ..... 01.4536 20.07 220057 ..... 01.4381 20.91 230022 ..... 01.2422 17.62 230120 ..... 01.2315 19.00

190206 ..... 01.4995 21.17 210023 ..... 01.2956 20.31 220058 ..... 01.0650 17.55 230024 ..... 01.4216 21.79 230121 ..... 01.2320 19.67

190207 ..... 01.1825 19.43 210024 ..... 01.5336 18.06 220060 ..... 01.2565 24.78 230027 ..... 01.0587 16.25 230122 ..... 01.3296 18.32

190208 ..... 00.8198 10.36 210025 ..... 01.3227 17.84 220062 ..... 00.6021 19.30 230029 ..... 01.5998 20.91 230124 ..... 01.1555 16.49

190218 ..... 01.1389 15.05 210026 ..... 01.3187 24.54 220063 ..... 01.2909 18.42 230030 ..... 01.2415 16.55 230125 ..... 01.3676 12.83

190223 ..... 00.5039 09.72 210027 ..... 01.2046 17.10 220064 ..... 01.2167 20.66 230031 ..... 01.4660 18.32 230128 ..... 01.3700 19.33

190227 ..... 00.8050 30.01 210028 ..... 01.2256 16.66 220065 ..... 01.2182 20.00 230032 ..... 01.7444 18.97 230129 ..... 01.8923 19.07

190230 ..... 00.8737 .......... 210029 ..... 01.3064 20.04 220066 ..... 01.2760 19.39 230034 ..... 01.1948 16.64 230130 ..... 01.6884 22.37

190231 ..... 01.2825 .......... 210030 ..... 01.0993 15.77 220067 ..... 01.2944 22.82 230035 ..... 01.1377 15.84 230132 ..... 01.5373 22.92

190232 ..... 01.6623 .......... 210031 ..... 01.6370 16.97 220068 ..... 00.5244 15.95 230036 ..... 01.2807 19.78 230133 ..... 01.2350 14.06

190233 ..... 01.0997 .......... 210032 ..... 01.2096 18.42 220070 ..... 01.2635 17.77 230037 ..... 01.1606 16.96 230134 ..... 01.1081 15.87

200001 ..... 01.2712 15.74 210033 ..... 01.1818 17.38 220071 ..... 01.8550 24.38 230038 ..... 01.6451 21.18 230135 ..... 01.1885 19.88

200002 ..... 01.0212 16.15 210034 ..... 01.3996 20.29 220073 ..... 01.3882 25.34 230040 ..... 01.1976 18.35 230137 ..... 01.1691 17.78

200003 ..... 01.1264 15.90 210035 ..... 01.1952 17.25 220074 ..... 01.2614 21.18 230041 ..... 01.2085 18.20 230141 ..... 01.6883 20.84

200006 ..... 01.0731 14.95 210037 ..... 01.2887 16.14 220075 ..... 01.3228 20.09 230042 ..... 01.1542 19.03 230142 ..... 01.2092 18.71

200007 ..... 01.0066 15.63 210038 ..... 01.3413 19.90 220076 ..... 01.1851 22.47 230046 ..... 01.8239 24.65 230143 ..... 01.1481 15.23

200008 ..... 01.2497 18.34 210039 ..... 01.1613 15.25 220077 ..... 01.7122 22.32 230047 ..... 01.3070 19.61 230144 ..... 01.1092 21.06

200009 ..... 01.7602 19.84 210040 ..... 01.2993 20.32 220079 ..... 01.1880 21.28 230053 ..... 01.5387 23.82 230145 ..... 01.1742 15.41

200012 ..... 01.1641 16.11 210043 ..... 01.2569 20.04 220080 ..... 01.2773 17.77 230054 ..... 01.8228 19.74 230146 ..... 01.2845 19.49

200013 ..... 01.1401 15.32 210044 ..... 01.2000 20.28 220081 ..... 00.9446 23.55 230055 ..... 01.1760 17.36 230147 ..... 01.4742 19.34

200015 ..... 01.2358 17.15 210045 ..... 01.0148 11.73 220082 ..... 01.2902 19.28 230056 ..... 00.9776 14.17 230149 ..... 01.2419 14.92

200016 ..... 01.0350 16.10 210046 ..... 01.1079 12.34 220083 ..... 01.1831 19.80 230058 ..... 01.0786 17.42 230151 ..... 01.3631 21.32

200017 ..... 01.2447 16.86 210048 ..... 01.1746 22.47 220084 ..... 01.2425 22.24 230059 ..... 01.4842 19.00 230153 ..... 01.1118 15.61

200018 ..... 01.1602 14.27 210049 ..... 01.1517 16.57 220086 ..... 01.5483 24.60 230060 ..... 01.2882 16.90 230154 ..... 00.9493 12.09

200019 ..... 01.2486 18.01 210051 ..... 01.4541 13.94 220088 ..... 01.5778 21.76 230062 ..... 01.0291 10.93 230155 ..... 00.9752 13.80

200020 ..... 01.1930 19.86 210054 ..... 01.2790 20.17 220089 ..... 01.3304 22.99 230063 ..... 01.3106 18.41 230156 ..... 01.6989 21.57

200021 ..... 01.1723 17.66 210055 ..... 01.2914 22.48 220090 ..... 01.2260 20.78 230065 ..... 01.4805 18.63 230157 ..... 01.2084 19.67

200023 ..... 00.8814 14.61 210056 ..... 01.4132 16.51 220092 ..... 01.2533 20.86 230066 ..... 01.3629 17.55 230159 ..... 01.3614 18.93

200024 ..... 01.2940 19.16 210057 ..... 01.3587 .......... 220094 ..... 01.2679 19.76 230068 ..... 01.4269 22.29 230162 ..... 00.9841 13.73

200025 ..... 01.2732 18.81 210058 ..... 01.6842 18.09 220095 ..... 01.2234 17.77 230069 ..... 01.1751 18.86 230165 ..... 01.8763 20.92

200026 ..... 01.0896 15.20 210059 ..... 01.2581 21.91 220098 ..... 01.2884 19.81 230070 ..... 01.4926 19.30 230167 ..... 01.3662 19.18

200027 ..... 01.1423 16.51 210060 ..... 01.1731 25.28 220099 ..... 01.1644 15.97 230071 ..... 01.1363 20.78 230169 ..... 01.4366 21.16

200028 ..... 00.9339 14.83 210061 ..... 01.0980 14.25 220100 ..... 01.2619 23.48 230072 ..... 01.2879 18.87 230171 ..... 00.9849 14.18

200031 ..... 01.2965 14.96 220001 ..... 01.1636 20.98 220101 ..... 01.5059 22.58 230075 ..... 01.5257 19.29 230172 ..... 01.3176 17.85

200032 ..... 01.3588 17.72 220002 ..... 01.5368 21.62 220104 ..... 01.2419 23.12 230076 ..... 01.3128 21.53 230174 ..... 01.3016 19.11

200033 ..... 01.7105 19.57 220003 ..... 01.0806 16.92 220105 ..... 01.2111 21.97 230077 ..... 01.9772 18.44 230176 ..... 01.2388 20.89

200034 ..... 01.1962 17.19 220004 ..... 01.1812 18.85 220106 ..... 01.2458 21.83 230078 ..... 01.0869 14.76 230178 ..... 01.0320 16.02

200037 ..... 01.2193 15.53 220006 ..... 01.4332 21.79 220107 ..... 01.1742 18.46 230080 ..... 01.1933 20.41 230180 ..... 01.0676 15.03

200038 ..... 01.1145 17.66 220008 ..... 01.2523 19.26 220108 ..... 01.1503 20.96 230081 ..... 01.2191 16.55 230184 ..... 01.2246 16.99

200039 ..... 01.2494 18.06 220010 ..... 01.2949 20.94 220110 ..... 01.9520 30.07 230082 ..... 01.1643 14.88 230186 ..... 01.3835 15.81

200040 ..... 01.0969 16.12 220011 ..... 01.1570 27.95 220111 ..... 01.2612 21.21 230085 ..... 01.1115 17.10 230188 ..... 01.1787 15.49

200041 ..... 01.2255 17.37 220012 ..... 01.3654 27.84 220116 ..... 01.9484 23.95 230086 ..... 00.9885 14.03 230189 ..... 00.8927 14.50

200043 ..... 00.5362 16.96 220015 ..... 01.1767 20.35 220118 ..... 02.0446 26.47 230087 ..... 01.0641 13.65 230190 ..... 01.0483 22.66

200050 ..... 01.2051 16.71 220016 ..... 01.3547 20.16 220119 ..... 01.3255 24.40 230089 ..... 01.3379 21.55 230191 ..... 00.8947 14.99

200051 ..... 00.9656 17.70 220017 ..... 01.4233 23.78 220123 ..... 01.0371 23.85 230092 ..... 01.3295 17.77 230193 ..... 01.2340 16.03

200052 ..... 00.9605 13.07 220019 ..... 01.1716 17.06 220126 ..... 01.3077 19.39 230093 ..... 01.2320 17.37 230194 ..... 01.2090 14.37

200055 ..... 01.1609 14.56 220020 ..... 01.2174 18.47 220128 ..... 01.1494 20.85 230095 ..... 01.2251 15.53 230195 ..... 01.2803 19.80

200062 ..... 00.9155 14.64 220021 ..... 01.3823 23.21 220133 ..... 00.8435 30.53 230096 ..... 01.1954 19.85 230197 ..... 01.2564 22.00

200063 ..... 01.1630 16.63 220023 ..... 01.1522 19.37 220135 ..... 01.2581 23.97 230097 ..... 01.5433 17.75 230199 ..... 01.1386 17.72

200066 ..... 01.1762 14.34 220024 ..... 01.1696 20.14 220153 ..... 01.0459 19.74 230099 ..... 01.2223 19.06 230201 ..... 01.2166 14.02

210001 ..... 01.4081 17.94 220025 ..... 01.1948 18.87 220154 ..... 00.8972 18.96 230100 ..... 01.1604 15.19 230204 ..... 01.3584 19.78

210002 ..... 01.9534 16.84 220028 ..... 01.4680 22.20 220162 ..... 01.0891 .......... 230101 ..... 01.0566 16.79 230205 ..... 01.0607 14.54

210003 ..... 01.5503 22.97 220029 ..... 01.1933 22.25 220163 ..... 02.0719 24.73 230102 ..... 01.1047 .......... 230207 ..... 01.2544 19.85
27512 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

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230208 ..... 01.1783 16.10 240047 ..... 01.5215 18.27 240132 ..... 01.2422 20.49 250034 ..... 01.5418 12.99 250138 ..... 01.3553 16.91

230211 ..... 00.9786 13.86 240048 ..... 01.2786 20.43 240133 ..... 01.1715 16.16 250035 ..... 00.9041 11.82 250140 ..... 00.9213 09.37

230212 ..... 01.0964 21.13 240049 ..... 01.7763 20.33 240135 ..... 00.8386 11.38 250036 ..... 00.9863 11.34 250141 ..... 01.2142 15.50

230213 ..... 01.0251 12.69 240050 ..... 01.1234 19.89 240137 ..... 01.2521 15.40 250037 ..... 00.8717 09.53 250144 ..... 00.9383 11.18

230216 ..... 01.5363 17.91 240051 ..... 00.9749 15.97 240138 ..... 00.8953 13.09 250038 ..... 00.9909 12.52 250145 ..... 00.9362 ..........

230217 ..... 01.2142 18.06 240052 ..... 01.2480 17.21 240139 ..... 00.9551 14.24 250039 ..... 01.0004 11.71 250146 ..... 01.0020 12.89

230219 ..... 01.0153 15.18 240053 ..... 01.5190 19.67 240141 ..... 01.0836 19.12 250040 ..... 01.2911 15.65 250148 ..... 01.1589 ..........

230221 ..... 01.1831 18.15 240056 ..... 01.2490 20.13 240142 ..... 01.1491 15.16 250042 ..... 01.1491 13.78 250149 ..... 00.9157 ..........

230222 ..... 01.3602 18.98 240057 ..... 01.7418 22.04 240143 ..... 01.0673 12.48 250043 ..... 01.0303 10.49 260001 ..... 01.6548 15.06

230223 ..... 01.3164 19.85 240058 ..... 00.9730 09.64 240144 ..... 00.9419 13.39 250044 ..... 00.9825 13.98 260002 ..... 01.4785 20.05

230227 ..... 01.5246 22.00 240059 ..... 01.1011 17.98 240145 ..... 00.9681 12.37 250045 ..... 01.1454 17.17 260003 ..... 00.9487 12.45

230228 ..... 01.2133 17.29 240061 ..... 01.7409 20.93 240146 ..... 00.9270 17.20 250047 ..... 00.9527 09.12 260004 ..... 01.0315 11.86

230230 ..... 01.5449 20.38 240063 ..... 01.4559 20.88 240148 ..... 00.9433 11.34 250048 ..... 01.4527 13.51 260005 ..... 01.6121 19.68

230232 ..... 01.0330 15.87 240064 ..... 01.2630 18.13 240150 ..... 00.8874 11.72 250049 ..... 00.9058 09.93 260006 ..... 01.5286 16.72

230235 ..... 01.1141 14.65 240065 ..... 01.1480 11.14 240152 ..... 01.0177 17.85 250050 ..... 01.2448 12.30 260007 ..... 01.4659 16.03

230236 ..... 01.3372 21.07 240066 ..... 01.3895 19.08 240153 ..... 01.0210 14.30 250051 ..... 00.8585 09.44 260008 ..... 01.2051 13.88

230239 ..... 01.1697 16.07 240069 ..... 01.1596 18.31 240154 ..... 01.0138 13.15 250057 ..... 01.1766 14.06 260009 ..... 01.2372 15.63

230241 ..... 01.1519 17.08 240071 ..... 01.1245 18.05 240155 ..... 00.9817 14.39 250058 ..... 01.1385 13.65 260011 ..... 01.6786 16.21

230244 ..... 01.3177 20.14 240072 ..... 01.0272 16.08 240157 ..... 01.1265 13.92 250059 ..... 01.0322 12.16 260012 ..... 01.0505 11.96

230253 ..... 01.0740 17.39 240073 ..... 00.9172 15.13 240160 ..... 00.9997 14.65 250060 ..... 00.8084 12.19 260013 ..... 01.1491 12.68

230254 ..... 01.2799 22.64 240075 ..... 01.2180 18.79 240161 ..... 00.9389 14.56 250061 ..... 00.8634 10.75 260014 ..... 01.7751 17.84

230257 ..... 01.1068 19.01 240076 ..... 01.1373 19.69 240162 ..... 00.9645 15.28 250063 ..... 00.8596 12.68 260015 ..... 01.2666 13.16

230259 ..... 01.1982 19.06 240077 ..... 01.0463 14.15 240163 ..... 00.9330 14.10 250065 ..... 00.8907 11.72 260017 ..... 01.2286 13.94

230264 ..... 00.9438 16.74 240078 ..... 01.4536 21.46 240166 ..... 01.1669 14.67 250066 ..... 00.9404 12.17 260018 ..... 00.9652 09.56

230269 ..... 01.3034 21.71 240079 ..... 01.0176 12.57 240169 ..... 00.9534 15.25 250067 ..... 01.1253 14.14 260019 ..... 00.9816 12.63

230270 ..... 01.2162 20.08 240080 ..... 01.3774 20.87 240170 ..... 01.1564 14.42 250068 ..... 00.8556 11.19 260020 ..... 01.7259 18.73

230273 ..... 01.6607 22.11 240082 ..... 01.1194 14.55 240171 ..... 00.9950 14.02 250069 ..... 01.1870 13.42 260021 ..... 01.5153 17.51

230275 ..... 00.5787 16.53 240083 ..... 01.3925 16.60 240172 ..... 01.0869 14.50 250071 ..... 00.9541 08.06 260022 ..... 01.3501 18.69

230276 ..... 00.8129 16.23 240084 ..... 01.3436 17.20 240173 ..... 00.9599 14.82 250072 ..... 01.2914 16.67 260023 ..... 01.2567 15.57

230277 ..... 01.2425 21.76 240085 ..... 00.9247 14.90 240179 ..... 01.0022 14.30 250076 ..... 00.9579 10.32 260024 ..... 01.0210 12.28

230278 ..... 02.0914 19.50 240086 ..... 01.0520 15.23 240180 ..... 01.0157 10.51 250077 ..... 00.9505 11.08 260025 ..... 01.3121 13.61

230279 ..... 00.6989 .......... 240087 ..... 01.0824 15.69 240184 ..... 01.0424 11.31 250078 ..... 01.4419 14.21 260027 ..... 01.5941 18.92

230280 ..... 01.0281 .......... 240088 ..... 01.4444 18.10 240187 ..... 01.2617 16.56 250079 ..... 00.8562 15.12 260029 ..... 01.1264 15.76

230281 ..... 01.7080 .......... 240089 ..... 01.0010 15.23 240193 ..... 01.0582 14.73 250081 ..... 01.3034 15.19 260030 ..... 01.0891 09.73

240001 ..... 01.5708 21.24 240090 ..... 01.0970 13.57 240196 ..... 00.6132 22.50 250082 ..... 01.2857 12.30 260031 ..... 01.4989 18.67

240002 ..... 01.6938 19.40 240093 ..... 01.3186 16.49 240200 ..... 00.8962 13.34 250083 ..... 01.0251 11.01 260032 ..... 01.5795 17.59

240004 ..... 01.4661 20.16 240094 ..... 01.0543 17.26 240205 ..... 00.9014 .......... 250084 ..... 01.0930 13.92 260034 ..... 00.9785 14.22

240005 ..... 00.9960 13.49 240096 ..... 01.0160 14.12 240206 ..... 00.8472 .......... 250085 ..... 01.0093 11.42 260035 ..... 01.0729 11.44

240006 ..... 01.1385 19.75 240097 ..... 01.1270 17.05 240207 ..... 01.2326 21.47 250088 ..... 00.9591 15.56 260036 ..... 01.0628 15.72

240007 ..... 01.1171 15.15 240098 ..... 00.9677 16.41 240210 ..... 01.2588 21.44 250089 ..... 01.0276 11.77 260037 ..... 01.4003 15.17

240008 ..... 01.0569 15.22 240099 ..... 01.1143 11.00 240211 ..... 00.9532 11.18 250093 ..... 01.1064 12.17 260039 ..... 01.1432 11.17

240009 ..... 00.9895 14.18 240100 ..... 01.3089 19.58 240212 ..... 01.9942 .......... 250094 ..... 01.2377 14.41 260040 ..... 01.6075 14.92

240010 ..... 01.9742 20.17 240101 ..... 01.1581 17.32 250001 ..... 01.6688 15.91 250095 ..... 00.9795 13.57 260042 ..... 01.4257 15.65

240011 ..... 01.1400 15.69 240102 ..... 00.8915 12.27 250002 ..... 00.7926 13.34 250096 ..... 01.2945 16.48 260044 ..... 01.0361 14.29

240013 ..... 01.3150 15.90 240103 ..... 01.0772 14.10 250003 ..... 01.0305 14.13 250097 ..... 01.1910 13.83 260047 ..... 01.3634 14.19

240014 ..... 01.0820 17.79 240104 ..... 01.2345 21.68 250004 ..... 01.4613 15.12 250098 ..... 00.8668 13.73 260048 ..... 01.2847 18.05

240016 ..... 01.3076 15.46 240105 ..... 01.0028 12.70 250005 ..... 00.9643 09.15 250099 ..... 01.2680 12.73 260050 ..... 01.0968 14.71

240017 ..... 01.1439 15.15 240106 ..... 01.3245 23.78 250006 ..... 00.9651 12.27 250100 ..... 01.2315 14.53 260052 ..... 01.3337 15.95

240018 ..... 01.2866 15.82 240107 ..... 00.9788 15.07 250007 ..... 01.2618 16.88 250101 ..... 00.9408 09.89 260053 ..... 01.1331 09.46

240019 ..... 01.2275 19.58 240108 ..... 00.9539 11.64 250008 ..... 00.8996 11.36 250102 ..... 01.5414 14.80 260054 ..... 01.3206 15.14

240020 ..... 01.1482 18.11 240109 ..... 00.9922 13.59 250009 ..... 01.1809 15.04 250104 ..... 01.3619 15.58 260055 ..... 01.0378 13.67

240021 ..... 00.9369 12.49 240110 ..... 01.0305 15.18 250010 ..... 01.0381 11.07 250105 ..... 00.9206 13.13 260057 ..... 01.1548 13.85

240022 ..... 01.1174 17.33 240111 ..... 00.9867 13.06 250012 ..... 00.9568 13.77 250107 ..... 00.9087 14.16 260059 ..... 01.1275 14.17

240023 ..... 01.0074 15.86 240112 ..... 01.0531 13.30 250015 ..... 01.0942 09.75 250109 ..... 00.9352 11.54 260061 ..... 01.1793 10.87

240025 ..... 01.1734 15.02 240114 ..... 00.9888 11.13 250017 ..... 01.0107 13.77 250112 ..... 00.9947 14.22 260062 ..... 01.1602 19.89

240027 ..... 01.0011 12.60 240115 ..... 01.6063 22.30 250018 ..... 00.9603 09.81 250117 ..... 01.0705 13.28 260063 ..... 01.1913 14.82

240028 ..... 01.1386 16.50 240116 ..... 00.9465 12.43 250019 ..... 01.4259 17.43 250119 ..... 01.2047 10.80 260064 ..... 01.3295 15.38

240029 ..... 01.1610 15.70 240117 ..... 01.0697 16.21 250020 ..... 01.0082 10.70 250120 ..... 01.0645 12.04 260065 ..... 01.7778 15.31

240030 ..... 01.3037 16.78 240119 ..... 00.8486 16.93 250021 ..... 00.8579 07.74 250122 ..... 01.2735 15.87 260066 ..... 01.0927 13.19

240031 ..... 00.9361 13.50 240121 ..... 00.9008 16.90 250023 ..... 00.8647 11.22 250123 ..... 01.3262 17.72 260067 ..... 00.9820 10.43

240036 ..... 01.5543 19.05 240122 ..... 01.0504 16.80 250024 ..... 00.9894 08.25 250124 ..... 00.9137 10.69 260068 ..... 01.6715 18.49

240037 ..... 01.0408 16.40 240123 ..... 01.0498 13.30 250025 ..... 01.1455 13.58 250125 ..... 01.3231 18.35 260070 ..... 01.0862 11.09

240038 ..... 01.4454 22.37 240124 ..... 01.0139 15.71 250027 ..... 01.0256 10.40 250126 ..... 00.9923 10.22 260073 ..... 00.9681 11.58

240040 ..... 01.2251 17.67 240125 ..... 00.9399 10.75 250029 ..... 00.8872 11.87 250127 ..... 00.7630 .......... 260074 ..... 01.2427 14.81

240041 ..... 01.2877 14.43 240127 ..... 01.0142 12.51 250030 ..... 00.9688 11.39 250128 ..... 01.1010 12.64 260077 ..... 01.7271 16.15

240043 ..... 01.1990 16.83 240128 ..... 01.1180 14.55 250031 ..... 01.3157 17.20 250131 ..... 01.0539 09.36 260078 ..... 01.1782 12.39

240044 ..... 01.2046 16.02 240129 ..... 01.0153 12.18 250032 ..... 01.2551 15.70 250134 ..... 00.9795 12.70 260079 ..... 00.9824 11.78

240045 ..... 01.0655 18.49 240130 ..... 01.0151 14.54 250033 ..... 00.9921 11.57 250136 ..... 00.7871 16.84 260080 ..... 00.9654 09.77
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27513

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260081 ..... 01.4971 16.44 270004 ..... 01.6477 16.49 280026 ..... 01.1254 12.80 280115 ..... 00.9809 13.59 310017 ..... 01.3295 21.95

260082 ..... 01.1231 13.50 270006 ..... 01.0290 18.67 280028 ..... 01.0559 13.64 280117 ..... 01.2229 14.48 310018 ..... 01.2194 21.06

260085 ..... 01.5684 18.57 270007 ..... 00.9630 12.26 280029 ..... 01.0506 12.62 280118 ..... 00.9757 13.28 310019 ..... 01.6403 20.84

260086 ..... 01.0649 12.67 270009 ..... 01.0387 14.91 280030 ..... 01.7392 23.13 280119 ..... 00.8364 .......... 310020 ..... 01.1974 19.66

260089 ..... 00.9614 13.31 270011 ..... 01.1242 .......... 280031 ..... 01.0575 12.48 280123 ..... 00.7918 .......... 310021 ..... 01.3472 21.15

260091 ..... 01.6022 18.86 270012 ..... 01.5945 17.10 280032 ..... 01.3182 15.11 290001 ..... 01.6372 22.35 310022 ..... 01.2384 19.38

260094 ..... 01.1872 14.91 270013 ..... 01.2847 16.78 280033 ..... 00.9766 13.62 290002 ..... 00.8981 17.99 310024 ..... 01.2566 22.60

260095 ..... 01.4432 16.05 270014 ..... 01.7192 15.97 280034 ..... 01.2078 13.41 290003 ..... 01.6179 21.15 310025 ..... 01.2260 21.92

260096 ..... 01.5521 21.52 270016 ..... 00.8187 11.51 280035 ..... 00.9433 11.75 290005 ..... 01.4399 19.66 310026 ..... 01.2647 21.91

260097 ..... 01.1913 15.82 270017 ..... 01.2275 18.32 280037 ..... 01.0146 13.55 290006 ..... 01.2170 16.54 310027 ..... 01.3646 18.17

260100 ..... 00.9630 13.12 270019 ..... 01.0625 13.34 280038 ..... 01.0763 13.39 290007 ..... 01.8961 25.07 310028 ..... 01.1530 20.46

260102 ..... 01.0125 16.75 270021 ..... 01.1007 15.55 280039 ..... 01.1970 14.24 290008 ..... 01.2200 17.14 310029 ..... 01.8925 20.69

260103 ..... 01.3849 16.73 270023 ..... 01.2916 18.76 280040 ..... 01.5940 18.30 290009 ..... 01.6244 21.07 310031 ..... 02.5990 24.14

260104 ..... 01.6403 19.57 270024 ..... 00.9931 11.15 280041 ..... 01.0014 10.95 290010 ..... 01.2053 19.33 310032 ..... 01.2921 20.00

260105 ..... 01.8664 19.47 270026 ..... 00.8654 11.95 280042 ..... 01.0880 13.22 290011 ..... 00.8812 14.39 310034 ..... 01.2545 19.14

260107 ..... 01.3815 18.77 270027 ..... 01.0389 12.69 280043 ..... 01.1268 12.75 290012 ..... 01.4385 19.97 310036 ..... 01.2092 18.44

260108 ..... 01.8100 17.90 270028 ..... 01.0741 14.91 280045 ..... 01.1401 13.48 290013 ..... 01.0185 14.85 310037 ..... 01.3076 24.97

260109 ..... 00.9959 11.92 270029 ..... 00.9031 14.51 280046 ..... 01.0732 11.09 290014 ..... 01.0444 16.52 310038 ..... 01.9146 22.82

260110 ..... 01.6120 14.16 270031 ..... 00.8747 09.71 280047 ..... 01.1620 15.70 290015 ..... 00.9730 15.38 310039 ..... 01.2871 20.51

260111 ..... 00.9980 08.04 270032 ..... 01.1788 16.46 280048 ..... 01.0800 11.17 290016 ..... 01.1392 18.71 310040 ..... 01.2688 23.12

260112 ..... 01.4171 17.75 270033 ..... 00.8766 11.39 280049 ..... 01.0408 13.82 290019 ..... 01.2774 17.92 310041 ..... 01.3218 22.90

260113 ..... 01.1053 14.05 270035 ..... 01.0275 15.87 280050 ..... 00.9290 13.11 290020 ..... 01.0859 17.65 310042 ..... 01.2459 21.74

260115 ..... 01.2345 14.63 270036 ..... 00.9483 10.42 280051 ..... 01.0735 13.72 290021 ..... 01.5601 19.17 310043 ..... 01.2080 20.60

260116 ..... 01.1223 13.70 270039 ..... 01.0661 11.99 280052 ..... 01.0491 11.85 290022 ..... 01.7399 22.47 310044 ..... 01.3055 20.16

260119 ..... 01.1640 14.93 270040 ..... 01.0825 17.60 280054 ..... 01.2628 17.92 290027 ..... 00.9567 14.68 310045 ..... 01.3849 25.76

260120 ..... 01.1599 15.72 270041 ..... 01.0693 11.14 280055 ..... 00.9347 11.63 290029 ..... 00.9400 .......... 310047 ..... 01.3410 23.05

260122 ..... 01.1502 13.12 270044 ..... 01.1913 13.40 280056 ..... 00.9886 10.99 290032 ..... 01.4149 18.66 310048 ..... 01.1852 20.69

260123 ..... 01.0312 11.56 270046 ..... 00.9346 13.50 280057 ..... 01.0055 14.48 290038 ..... 01.1064 .......... 310049 ..... 01.3294 23.54

260127 ..... 00.9514 13.71 270048 ..... 01.0940 13.30 280058 ..... 01.3123 13.75 300001 ..... 01.3957 20.70 310050 ..... 01.2677 20.88

260128 ..... 00.9851 08.95 270049 ..... 01.8346 18.19 280060 ..... 01.5884 18.35 300003 ..... 01.8607 20.92 310051 ..... 01.3207 24.26

260129 ..... 01.2124 13.51 270050 ..... 01.0380 15.96 280061 ..... 01.4628 14.76 300005 ..... 01.2620 18.65 310052 ..... 01.2545 20.53

260131 ..... 01.2940 16.32 270051 ..... 01.2980 17.65 280062 ..... 01.2187 11.92 300006 ..... 01.1221 16.24 310054 ..... 01.2880 23.19

260134 ..... 01.1526 13.82 270052 ..... 01.0663 18.02 280064 ..... 01.0759 12.61 300007 ..... 01.1527 16.76 310056 ..... 01.1826 20.11

260137 ..... 01.2614 13.71 270053 ..... 00.8678 09.53 280065 ..... 01.2879 16.22 300008 ..... 01.2481 16.95 310057 ..... 01.2933 20.10

260138 ..... 01.9711 20.66 270057 ..... 01.1715 17.35 280066 ..... 01.0191 11.38 300009 ..... 01.0977 17.45 310058 ..... 01.1025 25.35

260141 ..... 01.8695 16.53 270058 ..... 00.9411 11.20 280068 ..... 00.9659 09.31 300010 ..... 01.2364 17.80 310060 ..... 01.2116 17.55

260142 ..... 01.1566 14.50 270059 ..... 00.8676 19.21 280070 ..... 01.0724 10.75 300011 ..... 01.3481 21.53 310061 ..... 01.2085 19.85

260143 ..... 00.9463 10.52 270060 ..... 00.9702 11.92 280073 ..... 01.0386 12.78 300012 ..... 01.2749 21.64 310062 ..... 01.2936 23.90

260147 ..... 01.0469 12.81 270063 ..... 00.8933 12.94 280074 ..... 01.1165 12.87 300013 ..... 01.2241 16.87 310063 ..... 01.3528 20.78

260148 ..... 00.9572 09.33 270068 ..... 00.8629 12.38 280075 ..... 01.2096 12.90 300014 ..... 01.2293 18.41 310064 ..... 01.2956 21.35

260158 ..... 01.1275 11.80 270072 ..... 00.8605 14.88 280076 ..... 01.0719 12.54 300015 ..... 01.1807 17.56 310067 ..... 01.3198 21.14

260159 ..... 01.2924 18.02 270073 ..... 01.0764 11.06 280077 ..... 01.3635 17.36 300016 ..... 01.3137 17.41 310069 ..... 01.1292 18.19

260160 ..... 01.0663 14.07 270074 ..... 00.8832 .......... 280079 ..... 01.0636 09.40 300017 ..... 01.2137 20.49 310070 ..... 01.3977 22.16

260162 ..... 01.7006 17.70 270075 ..... 00.8610 .......... 280080 ..... 01.0860 11.34 300018 ..... 01.2397 18.85 310072 ..... 01.3053 20.74

260163 ..... 01.3037 14.11 270076 ..... 00.8395 .......... 280081 ..... 01.5614 17.24 300019 ..... 01.2613 18.43 310073 ..... 01.5567 22.31

260164 ..... 01.0000 12.07 270079 ..... 00.9594 13.36 280082 ..... 01.0967 13.03 300020 ..... 01.2666 19.78 310074 ..... 01.4153 21.08

260166 ..... 01.2144 21.51 270080 ..... 01.1499 14.27 280083 ..... 01.0671 15.64 300021 ..... 01.1635 15.69 310075 ..... 01.2965 21.67

260172 ..... 01.0176 12.07 270081 ..... 01.0780 09.77 280084 ..... 01.0314 10.92 300022 ..... 01.0939 17.08 310076 ..... 01.3883 28.16

260173 ..... 00.9560 11.15 270082 ..... 01.0050 16.10 280085 ..... 00.7201 14.72 300023 ..... 01.3251 20.13 310077 ..... 01.5000 23.09

260175 ..... 01.1270 14.60 270083 ..... 01.1179 10.96 280088 ..... 01.8180 17.33 300024 ..... 01.2662 16.56 310078 ..... 01.3399 22.70

260176 ..... 01.6758 18.44 270084 ..... 00.9031 12.77 280089 ..... 01.0614 13.79 300028 ..... 01.2716 15.52 310081 ..... 01.2643 20.80

260177 ..... 01.3871 19.46 280001 ..... 01.0866 14.11 280090 ..... 00.9838 11.70 300029 ..... 01.3165 21.79 310083 ..... 01.2405 22.20

260178 ..... 01.4760 19.06 280003 ..... 01.9467 18.11 280091 ..... 01.1320 13.17 300033 ..... 01.1041 13.70 310084 ..... 01.2611 20.43

260179 ..... 01.5653 18.02 280005 ..... 01.3791 16.72 280092 ..... 00.8959 11.63 300034 ..... 01.9294 21.31 310086 ..... 01.1743 20.89

260180 ..... 01.7024 18.45 280009 ..... 01.7304 16.70 280094 ..... 01.1287 13.55 310001 ..... 01.7682 24.56 310087 ..... 01.2357 18.95

260183 ..... 01.6443 16.51 280011 ..... 00.9606 11.56 280097 ..... 01.0459 12.56 310002 ..... 01.7260 25.58 310088 ..... 01.2439 19.57

260186 ..... 01.2600 15.20 280012 ..... 01.2348 14.88 280098 ..... 01.0110 09.68 310003 ..... 01.2210 23.16 310090 ..... 01.1901 22.86

260188 ..... 01.2714 15.70 280013 ..... 02.0127 19.71 280101 ..... 01.1114 10.92 310005 ..... 01.2226 19.20 310091 ..... 01.2170 21.35

260189 ..... 00.9400 11.23 280014 ..... 01.0034 10.78 280102 ..... 01.1187 11.77 310006 ..... 01.2198 19.02 310092 ..... 01.3046 20.52

260190 ..... 01.2072 18.46 280015 ..... 01.0314 13.78 280104 ..... 00.9608 09.88 310008 ..... 01.2739 21.23 310093 ..... 01.2163 19.52

260191 ..... 01.1707 19.44 280017 ..... 01.1537 13.42 280105 ..... 01.2920 16.46 310009 ..... 01.2782 21.35 310096 ..... 01.9004 21.19

260193 ..... 01.2240 19.13 280018 ..... 01.1931 12.25 280106 ..... 00.9402 13.23 310010 ..... 01.2912 21.05 310105 ..... 01.1999 22.41

260195 ..... 01.1660 .......... 280020 ..... 01.5257 18.97 280107 ..... 01.0294 12.36 310011 ..... 01.3017 21.71 310108 ..... 01.3824 21.08

260197 ..... 01.3182 20.38 280021 ..... 01.3499 14.01 280108 ..... 01.1461 13.26 310012 ..... 01.5940 23.47 310110 ..... 01.2143 19.69

260198 ..... 01.2213 14.98 280022 ..... 00.9770 11.07 280109 ..... 00.9501 10.61 310013 ..... 01.2768 19.91 310111 ..... 01.2557 19.70

260200 ..... 01.3554 19.14 280023 ..... 01.3780 13.73 280110 ..... 00.9942 10.88 310014 ..... 01.7025 23.69 310112 ..... 01.2426 20.58

270002 ..... 01.1911 13.92 280024 ..... 01.0114 13.22 280111 ..... 01.2372 16.06 310015 ..... 01.7776 24.34 310113 ..... 01.2089 20.70

270003 ..... 01.2465 18.65 280025 ..... 00.9810 11.07 280114 ..... 00.9353 10.26 310016 ..... 01.2225 22.93 310115 ..... 01.1943 19.78
27514 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

PAGE 10 OF 16

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310116 ..... 01.2919 21.67 330028 ..... 01.3448 23.76 330132 ..... 01.1620 13.74 330233 ..... 01.5441 29.08 330399 ..... 01.3239 29.65

310118 ..... 01.1849 21.86 330029 ..... 01.1111 17.36 330133 ..... 01.3428 28.31 330234 ..... 02.1918 24.17 340001 ..... 01.4951 19.39

310119 ..... 01.5594 27.27 330030 ..... 01.2349 14.89 330135 ..... 01.2563 16.25 330235 ..... 01.1332 17.37 340002 ..... 01.8825 18.53

310120 ..... 01.0603 17.24 330033 ..... 01.2846 13.46 330136 ..... 01.2637 20.45 330236 ..... 01.3832 26.18 340003 ..... 01.1188 16.56

310121 ..... 01.0460 16.61 330034 ..... 00.7718 36.61 330140 ..... 01.7132 17.19 330238 ..... 01.1820 14.53 340004 ..... 01.4966 17.21

320001 ..... 01.4620 16.76 330036 ..... 01.3298 21.00 330141 ..... 01.3504 23.17 330239 ..... 01.2013 15.44 340005 ..... 01.2221 14.57

320002 ..... 01.4159 21.55 330037 ..... 01.1242 15.17 330144 ..... 00.9758 13.17 330240 ..... 01.3354 26.47 340006 ..... 01.2338 14.56

320003 ..... 01.1576 15.57 330038 ..... 01.2140 14.91 330148 ..... 01.0784 14.39 330241 ..... 01.8652 20.92 340007 ..... 01.1848 14.81

320004 ..... 01.2677 17.86 330039 ..... 00.8486 13.18 330151 ..... 01.0421 13.73 330242 ..... 01.3516 18.35 340008 ..... 01.1458 16.48

320005 ..... 01.3217 17.80 330041 ..... 01.3912 27.81 330152 ..... 01.4273 27.77 330245 ..... 01.2716 17.15 340009 ..... 01.4043 18.58

320006 ..... 01.3699 15.02 330043 ..... 01.2400 25.15 330153 ..... 01.6522 17.44 330246 ..... 01.2502 22.99 340010 ..... 01.3129 16.41

320009 ..... 01.5348 16.75 330044 ..... 01.2405 16.99 330154 ..... 01.5884 .......... 330247 ..... 00.7071 26.49 340011 ..... 01.1134 13.98

320011 ..... 00.9939 17.79 330045 ..... 01.4167 24.83 330157 ..... 01.3091 18.41 330249 ..... 01.2314 15.89 340012 ..... 01.2605 15.82

320012 ..... 01.0231 16.57 330046 ..... 01.5105 28.39 330158 ..... 01.3668 24.33 330250 ..... 01.3166 16.01 340013 ..... 01.2719 16.58

320013 ..... 01.2225 18.28 330047 ..... 01.2265 16.63 330159 ..... 01.3291 17.35 330252 ..... 00.9141 15.40 340014 ..... 01.5921 22.15

320014 ..... 01.0141 08.42 330048 ..... 01.2888 16.10 330160 ..... 01.4618 26.09 330254 ..... 01.0327 15.52 340015 ..... 01.2388 16.44

320016 ..... 01.1571 12.00 330049 ..... 01.2436 17.52 330161 ..... 00.7163 16.00 330258 ..... 01.4234 25.28 340016 ..... 01.1961 15.18

320017 ..... 01.2175 17.67 330053 ..... 01.1270 14.39 330162 ..... 01.2602 26.18 330259 ..... 01.4434 21.99 340017 ..... 01.2581 15.69

320018 ..... 01.4643 16.61 330055 ..... 01.5089 29.02 330163 ..... 01.2099 17.75 330261 ..... 01.2224 24.35 340018 ..... 01.1212 14.78

320019 ..... 01.4799 19.01 330056 ..... 01.4367 28.30 330164 ..... 01.3999 18.96 330263 ..... 00.9948 17.00 340019 ..... 01.0453 13.69

320021 ..... 01.7045 20.62 330057 ..... 01.7192 15.43 330166 ..... 00.9641 13.96 330264 ..... 01.2753 20.00 340020 ..... 01.1711 17.33

320022 ..... 01.1678 16.34 330058 ..... 01.3255 15.69 330167 ..... 01.6419 27.45 330265 ..... 01.3114 15.78 340021 ..... 01.2221 15.08

320023 ..... 01.0224 13.29 330059 ..... 01.6149 29.66 330169 ..... 01.4285 31.70 330267 ..... 01.2789 22.78 340022 ..... 01.0451 14.56

320030 ..... 00.9845 16.54 330061 ..... 01.2961 23.38 330171 ..... 01.2758 21.15 330268 ..... 00.9689 15.79 340023 ..... 01.3842 18.44

320031 ..... 00.8961 14.78 330062 ..... 01.1834 14.99 330175 ..... 01.1250 14.28 330270 ..... 01.9667 30.33 340024 ..... 01.2260 15.05

320032 ..... 01.0053 16.66 330064 ..... 01.3837 28.38 330177 ..... 01.0204 12.46 330273 ..... 01.2909 21.36 340025 ..... 01.1908 14.15

320033 ..... 01.1561 19.23 330065 ..... 01.1753 17.14 330179 ..... 00.8644 14.09 330275 ..... 01.2168 18.19 340027 ..... 01.2025 15.46

320035 ..... 01.0000 14.82 330066 ..... 01.2326 17.26 330180 ..... 01.1942 16.09 330276 ..... 01.1889 16.58 340028 ..... 01.5288 17.48

320037 ..... 01.2063 15.17 330067 ..... 01.3792 19.68 330181 ..... 01.3113 28.32 330277 ..... 01.1317 16.35 340030 ..... 02.0064 19.06

320038 ..... 01.1613 15.62 330072 ..... 01.3367 26.92 330182 ..... 02.5604 26.92 330279 ..... 01.2905 17.24 340031 ..... 00.9382 12.56

320046 ..... 01.1938 18.23 330073 ..... 01.1865 14.20 330183 ..... 01.4402 18.88 330285 ..... 01.8179 21.81 340032 ..... 01.3951 17.87

320048 ..... 01.3453 13.90 330074 ..... 01.1952 16.89 330184 ..... 01.3357 25.83 330286 ..... 01.3134 22.59 340035 ..... 01.1716 14.97

320056 ..... 00.9819 .......... 330075 ..... 01.0925 16.48 330185 ..... 01.2303 24.23 330290 ..... 01.7595 28.28 340036 ..... 01.1656 17.04

320057 ..... 01.0612 .......... 330078 ..... 01.4429 16.90 330186 ..... 00.9205 18.79 330293 ..... 01.1658 13.72 340037 ..... 01.1731 15.50

320058 ..... 00.9103 .......... 330079 ..... 01.3056 16.60 330188 ..... 01.1826 17.75 330304 ..... 01.2716 25.62 340038 ..... 01.1099 14.52

320059 ..... 00.9799 .......... 330080 ..... 01.4028 24.95 330189 ..... 01.3836 16.20 330306 ..... 01.4564 26.59 340039 ..... 01.2731 19.18

320060 ..... 00.9135 .......... 330082 ..... 01.1164 16.29 330191 ..... 01.2642 17.14 330307 ..... 01.2198 18.33 340040 ..... 01.7730 17.75

320061 ..... 01.0790 .......... 330084 ..... 00.9954 15.59 330193 ..... 01.2990 27.34 330308 ..... 01.1771 28.68 340041 ..... 01.2428 15.99

320062 ..... 00.9353 .......... 330085 ..... 01.3139 18.66 330194 ..... 01.8175 26.07 330309 ..... 01.2301 24.67 340042 ..... 01.1875 13.80

320063 ..... 01.3344 15.84 330086 ..... 01.2522 24.13 330195 ..... 01.6251 29.02 330314 ..... 01.3625 21.07 340044 ..... 01.1061 13.26

320065 ..... 01.2800 16.76 330088 ..... 01.1053 24.41 330196 ..... 01.3279 25.53 330315 ..... 01.2528 24.58 340045 ..... 01.0396 10.95

320067 ..... 00.8183 09.19 330090 ..... 01.5574 16.86 330197 ..... 01.0999 14.43 330316 ..... 01.3007 26.23 340047 ..... 01.8881 17.90

320068 ..... 00.9221 17.98 330091 ..... 01.3825 17.64 330198 ..... 01.3312 22.17 330327 ..... 00.9294 15.30 340048 ..... 00.9055 09.39

320069 ..... 01.0367 09.08 330092 ..... 01.1062 13.64 330199 ..... 01.4730 24.90 330331 ..... 01.2281 27.78 340049 ..... 00.6394 15.10

320070 ..... 01.0220 .......... 330094 ..... 01.2285 15.57 330201 ..... 01.5327 27.38 330332 ..... 01.2569 24.30 340050 ..... 01.1927 14.69

320074 ..... 01.1134 17.15 330095 ..... 01.2586 16.43 330202 ..... 01.4667 25.07 330333 ..... 01.3666 22.00 340051 ..... 01.2724 16.23

320079 ..... 01.1977 17.41 330096 ..... 01.0690 14.47 330203 ..... 01.4028 19.16 330336 ..... 01.3373 27.39 340052 ..... 01.0387 18.62

330001 ..... 01.1965 24.84 330097 ..... 01.1645 14.51 330204 ..... 01.4276 24.90 330338 ..... 01.1337 22.52 340053 ..... 01.6979 18.94

330002 ..... 01.4946 24.26 330100 ..... 00.6809 25.95 330205 ..... 01.1548 19.46 330339 ..... 00.8047 18.09 340054 ..... 01.0903 12.68

330003 ..... 01.3431 19.29 330101 ..... 01.7909 33.09 330208 ..... 01.2046 23.16 330340 ..... 01.2007 23.91 340055 ..... 01.2066 16.69

330004 ..... 01.2765 19.10 330102 ..... 01.2998 16.32 330209 ..... 01.1899 21.17 330350 ..... 01.8078 27.96 340060 ..... 01.1317 16.38

330005 ..... 01.8086 19.53 330103 ..... 01.2457 15.94 330211 ..... 01.2056 16.31 330353 ..... 01.3988 27.49 340061 ..... 01.7130 19.20

330006 ..... 01.3140 24.11 330104 ..... 01.3533 25.44 330212 ..... 01.1780 20.25 330354 ..... 01.3850 .......... 340063 ..... 01.0618 13.01

330007 ..... 01.3275 17.39 330106 ..... 01.5693 33.04 330213 ..... 01.1258 16.19 330357 ..... 01.3770 32.07 340064 ..... 01.2274 16.89

330008 ..... 01.1201 15.74 330107 ..... 01.2581 24.38 330214 ..... 01.7374 28.82 330359 ..... 00.9481 23.70 340065 ..... 01.3093 12.82

330009 ..... 01.3524 28.08 330108 ..... 01.2108 15.85 330215 ..... 01.2093 15.65 330372 ..... 01.2689 22.53 340067 ..... 01.1980 12.84

330010 ..... 01.1699 15.34 330111 ..... 01.0835 14.62 330218 ..... 01.1561 17.16 330381 ..... 01.1775 26.80 340068 ..... 01.2347 14.09

330011 ..... 01.2484 17.22 330114 ..... 00.8917 15.48 330219 ..... 01.6451 18.39 330385 ..... 01.1714 29.27 340069 ..... 01.7147 18.31

330012 ..... 01.6092 27.82 330115 ..... 01.2026 14.46 330221 ..... 01.3287 26.57 330386 ..... 01.1388 20.82 340070 ..... 01.3855 16.89

330013 ..... 02.0610 16.84 330116 ..... 00.9205 13.82 330222 ..... 01.2641 15.28 330387 ..... 00.8466 23.28 340071 ..... 01.0722 14.30

330014 ..... 01.3839 27.12 330118 ..... 01.6256 18.16 330223 ..... 01.0773 15.10 330389 ..... 01.8147 29.95 340072 ..... 01.1441 13.86

330016 ..... 01.0259 14.55 330119 ..... 01.7361 29.88 330224 ..... 01.2693 18.85 330390 ..... 01.2508 28.38 340073 ..... 01.4620 20.47

330019 ..... 01.1269 23.60 330121 ..... 01.0046 14.35 330225 ..... 01.1710 23.34 330393 ..... 01.7066 25.24 340075 ..... 01.1488 15.98

330020 ..... 01.0498 14.20 330122 ..... 01.2006 20.92 330226 ..... 01.2690 16.53 330394 ..... 01.5060 17.27 340080 ..... 01.1232 13.55

330023 ..... 01.2458 22.76 330125 ..... 01.8084 19.69 330229 ..... 01.3174 14.90 330395 ..... 01.3465 30.16 340084 ..... 01.0577 14.51

330024 ..... 01.9139 30.03 330126 ..... 01.2271 20.35 330230 ..... 01.5132 26.44 330396 ..... 01.2729 26.86 340085 ..... 01.2634 15.46

330025 ..... 01.1935 13.80 330127 ..... 01.3930 25.99 330231 ..... 01.1306 27.57 330397 ..... 01.2901 23.98 340087 ..... 01.1402 16.80

330027 ..... 01.4632 28.56 330128 ..... 01.3068 25.26 330232 ..... 01.2194 15.46 330398 ..... 01.2229 26.59 340088 ..... 01.1242 16.32
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27515

PAGE 11 OF 16

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340089 ..... 00.9624 12.28 350011 ..... 01.9150 17.37 360036 ..... 01.3220 17.27 360113 ..... 01.3029 18.24 360204 ..... 01.2911 16.96

340090 ..... 01.1324 15.49 350012 ..... 01.1423 12.36 360037 ..... 02.1403 20.14 360114 ..... 01.1471 16.05 360210 ..... 01.2281 19.23

340091 ..... 01.6487 18.32 350013 ..... 01.0828 14.58 360038 ..... 01.5899 17.85 360115 ..... 01.3208 18.08 360211 ..... 01.2341 17.25

340093 ..... 01.0683 11.60 350014 ..... 01.0438 14.29 360039 ..... 01.2504 15.38 360116 ..... 01.1336 16.04 360212 ..... 01.3982 20.25

340094 ..... 01.3312 16.83 350015 ..... 01.7039 14.44 360040 ..... 01.3208 17.72 360118 ..... 01.3257 17.37 360213 ..... 01.1677 15.77

340096 ..... 01.2015 17.18 350016 ..... 01.0482 10.35 360041 ..... 01.3759 18.25 360121 ..... 01.2853 16.74 360218 ..... 01.2994 16.21

340097 ..... 01.1584 16.04 350017 ..... 01.4595 14.52 360042 ..... 01.1088 16.74 360122 ..... 01.3802 17.77 360230 ..... 01.3282 20.27

340098 ..... 01.6790 19.05 350018 ..... 01.1672 10.67 360044 ..... 01.1425 15.79 360123 ..... 01.2539 17.50 360231 ..... 01.1364 12.45

340099 ..... 01.0973 13.36 350019 ..... 01.6119 18.69 360045 ..... 01.4898 19.25 360124 ..... 01.2571 17.08 360234 ..... 01.3614 17.90

340101 ..... 01.0284 11.11 350020 ..... 01.4933 17.82 360046 ..... 01.1375 18.60 360125 ..... 01.1173 16.87 360236 ..... 01.1885 18.56

340104 ..... 00.9509 10.60 350021 ..... 01.0719 10.94 360047 ..... 01.2246 13.85 360126 ..... 01.2013 18.97 360239 ..... 01.2445 18.70

340105 ..... 01.3875 17.75 350023 ..... 00.8794 15.59 360048 ..... 01.7427 21.00 360127 ..... 01.1556 16.28 360241 ..... 00.5303 17.69

340106 ..... 01.1119 17.79 350024 ..... 01.1055 13.69 360049 ..... 01.2627 17.36 360128 ..... 01.1296 13.85 360242 ..... 01.6927 ..........

340107 ..... 01.3175 16.17 350025 ..... 01.0584 12.60 360050 ..... 01.1772 12.43 360129 ..... 01.0407 14.06 360243 ..... 00.7499 14.35

340109 ..... 01.3284 15.91 350027 ..... 00.9693 12.57 360051 ..... 01.5377 21.83 360130 ..... 01.1314 15.16 360244 ..... 00.7183 16.77

340111 ..... 01.1696 13.78 350029 ..... 01.0052 12.34 360052 ..... 01.7099 17.88 360131 ..... 01.4113 16.27 360245 ..... 00.8026 12.10

340112 ..... 01.2281 14.03 350030 ..... 01.0850 16.04 360054 ..... 01.2577 15.55 360132 ..... 01.2353 20.78 360246 ..... 00.8761 15.05

340113 ..... 01.9956 19.50 350033 ..... 00.9626 13.23 360055 ..... 01.2369 18.92 360133 ..... 01.4730 17.61 360247 ..... 00.4357 ..........

340114 ..... 01.5144 19.16 350034 ..... 01.0422 13.58 360056 ..... 01.3471 16.92 360134 ..... 01.5906 18.25 370001 ..... 01.6940 18.41

340115 ..... 01.5599 17.23 350035 ..... 00.9058 10.11 360057 ..... 01.0323 13.04 360135 ..... 01.1609 17.12 370002 ..... 01.2409 13.60

340116 ..... 01.9326 20.30 350038 ..... 01.0433 13.26 360058 ..... 01.2713 15.35 360136 ..... 01.0537 14.73 370004 ..... 01.2787 15.30

340119 ..... 01.2864 15.21 350039 ..... 00.9735 13.53 360059 ..... 01.5326 20.00 360137 ..... 01.5595 18.98 370005 ..... 01.0310 14.12

340120 ..... 01.1407 12.33 350041 ..... 01.0473 13.05 360062 ..... 01.4664 18.40 360140 ..... 01.0061 15.47 370006 ..... 01.3098 14.88

340121 ..... 01.0454 14.52 350042 ..... 01.0545 12.39 360063 ..... 01.1442 17.19 360141 ..... 01.4435 19.84 370007 ..... 01.1454 12.80

340122 ..... 00.9955 10.30 350043 ..... 01.6433 16.58 360064 ..... 01.5484 19.65 360142 ..... 01.0217 14.99 370008 ..... 01.4101 16.02

340123 ..... 01.1301 14.07 350044 ..... 00.9167 10.01 360065 ..... 01.2285 16.97 360143 ..... 01.2936 17.74 370011 ..... 01.0535 12.51

340124 ..... 01.0290 12.27 350047 ..... 01.2270 16.64 360066 ..... 01.3888 17.16 360144 ..... 01.3153 20.19 370012 ..... 00.8431 09.22

340125 ..... 01.4128 16.94 350049 ..... 01.2236 10.38 360067 ..... 01.2739 12.11 360145 ..... 01.6266 16.84 370013 ..... 01.7649 18.61

340126 ..... 01.4341 16.23 350050 ..... 00.9361 10.25 360068 ..... 01.6561 21.91 360147 ..... 01.2668 15.55 370014 ..... 01.3220 17.14

340127 ..... 01.3124 16.30 350051 ..... 00.9479 14.13 360069 ..... 01.1403 16.38 360148 ..... 01.0725 16.50 370015 ..... 01.2733 13.84

340129 ..... 01.3428 18.65 350053 ..... 01.0745 09.47 360070 ..... 01.6756 16.57 360149 ..... 01.1481 20.33 370016 ..... 01.3805 14.25

340130 ..... 01.3270 16.03 350055 ..... 00.9216 11.50 360071 ..... 01.2663 15.42 360150 ..... 01.2805 17.70 370017 ..... 01.1032 12.14

340131 ..... 01.4309 15.77 350056 ..... 00.9559 12.92 360072 ..... 01.1415 16.29 360151 ..... 01.3134 16.55 370018 ..... 01.2603 14.06

340132 ..... 01.3108 12.41 350058 ..... 00.9358 12.18 360074 ..... 01.3554 19.15 360152 ..... 01.4800 17.65 370019 ..... 01.3065 11.91

340133 ..... 01.0442 13.87 350060 ..... 00.7458 07.59 360075 ..... 01.4959 20.80 360153 ..... 01.1489 13.64 370020 ..... 01.2921 12.53

340136 ..... 00.7885 24.45 350061 ..... 01.0638 13.77 360076 ..... 01.3053 18.84 360154 ..... 01.0301 12.39 370021 ..... 00.9804 10.01

340137 ..... 01.2184 12.68 350063 ..... 00.8926 .......... 360077 ..... 01.4743 18.59 360155 ..... 01.3265 18.75 370022 ..... 01.2770 15.09

340138 ..... 01.1777 17.60 350064 ..... 00.9587 .......... 360078 ..... 01.2792 18.97 360156 ..... 01.3473 16.47 370023 ..... 01.3268 14.95

340141 ..... 01.6350 18.27 350066 ..... 00.7912 .......... 360079 ..... 01.7583 19.31 360159 ..... 01.1944 18.50 370025 ..... 01.3983 15.37

340142 ..... 01.2013 14.94 360001 ..... 01.3143 17.88 360080 ..... 01.1127 14.39 360161 ..... 01.2723 18.78 370026 ..... 01.4214 16.08

340143 ..... 01.3902 18.50 360002 ..... 01.1965 15.17 360081 ..... 01.3567 17.92 360162 ..... 01.2555 17.27 370028 ..... 01.8667 17.67

340144 ..... 01.4374 14.85 360003 ..... 01.7521 19.64 360082 ..... 01.3134 19.81 360163 ..... 01.8595 19.87 370029 ..... 01.2233 12.79

340145 ..... 01.3310 16.80 360006 ..... 01.7493 19.53 360083 ..... 01.2570 15.49 360164 ..... 00.8555 13.98 370030 ..... 01.2426 12.05

340146 ..... 01.0146 15.42 360007 ..... 01.0552 15.41 360084 ..... 01.6203 18.16 360165 ..... 01.2257 14.31 370032 ..... 01.5278 14.28

340147 ..... 01.2935 17.80 360008 ..... 01.2985 16.20 360085 ..... 01.8174 19.63 360166 ..... 01.1556 15.83 370033 ..... 01.0835 11.23

340148 ..... 01.4339 18.28 360009 ..... 01.3946 17.35 360086 ..... 01.4601 16.75 360169 ..... 00.9799 16.99 370034 ..... 01.2667 12.80

340151 ..... 01.1224 14.05 360010 ..... 01.2275 15.38 360087 ..... 01.4074 17.32 360170 ..... 01.2837 16.07 370035 ..... 01.6190 15.21

340153 ..... 01.9701 21.08 360011 ..... 01.2285 17.83 360088 ..... 01.2127 15.48 360172 ..... 01.3763 16.62 370036 ..... 01.0290 ..........

340155 ..... 01.3926 20.91 360012 ..... 01.3020 17.61 360089 ..... 01.1680 16.92 360174 ..... 01.2365 19.24 370037 ..... 01.7236 17.83

340156 ..... 00.8066 .......... 360013 ..... 01.0836 16.71 360090 ..... 01.2316 17.90 360175 ..... 01.2401 17.61 370038 ..... 00.9187 12.01

340158 ..... 01.1738 16.16 360014 ..... 01.1219 17.57 360091 ..... 01.2648 18.90 360176 ..... 01.1559 15.53 370039 ..... 01.4573 17.22

340159 ..... 01.1571 16.88 360016 ..... 01.6012 17.81 360092 ..... 01.2659 17.85 360177 ..... 01.2581 16.30 370040 ..... 01.1051 10.89

340160 ..... 01.0774 12.88 360017 ..... 01.7592 19.82 360093 ..... 01.2188 16.66 360178 ..... 01.2276 15.58 370041 ..... 01.0285 13.52

340162 ..... 01.2237 17.29 360018 ..... 01.5445 18.51 360094 ..... 01.2950 20.27 360179 ..... 01.2916 19.01 370042 ..... 00.8575 10.56

340164 ..... 01.4566 18.15 360019 ..... 01.2857 18.22 360095 ..... 01.3340 16.68 360180 ..... 02.0922 22.07 370043 ..... 00.9719 12.91

340166 ..... 01.4166 18.51 360020 ..... 01.4313 20.05 360096 ..... 01.1097 16.20 360184 ..... 00.4913 17.11 370045 ..... 01.0983 10.20

340168 ..... 00.5085 14.78 360021 ..... 01.2770 18.04 360098 ..... 01.4006 18.00 360185 ..... 01.2493 17.09 370046 ..... 00.9827 09.22

340171 ..... 01.1229 .......... 360024 ..... 01.4310 17.76 360099 ..... 01.1130 16.91 360186 ..... 01.1727 15.04 370047 ..... 01.3245 15.40

350001 ..... 01.0099 11.13 360025 ..... 01.2355 17.66 360100 ..... 01.3239 15.63 360187 ..... 01.2787 16.00 370048 ..... 01.1876 13.46

350002 ..... 01.7678 16.04 360026 ..... 01.1897 15.59 360101 ..... 01.7334 19.71 360188 ..... 00.9998 14.77 370049 ..... 01.3566 15.60

350003 ..... 01.1971 15.67 360027 ..... 01.5255 19.06 360102 ..... 01.2713 19.68 360189 ..... 01.0092 15.40 370051 ..... 00.9627 13.31

350004 ..... 01.9429 17.88 360028 ..... 01.4563 15.28 360103 ..... 01.3290 18.70 360192 ..... 01.2404 19.28 370054 ..... 01.3878 14.79

350005 ..... 01.0670 13.14 360029 ..... 01.1611 16.41 360104 ..... 01.8950 20.28 360193 ..... 01.3104 16.77 370056 ..... 01.5609 15.41

350006 ..... 01.3958 16.16 360030 ..... 01.1326 14.82 360106 ..... 01.0509 13.89 360194 ..... 01.1180 16.14 370057 ..... 01.1711 15.05

350007 ..... 00.9510 12.20 360031 ..... 01.3534 18.42 360107 ..... 01.2373 16.98 360195 ..... 01.1319 17.72 370059 ..... 01.1178 13.53

350008 ..... 01.0408 15.15 360032 ..... 01.0876 16.18 360108 ..... 01.0371 15.08 360197 ..... 01.2030 16.76 370060 ..... 01.0787 12.88

350009 ..... 01.1648 15.74 360034 ..... 01.1698 13.30 360109 ..... 01.0970 17.43 360200 ..... 00.9989 13.48 370063 ..... 01.0947 13.12

350010 ..... 01.1768 12.30 360035 ..... 01.5734 19.90 360112 ..... 01.7594 21.61 360203 ..... 01.1502 15.55 370064 ..... 01.0006 10.14
27516 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

PAGE 12 OF 16

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370065 ..... 01.0475 14.76 370195 ..... 00.9505 .......... 390004 ..... 01.3767 16.70 390080 ..... 01.2555 18.66 390167 ..... 01.2691 20.71

370071 ..... 01.0381 10.18 380001 ..... 01.3213 19.27 390005 ..... 01.0865 14.82 390081 ..... 01.3510 20.23 390168 ..... 01.1971 17.49

370072 ..... 00.9034 11.67 380002 ..... 01.2104 22.74 390006 ..... 01.7405 17.39 390083 ..... 01.2377 20.87 390169 ..... 01.2059 18.63

370076 ..... 01.3228 12.42 380003 ..... 01.1411 18.75 390007 ..... 01.1827 21.33 390084 ..... 01.2406 15.29 390170 ..... 01.8512 22.43

370077 ..... 01.2244 16.30 380004 ..... 01.6835 22.89 390008 ..... 01.1329 15.08 390086 ..... 01.1338 16.87 390173 ..... 01.1970 17.08

370078 ..... 01.7096 14.58 380005 ..... 01.1844 19.47 390009 ..... 01.6076 17.97 390088 ..... 01.3128 18.42 390174 ..... 01.7084 24.17

370079 ..... 00.9596 11.98 380006 ..... 01.3941 18.29 390010 ..... 01.1788 16.58 390090 ..... 01.7984 19.42 390176 ..... 01.1554 16.79

370080 ..... 00.9895 11.12 380007 ..... 01.5747 22.66 390011 ..... 01.2486 16.49 390091 ..... 01.1719 17.09 390178 ..... 01.2863 17.63

370082 ..... 00.9026 12.48 380008 ..... 01.0694 18.69 390012 ..... 01.1879 19.15 390093 ..... 01.1483 15.20 390179 ..... 01.2723 22.80

370083 ..... 00.9519 10.95 380009 ..... 01.8168 22.17 390013 ..... 01.2292 16.77 390095 ..... 01.1706 13.95 390180 ..... 01.5471 22.83

370084 ..... 01.0346 08.88 380010 ..... 01.0963 24.15 390014 ..... 01.6409 16.42 390096 ..... 01.2685 16.88 390181 ..... 01.0604 17.80

370085 ..... 00.8099 12.94 380011 ..... 01.0945 14.95 390015 ..... 01.1953 13.06 390097 ..... 01.3276 20.91 390183 ..... 01.1832 17.16

370086 ..... 01.1956 09.89 380013 ..... 01.2681 21.54 390016 ..... 01.2237 15.58 390098 ..... 01.7625 20.06 390184 ..... 01.1052 17.69

370089 ..... 01.2826 14.01 380014 ..... 01.4140 18.89 390017 ..... 01.1682 14.20 390100 ..... 01.6300 19.30 390185 ..... 01.2228 16.12

370091 ..... 01.6822 16.13 380017 ..... 01.7069 21.77 390018 ..... 01.2273 19.41 390101 ..... 01.1992 15.70 390189 ..... 01.0395 17.78

370092 ..... 01.0705 12.73 380018 ..... 01.8382 19.21 390019 ..... 01.1151 14.53 390102 ..... 01.3664 20.34 390191 ..... 01.0524 13.91

370093 ..... 01.8611 18.67 380019 ..... 01.2076 18.88 390022 ..... 01.3923 21.81 390103 ..... 01.0990 17.17 390192 ..... 01.1238 17.15

370094 ..... 01.4135 16.67 380020 ..... 01.4350 20.06 390023 ..... 01.2514 19.71 390104 ..... 01.0557 15.15 390193 ..... 01.1950 15.39

370095 ..... 00.9154 11.62 380021 ..... 01.2873 19.10 390024 ..... 00.8646 22.54 390106 ..... 01.0122 14.85 390194 ..... 01.1560 18.97

370097 ..... 01.3691 18.65 380022 ..... 01.1702 19.92 390025 ..... 00.6443 16.64 390107 ..... 01.2482 18.52 390195 ..... 01.8265 22.08

370099 ..... 01.1663 13.22 380023 ..... 01.2350 17.76 390026 ..... 01.2687 20.58 390108 ..... 01.4077 19.97 390196 ..... 01.4066 ..........

370100 ..... 01.0423 13.02 380025 ..... 01.2670 21.81 390027 ..... 01.9708 23.48 390109 ..... 01.1523 14.44 390197 ..... 01.3091 18.40

370103 ..... 00.9024 11.77 380026 ..... 01.1899 16.87 390028 ..... 01.7871 18.54 390110 ..... 01.6465 17.36 390198 ..... 01.1942 15.21

370105 ..... 02.0043 17.06 380027 ..... 01.2587 20.25 390029 ..... 01.9395 18.73 390111 ..... 01.8583 26.22 390199 ..... 01.2016 14.89

370106 ..... 01.5411 16.96 380029 ..... 01.1474 17.29 390030 ..... 01.2365 16.29 390112 ..... 01.1488 12.16 390200 ..... 01.0147 14.67

370108 ..... 01.0551 10.82 380031 ..... 01.0329 15.92 390031 ..... 01.1587 16.93 390113 ..... 01.2113 16.04 390201 ..... 01.2666 18.75

370112 ..... 01.0769 12.33 380033 ..... 01.7783 22.97 390032 ..... 01.2498 17.80 390114 ..... 01.1217 21.07 390203 ..... 01.3102 20.45

370113 ..... 01.1674 12.33 380035 ..... 01.3580 18.58 390035 ..... 01.2774 17.24 390115 ..... 01.3154 21.40 390204 ..... 01.2596 20.05

370114 ..... 01.6305 14.69 380036 ..... 01.1305 17.27 390036 ..... 01.3337 17.63 390116 ..... 01.2237 19.91 390205 ..... 01.3479 22.42

370121 ..... 01.1729 15.78 380037 ..... 01.2063 18.24 390037 ..... 01.3426 18.07 390117 ..... 01.1636 15.65 390206 ..... 01.3349 19.91

370122 ..... 01.1291 09.78 380038 ..... 01.3425 21.15 390039 ..... 01.0948 15.60 390118 ..... 01.1524 16.29 390209 ..... 01.0438 15.48

370123 ..... 01.2098 14.12 380039 ..... 01.3082 18.89 390040 ..... 01.0024 12.71 390119 ..... 01.3475 17.17 390211 ..... 01.1929 16.47

370125 ..... 01.0284 11.90 380040 ..... 01.2507 19.23 390041 ..... 01.2475 16.82 390121 ..... 01.3363 18.95 390213 ..... 00.9476 14.55

370126 ..... 00.9483 10.66 380042 ..... 01.1550 18.06 390042 ..... 01.4374 20.74 390122 ..... 01.0719 16.06 390215 ..... 01.1565 20.69

370131 ..... 01.0232 12.93 380047 ..... 01.6960 19.84 390043 ..... 01.0988 15.65 390123 ..... 01.3041 20.58 390217 ..... 01.2781 17.92

370133 ..... 01.1213 09.82 380048 ..... 01.0936 13.92 390044 ..... 01.5993 18.80 390125 ..... 01.2255 15.08 390219 ..... 01.3149 18.57

370138 ..... 01.1138 14.40 380050 ..... 01.3349 16.37 390045 ..... 01.7321 17.35 390126 ..... 01.3266 20.07 390220 ..... 01.2126 19.33

370139 ..... 01.0944 10.62 380051 ..... 01.5217 19.13 390046 ..... 01.5446 18.49 390127 ..... 01.2319 20.26 390222 ..... 01.3083 20.42

370140 ..... 01.0059 11.71 380052 ..... 01.1764 16.70 390047 ..... 01.6845 18.24 390128 ..... 01.2014 17.96 390223 ..... 01.6376 23.15

370141 ..... 01.3883 19.17 380055 ..... 01.2275 23.88 390048 ..... 01.1857 16.26 390130 ..... 01.1480 16.62 390224 ..... 00.9314 13.04

370146 ..... 01.0486 12.03 380056 ..... 01.0753 15.78 390049 ..... 01.5514 19.82 390131 ..... 01.2704 16.06 390225 ..... 01.2124 15.42

370148 ..... 01.6050 19.01 380060 ..... 01.5375 21.51 390050 ..... 02.1389 21.60 390132 ..... 01.2425 20.25 390226 ..... 01.7861 23.22

370149 ..... 01.2373 15.19 380061 ..... 01.5190 22.00 390051 ..... 02.1828 24.98 390133 ..... 01.7790 20.57 390228 ..... 01.2071 18.67

370153 ..... 01.0915 13.17 380062 ..... 01.1039 15.07 390052 ..... 01.1846 16.68 390135 ..... 01.2913 19.73 390231 ..... 01.3122 21.89

370154 ..... 01.0164 12.31 380063 ..... 01.3354 21.48 390054 ..... 01.2245 14.56 390136 ..... 01.2338 15.66 390233 ..... 01.3268 16.71

370156 ..... 01.1022 13.37 380064 ..... 01.4398 18.47 390055 ..... 01.7751 21.82 390137 ..... 01.2962 17.80 390235 ..... 01.5635 23.94

370158 ..... 01.0538 12.08 380065 ..... 01.0680 19.24 390056 ..... 01.1222 15.73 390138 ..... 01.3365 17.41 390236 ..... 01.1643 15.90

370159 ..... 01.3427 13.95 380066 ..... 01.3162 17.60 390057 ..... 01.3263 18.94 390139 ..... 01.4984 23.50 390237 ..... 01.6149 20.17

370163 ..... 00.8558 10.99 380068 ..... 01.0655 19.31 390058 ..... 01.3239 17.46 390142 ..... 01.6716 22.64 390238 ..... 01.3009 16.12

370165 ..... 01.0872 11.74 380069 ..... 01.1328 17.51 390060 ..... 01.1432 16.68 390145 ..... 01.3596 18.64 390242 ..... 01.2772 18.69

370166 ..... 01.0886 15.48 380070 ..... 01.3924 21.21 390061 ..... 01.4426 20.47 390146 ..... 01.3088 16.19 390244 ..... 00.9339 13.32

370169 ..... 01.1024 10.66 380071 ..... 01.2894 18.06 390062 ..... 01.1400 15.76 390147 ..... 01.2505 19.22 390245 ..... 01.3465 23.15

370170 ..... 00.9792 .......... 380072 ..... 00.9714 14.15 390063 ..... 01.7324 19.20 390149 ..... 01.2579 19.59 390246 ..... 01.2349 15.91

370171 ..... 01.0341 .......... 380075 ..... 01.4281 20.90 390064 ..... 01.5561 16.25 390150 ..... 01.1065 17.50 390247 ..... 01.0497 17.22

370172 ..... 00.8587 .......... 380078 ..... 01.1638 16.95 390065 ..... 01.2903 18.85 390151 ..... 01.2927 18.26 390249 ..... 01.0291 10.81

370173 ..... 01.2420 .......... 380081 ..... 01.1568 17.66 390066 ..... 01.2933 17.15 390152 ..... 01.0351 17.07 390256 ..... 01.7792 23.51

370174 ..... 00.9656 .......... 380082 ..... 01.2906 20.35 390067 ..... 01.8083 18.03 390153 ..... 01.2473 21.93 390258 ..... 01.2502 19.78

370176 ..... 01.1495 16.48 380083 ..... 01.2487 18.93 390068 ..... 01.3245 18.13 390154 ..... 01.1877 13.93 390260 ..... 01.1823 15.95

370177 ..... 00.9686 10.10 380084 ..... 01.2127 20.61 390069 ..... 01.3242 19.23 390155 ..... 01.2985 20.06 390262 ..... 01.9798 17.25

370178 ..... 01.0015 12.17 380087 ..... 01.0083 12.30 390070 ..... 01.2898 19.49 390156 ..... 01.4337 22.61 390263 ..... 01.4331 18.66

370179 ..... 00.8966 14.28 380088 ..... 01.0059 15.71 390071 ..... 01.1154 13.36 390157 ..... 01.3427 17.97 390265 ..... 01.3123 17.72

370180 ..... 01.0716 .......... 380089 ..... 01.2909 21.87 390072 ..... 01.1133 15.76 390158 ..... 01.5891 .......... 390266 ..... 01.2098 16.69

370183 ..... 01.0864 14.00 380090 ..... 01.3011 24.41 390073 ..... 01.6002 18.94 390160 ..... 01.2031 17.67 390267 ..... 01.2930 18.93

370186 ..... 01.0206 12.72 380091 ..... 01.2113 23.79 390074 ..... 01.2369 16.26 390161 ..... 01.0981 14.87 390268 ..... 01.3884 19.94

370189 ..... 00.9754 10.13 380897 ..... 04.9268 .......... 390075 ..... 01.2410 15.92 390162 ..... 01.4238 19.03 390270 ..... 01.3090 15.89

370190 ..... 01.5480 17.49 390001 ..... 01.3578 18.16 390076 ..... 01.3094 20.45 390163 ..... 01.2248 16.55 390272 ..... 00.4549 ..........

370192 ..... 01.1656 .......... 390002 ..... 01.3668 17.03 390078 ..... 01.0633 15.98 390164 ..... 01.9412 19.14 390277 ..... 00.5643 20.34

370194 ..... 01.1343 .......... 390003 ..... 01.2571 15.57 390079 ..... 01.7083 16.83 390166 ..... 01.1041 17.40 390278 ..... 00.7673 17.52
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27517

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390279 ..... 01.0726 09.45 420005 ..... 01.2017 14.35 430013 ..... 01.2330 15.06 440029 ..... 01.2864 16.30 440148 ..... 01.1406 14.37

390281 ..... 03.1739 .......... 420006 ..... 01.2785 18.90 430014 ..... 01.2742 16.77 440030 ..... 01.1989 13.21 440149 ..... 01.1993 15.19

400001 ..... 01.2170 08.68 420007 ..... 01.5103 16.31 430015 ..... 01.1801 14.41 440031 ..... 00.9653 12.29 440150 ..... 01.2853 19.58

400002 ..... 01.4586 10.39 420009 ..... 01.2131 15.70 430016 ..... 01.8185 17.59 440032 ..... 01.0553 12.65 440151 ..... 01.3706 15.86

400003 ..... 01.2378 07.14 420010 ..... 01.1070 14.35 430018 ..... 00.9882 14.06 440033 ..... 01.0675 14.84 440152 ..... 01.5616 16.91

400004 ..... 01.1516 07.34 420011 ..... 01.0905 14.89 430022 ..... 00.9656 10.91 440034 ..... 01.5798 16.64 440153 ..... 01.2607 15.10

400005 ..... 01.1122 06.10 420014 ..... 01.1343 14.11 430023 ..... 00.9173 09.95 440035 ..... 01.3176 15.65 440156 ..... 01.5650 18.85

400006 ..... 01.2005 08.16 420015 ..... 01.3145 15.96 430024 ..... 00.9117 12.28 440039 ..... 01.6355 16.76 440157 ..... 01.0913 13.64

400007 ..... 01.2599 07.55 420016 ..... 01.0635 14.39 430026 ..... 01.0798 11.36 440040 ..... 00.9697 17.03 440159 ..... 01.2358 14.83

400009 ..... 01.0253 07.68 420018 ..... 01.7204 18.94 430027 ..... 01.8117 16.54 440041 ..... 01.0374 12.35 440161 ..... 01.6916 20.58

400010 ..... 00.9067 07.94 420019 ..... 01.2221 14.90 430028 ..... 01.0938 13.68 440046 ..... 01.3271 13.59 440166 ..... 01.4407 17.80

400011 ..... 00.9999 08.65 420020 ..... 01.3908 15.98 430029 ..... 00.9886 13.10 440047 ..... 00.9568 15.31 440168 ..... 01.0199 13.03

400012 ..... 01.2156 07.09 420023 ..... 01.4241 18.07 430031 ..... 00.9673 11.31 440048 ..... 01.7988 16.64 440173 ..... 01.5155 16.91

400013 ..... 01.2969 08.96 420026 ..... 01.9266 18.05 430033 ..... 01.0218 11.90 440049 ..... 01.6566 15.62 440174 ..... 00.9837 13.30

400014 ..... 01.3613 07.51 420027 ..... 01.3790 15.50 430034 ..... 01.0752 11.58 440050 ..... 01.2035 15.14 440175 ..... 01.2366 18.06

400015 ..... 01.2211 10.88 420030 ..... 01.2885 15.83 430036 ..... 01.0398 10.11 440051 ..... 00.9285 13.29 440176 ..... 01.2916 18.36

400016 ..... 01.3614 10.48 420031 ..... 00.9586 12.15 430037 ..... 00.9784 12.89 440052 ..... 01.2226 14.15 440178 ..... 01.1880 20.20

400017 ..... 01.2405 06.27 420033 ..... 01.2216 19.24 430038 ..... 01.0179 10.77 440053 ..... 01.3071 15.64 440180 ..... 01.1517 16.68

400018 ..... 01.3516 09.35 420035 ..... 00.7985 12.43 430039 ..... 01.0871 11.53 440054 ..... 01.2182 13.84 440181 ..... 01.0190 11.75

400019 ..... 01.6737 09.48 420036 ..... 01.2011 15.38 430040 ..... 00.9098 12.17 440056 ..... 01.0857 13.45 440182 ..... 00.9568 15.33

400021 ..... 01.4421 07.62 420037 ..... 01.2778 19.65 430041 ..... 00.9376 11.91 440057 ..... 01.0155 10.77 440183 ..... 01.5296 15.06

400022 ..... 01.3098 09.79 420038 ..... 01.2852 14.43 430042 ..... 00.9807 10.63 440058 ..... 01.3158 14.95 440184 ..... 01.3494 18.63

400024 ..... 01.0265 08.62 420039 ..... 01.1511 14.52 430043 ..... 01.1938 11.97 440059 ..... 01.3336 15.98 440185 ..... 01.1231 14.24

400026 ..... 00.9430 05.90 420042 ..... 01.2035 12.15 430044 ..... 00.9249 13.17 440060 ..... 01.1799 14.76 440186 ..... 01.1885 16.21

400027 ..... 01.1317 08.32 420043 ..... 01.1800 18.82 430047 ..... 01.1381 12.24 440061 ..... 01.2121 15.46 440187 ..... 01.1952 14.85

400028 ..... 01.0328 07.14 420048 ..... 01.1376 14.26 430048 ..... 01.2063 15.01 440063 ..... 01.6136 17.43 440189 ..... 01.4819 18.81

400029 ..... 01.1287 06.64 420049 ..... 01.1769 14.55 430049 ..... 00.9360 12.66 440064 ..... 01.1860 15.05 440192 ..... 01.1489 13.99

400031 ..... 01.1446 08.00 420051 ..... 01.5568 17.99 430051 ..... 01.0355 13.48 440065 ..... 01.2301 16.18 440193 ..... 01.2852 17.88

400032 ..... 01.1257 07.75 420053 ..... 01.1378 14.03 430054 ..... 01.0034 13.13 440067 ..... 01.1879 15.54 440194 ..... 01.4249 16.89

400044 ..... 01.2430 09.09 420054 ..... 01.3709 16.39 430056 ..... 00.8479 08.93 440068 ..... 01.2130 16.43 440196 ..... 00.9475 13.32

400048 ..... 01.1320 07.91 420055 ..... 01.0623 12.51 430057 ..... 00.9205 10.47 440069 ..... 01.1874 14.17 440197 ..... 01.4007 19.15

400061 ..... 01.7050 13.68 420056 ..... 01.1625 13.41 430060 ..... 01.1594 08.46 440070 ..... 01.1257 12.52 440200 ..... 01.1917 15.41

400079 ..... 01.2488 08.95 420057 ..... 01.1395 14.96 430062 ..... 00.8739 10.31 440071 ..... 01.3946 14.87 440203 ..... 00.9346 13.17

400087 ..... 01.3761 08.90 420059 ..... 00.9844 13.96 430064 ..... 01.1205 11.89 440072 ..... 01.5118 13.92 440205 ..... 01.0962 15.86

400094 ..... 01.0405 07.41 420061 ..... 01.1517 16.16 430065 ..... 00.9527 09.93 440073 ..... 01.3464 16.95 440206 ..... 01.0340 13.82

400098 ..... 01.2435 07.17 420062 ..... 01.4444 15.65 430066 ..... 00.9685 10.93 440078 ..... 01.0260 13.28 440208 ..... 02.0269 ..........

400102 ..... 01.1413 08.65 420064 ..... 01.1161 13.45 430073 ..... 01.0814 .......... 440081 ..... 01.1575 15.31 450002 ..... 01.4623 19.35

400103 ..... 01.3671 08.80 420065 ..... 01.3051 16.72 430076 ..... 00.9768 09.41 440082 ..... 01.9905 20.54 450004 ..... 01.1684 12.38

400104 ..... 01.3703 08.97 420066 ..... 00.9099 14.40 430077 ..... 01.5832 16.53 440083 ..... 01.1099 10.96 450005 ..... 01.1503 13.79

400105 ..... 01.1725 08.37 420067 ..... 01.2333 16.24 430079 ..... 00.9628 11.47 440084 ..... 01.1544 11.41 450007 ..... 01.2442 13.73

400106 ..... 01.2084 08.12 420068 ..... 01.2885 16.08 430080 ..... 01.1317 08.89 440087 ..... 00.9572 14.44 450008 ..... 01.3624 14.96

400109 ..... 01.5298 09.13 420069 ..... 01.1002 13.71 430081 ..... 01.0452 .......... 440090 ..... 00.9308 13.29 450010 ..... 01.3415 15.37

400110 ..... 01.1119 07.87 420070 ..... 01.2639 15.05 430082 ..... 00.8001 .......... 440091 ..... 01.5472 16.53 450011 ..... 01.5000 17.43

400111 ..... 01.1553 07.98 420071 ..... 01.3110 16.13 430083 ..... 00.8672 .......... 440100 ..... 01.0273 12.82 450014 ..... 01.0699 13.84

400112 ..... 01.2298 09.26 420072 ..... 01.0735 10.64 430084 ..... 00.9280 .......... 440102 ..... 01.0695 12.26 450015 ..... 01.5543 14.96

400113 ..... 01.2400 07.57 420073 ..... 01.3095 18.10 430085 ..... 00.8385 .......... 440103 ..... 01.2284 17.24 450016 ..... 01.6256 17.57

400114 ..... 01.0377 06.50 420074 ..... 00.8992 11.72 430087 ..... 00.9105 09.29 440104 ..... 01.6509 17.68 450018 ..... 01.6091 21.75

400115 ..... 01.0054 07.56 420075 ..... 00.9719 12.66 440001 ..... 01.1227 12.18 440105 ..... 01.3723 16.69 450020 ..... 01.0171 15.47

400117 ..... 01.1773 09.23 420078 ..... 01.8088 18.59 440002 ..... 01.5965 15.80 440109 ..... 01.1308 12.28 450021 ..... 01.8117 21.11

400118 ..... 01.1900 08.14 420079 ..... 01.5669 16.94 440003 ..... 01.0714 15.23 440110 ..... 00.9687 16.06 450023 ..... 01.4846 15.80

400120 ..... 01.3084 09.14 420080 ..... 01.2589 19.18 440006 ..... 01.6500 17.60 440111 ..... 01.3613 18.00 450024 ..... 01.3672 16.45

400121 ..... 01.0121 06.51 420082 ..... 01.3946 19.13 440007 ..... 01.0148 11.83 440114 ..... 01.0474 12.68 450025 ..... 01.5058 16.27

400122 ..... 01.0009 05.88 420083 ..... 01.2042 18.36 440008 ..... 00.9878 13.50 440115 ..... 01.1172 14.66 450028 ..... 01.6335 17.17

400123 ..... 01.1728 08.05 420084 ..... 00.7413 13.56 440009 ..... 01.1753 13.22 440120 ..... 01.5385 16.14 450029 ..... 01.3991 12.98

400124 ..... 02.6604 09.27 420085 ..... 01.3970 16.86 440010 ..... 00.9235 08.75 440125 ..... 01.4408 16.09 450031 ..... 01.5830 18.72

410001 ..... 01.3246 23.02 420086 ..... 01.3613 16.90 440011 ..... 01.2901 16.28 440130 ..... 01.1687 14.16 450032 ..... 01.2715 13.63

410004 ..... 01.3655 21.15 420087 ..... 01.5946 16.53 440012 ..... 01.4699 17.72 440131 ..... 01.1317 13.44 450033 ..... 01.6308 16.84

410005 ..... 01.3492 21.90 420088 ..... 01.1349 15.05 440014 ..... 01.0615 09.06 440132 ..... 01.1116 14.01 450034 ..... 01.6445 16.28

410006 ..... 01.2670 21.40 420089 ..... 01.2336 19.40 440015 ..... 01.6051 16.42 440133 ..... 01.5494 17.78 450035 ..... 01.4519 18.91

410007 ..... 01.6550 20.96 420091 ..... 01.2147 13.16 440016 ..... 01.0116 11.35 440135 ..... 01.3062 14.03 450037 ..... 01.6279 17.69

410008 ..... 01.1691 21.05 430004 ..... 01.0955 17.25 440017 ..... 01.6136 18.42 440137 ..... 00.9770 12.14 450039 ..... 01.3345 18.70

410009 ..... 01.2968 20.66 430005 ..... 01.3167 14.06 440018 ..... 01.4675 16.10 440141 ..... 01.0771 13.59 450040 ..... 01.5518 17.75

410010 ..... 01.0160 25.40 430007 ..... 01.0540 12.52 440019 ..... 01.6253 19.06 440142 ..... 01.0311 10.75 450042 ..... 01.6646 15.75

410011 ..... 01.2110 22.25 430008 ..... 01.1248 14.01 440020 ..... 01.2392 15.43 440143 ..... 01.1020 17.21 450043 ..... 01.4473 20.40

410012 ..... 01.7208 19.51 430009 ..... 01.0939 12.21 440022 ..... 01.2040 13.72 440144 ..... 01.3327 18.35 450044 ..... 01.6182 20.04

410013 ..... 01.3105 24.63 430010 ..... 01.1273 09.23 440023 ..... 00.9963 11.58 440145 ..... 01.0439 10.99 450046 ..... 01.3724 14.67

420002 ..... 01.3794 18.80 430011 ..... 01.3139 14.33 440024 ..... 01.3302 16.61 440146 ..... 01.0036 12.98 450047 ..... 01.1155 13.43

420004 ..... 01.8612 18.35 430012 ..... 01.3055 14.97 440025 ..... 01.1317 13.01 440147 ..... 01.1079 17.06 450050 ..... 01.0582 16.00
27518 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

PAGE 14 OF 16

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450051 ..... 01.5923 18.22 450154 ..... 01.2004 12.23 450296 ..... 01.3139 16.46 450484 ..... 01.4849 18.53 450651 ..... 01.8166 21.92

450052 ..... 01.0171 13.13 450155 ..... 01.0191 12.61 450297 ..... 01.0190 12.01 450488 ..... 01.2528 14.98 450652 ..... 00.9114 13.44

450053 ..... 01.1479 13.11 450157 ..... 01.0041 12.97 450299 ..... 01.3455 16.28 450489 ..... 00.9859 11.56 450653 ..... 01.2485 17.98

450054 ..... 01.7181 21.32 450160 ..... 00.9838 17.50 450303 ..... 00.9458 09.97 450497 ..... 01.1299 12.05 450654 ..... 01.0034 11.11

450055 ..... 01.1238 12.92 450162 ..... 01.1851 16.63 450306 ..... 01.0878 12.50 450498 ..... 01.2653 13.88 450656 ..... 01.4908 16.48

450056 ..... 01.6174 18.26 450163 ..... 01.0364 15.34 450307 ..... 00.9041 13.62 450508 ..... 01.5582 16.37 450658 ..... 00.9746 14.01

450058 ..... 01.5774 14.76 450164 ..... 01.0684 12.56 450309 ..... 01.0677 12.74 450514 ..... 01.2163 18.78 450659 ..... 01.5762 22.12

450059 ..... 01.2421 13.21 450165 ..... 00.9569 14.34 450315 ..... 01.1137 19.65 450517 ..... 01.0029 10.94 450660 ..... 01.5698 21.85

450060 ..... 01.3622 22.17 450166 ..... 00.9672 10.06 450320 ..... 01.3364 18.20 450518 ..... 01.5325 16.84 450661 ..... 01.1378 18.94

450063 ..... 00.9758 11.51 450169 ..... 00.9171 13.82 450321 ..... 00.9661 12.45 450523 ..... 01.5243 21.18 450662 ..... 01.6712 16.53

450064 ..... 01.5083 15.34 450170 ..... 00.9792 11.32 450322 ..... 00.7151 15.40 450530 ..... 01.4505 21.64 450665 ..... 00.9334 11.45

450065 ..... 01.1393 14.75 450176 ..... 01.2241 15.23 450324 ..... 01.6484 15.19 450534 ..... 00.9542 20.29 450666 ..... 01.2708 19.05

450068 ..... 01.7951 20.31 450177 ..... 01.0967 13.18 450325 ..... 01.2279 11.93 450535 ..... 01.2557 14.12 450668 ..... 01.5484 18.90

450070 ..... 01.2671 15.46 450178 ..... 01.0123 14.64 450327 ..... 00.9734 12.11 450537 ..... 01.3698 17.80 450669 ..... 01.2923 19.10

450072 ..... 01.2351 18.19 450181 ..... 01.0065 15.15 450330 ..... 01.2256 16.86 450538 ..... 01.3931 21.17 450670 ..... 01.2960 19.44

450073 ..... 01.1202 12.84 450184 ..... 01.5429 17.74 450334 ..... 01.0568 11.65 450539 ..... 01.2925 13.27 450672 ..... 01.6578 18.91

450076 ..... 01.5802 .......... 450185 ..... 01.1137 08.47 450337 ..... 01.2313 17.14 450544 ..... 01.4408 22.65 450673 ..... 01.1428 11.38

450078 ..... 00.9949 11.17 450187 ..... 01.2789 16.44 450340 ..... 01.3177 14.54 450545 ..... 01.2710 14.13 450674 ..... 01.0203 22.09

450079 ..... 01.4395 19.03 450188 ..... 01.0085 12.46 450341 ..... 01.0264 16.26 450546 ..... 01.8365 18.37 450675 ..... 01.5171 17.78

450080 ..... 01.2966 15.79 450190 ..... 01.1841 19.53 450346 ..... 01.3443 16.27 450547 ..... 01.1613 15.09 450677 ..... 01.4324 19.18

450081 ..... 01.1087 12.87 450191 ..... 01.0864 15.75 450347 ..... 01.1430 15.48 450550 ..... 00.9800 17.01 450678 ..... 01.4776 20.45

450082 ..... 00.9627 12.75 450192 ..... 01.2403 15.49 450348 ..... 00.9975 10.99 450551 ..... 01.1957 13.75 450681 ..... 03.0551 17.29

450083 ..... 01.7142 17.21 450193 ..... 01.8944 21.32 450351 ..... 01.1727 18.76 450558 ..... 01.7767 17.17 450683 ..... 01.3083 20.17

450085 ..... 01.0903 14.38 450194 ..... 01.2291 18.11 450352 ..... 01.1141 16.21 450559 ..... 00.9811 12.75 450684 ..... 01.2695 18.53

450087 ..... 01.4141 19.35 450196 ..... 01.5101 17.34 450353 ..... 01.3226 16.13 450561 ..... 01.6522 17.65 450686 ..... 01.5555 14.30

450090 ..... 01.2144 12.40 450197 ..... 01.0544 19.66 450355 ..... 01.1121 11.18 450563 ..... 01.2306 21.98 450688 ..... 01.2802 18.65

450092 ..... 01.2129 13.12 450200 ..... 01.3827 16.35 450358 ..... 02.0930 20.57 450565 ..... 01.2925 15.63 450690 ..... 01.4169 21.31

450094 ..... 01.2531 19.39 450201 ..... 01.0233 15.38 450362 ..... 01.1896 17.62 450570 ..... 01.0316 11.23 450691 ..... 01.1089 14.91

450096 ..... 01.5315 19.25 450203 ..... 01.1919 16.13 450369 ..... 01.0842 10.21 450571 ..... 01.4989 14.52 450694 ..... 01.2338 15.91

450097 ..... 01.4577 18.33 450209 ..... 01.5494 16.26 450370 ..... 01.1269 13.02 450573 ..... 01.0008 13.58 450696 ..... 01.6701 23.37

450098 ..... 01.1683 13.75 450210 ..... 01.1950 12.03 450371 ..... 01.1487 11.02 450574 ..... 00.9382 13.41 450697 ..... 01.5431 16.28

450099 ..... 01.2816 17.70 450211 ..... 01.3861 14.13 450372 ..... 01.2680 20.49 450575 ..... 01.0572 16.98 450698 ..... 00.9742 11.66

450101 ..... 01.4848 15.03 450213 ..... 01.5055 16.27 450373 ..... 01.1462 13.68 450578 ..... 00.9224 12.94 450700 ..... 00.9302 12.68

450102 ..... 01.7093 21.87 450214 ..... 01.3721 18.61 450374 ..... 00.9541 12.20 450580 ..... 01.1076 12.59 450702 ..... 01.6063 17.58

450104 ..... 01.2182 13.74 450217 ..... 01.0508 12.61 450376 ..... 01.5102 16.26 450583 ..... 01.0094 12.24 450703 ..... 01.5299 20.96

450107 ..... 01.6171 18.75 450219 ..... 01.1346 14.22 450378 ..... 01.0973 21.56 450584 ..... 01.2257 12.86 450704 ..... 01.3719 17.86

450108 ..... 00.9967 14.49 450221 ..... 01.0814 14.05 450379 ..... 01.5198 21.28 450586 ..... 00.9987 11.26 450705 ..... 01.0246 16.80

450109 ..... 00.9911 15.36 450222 ..... 01.6508 17.32 450381 ..... 01.0567 12.56 450587 ..... 01.2266 16.93 450706 ..... 01.2165 21.90

450110 ..... 01.2522 19.34 450224 ..... 01.3702 15.85 450388 ..... 01.7602 17.41 450591 ..... 01.1417 16.28 450709 ..... 01.2281 20.05

450111 ..... 01.2466 18.63 450229 ..... 01.5708 14.82 450389 ..... 01.2066 16.74 450596 ..... 01.3150 17.29 450711 ..... 01.6431 17.88

450112 ..... 01.3508 13.87 450231 ..... 01.5945 16.94 450393 ..... 01.3320 20.94 450597 ..... 01.0561 14.23 450712 ..... 00.7387 15.03

450113 ..... 01.2359 16.99 450234 ..... 00.9823 11.27 450395 ..... 01.0348 14.68 450603 ..... 00.8332 16.27 450713 ..... 01.4783 18.10

450118 ..... 01.5629 20.94 450235 ..... 01.0563 13.47 450399 ..... 00.9957 13.37 450604 ..... 01.3817 13.57 450715 ..... 01.4531 17.40

450119 ..... 01.2958 16.37 450236 ..... 01.0665 14.17 450400 ..... 01.1526 13.70 450605 ..... 01.4745 17.91 450716 ..... 01.2682 19.64

450121 ..... 01.4393 18.70 450237 ..... 01.5510 16.60 450403 ..... 01.3684 19.90 450609 ..... 00.8790 12.25 450717 ..... 01.3585 22.95

450123 ..... 01.1554 17.47 450239 ..... 01.1977 12.35 450411 ..... 00.9524 11.46 450610 ..... 01.4506 15.52 450718 ..... 01.2381 19.18

450124 ..... 01.5864 19.48 450241 ..... 01.0458 15.67 450417 ..... 01.0539 12.95 450614 ..... 01.0471 12.43 450723 ..... 01.3474 18.17

450126 ..... 01.3845 11.95 450243 ..... 00.8395 11.57 450418 ..... 01.3370 17.42 450615 ..... 01.0767 11.70 450724 ..... 01.2905 16.59

450128 ..... 01.2434 14.78 450246 ..... 00.9676 15.02 450419 ..... 01.2738 22.40 450617 ..... 01.2885 20.82 450725 ..... 00.9969 20.18

450130 ..... 01.5025 15.17 450249 ..... 00.9712 10.70 450422 ..... 00.8075 23.47 450620 ..... 01.0455 12.48 450726 ..... 00.8676 14.54

450131 ..... 01.3707 19.58 450250 ..... 00.9532 09.93 450423 ..... 01.4394 21.03 450623 ..... 01.1429 17.62 450727 ..... 00.9596 09.78

450132 ..... 01.6610 16.45 450253 ..... 01.3163 13.51 450424 ..... 01.2047 16.33 450626 ..... 01.0877 14.09 450728 ..... 00.9627 14.31

450133 ..... 01.5384 16.49 450258 ..... 01.0962 11.17 450429 ..... 01.1242 13.35 450628 ..... 00.9420 15.48 450730 ..... 01.3579 21.14

450135 ..... 01.7273 21.81 450259 ..... 01.2084 17.44 450431 ..... 01.6589 17.28 450630 ..... 01.6424 20.60 450733 ..... 01.3470 16.91

450137 ..... 01.5099 24.28 450264 ..... 00.8643 11.94 450438 ..... 01.1793 14.39 450631 ..... 01.7535 18.05 450735 ..... 00.8720 11.91

450140 ..... 00.8414 16.46 450269 ..... 01.1388 12.62 450446 ..... 00.8625 13.07 450632 ..... 01.0125 11.17 450742 ..... 01.3448 21.43

450142 ..... 01.4366 19.50 450270 ..... 01.1746 10.16 450447 ..... 01.3505 17.69 450633 ..... 01.5938 19.18 450743 ..... 01.4622 18.40

450143 ..... 01.0982 12.23 450271 ..... 01.2762 14.41 450450 ..... 01.0872 .......... 450634 ..... 01.6943 21.57 450746 ..... 01.0500 13.39

450144 ..... 01.1175 16.23 450272 ..... 01.2923 16.29 450451 ..... 01.1254 20.23 450637 ..... 01.3647 18.24 450747 ..... 01.3619 16.51

450145 ..... 00.8692 12.46 450276 ..... 01.0996 10.44 450457 ..... 01.7832 17.14 450638 ..... 01.5844 22.52 450749 ..... 01.0128 12.35

450146 ..... 00.9881 16.53 450278 ..... 00.8495 18.12 450460 ..... 01.0299 12.06 450639 ..... 01.4141 21.41 450750 ..... 01.0228 11.86

450147 ..... 01.4175 17.66 450280 ..... 01.5286 20.58 450462 ..... 01.8354 17.99 450641 ..... 01.0224 12.60 450751 ..... 01.3246 21.80

450148 ..... 01.3079 19.02 450283 ..... 01.0519 12.09 450464 ..... 00.9825 13.41 450643 ..... 01.2796 17.60 450754 ..... 00.8884 13.19

450149 ..... 01.3501 19.33 450286 ..... 01.0373 14.54 450465 ..... 01.3178 14.66 450644 ..... 01.4715 20.30 450755 ..... 01.1540 13.66

450150 ..... 00.8919 13.62 450288 ..... 01.2105 12.58 450467 ..... 00.9653 14.39 450646 ..... 01.6143 19.59 450757 ..... 00.9784 13.32

450151 ..... 01.1057 13.27 450289 ..... 01.4907 17.37 450469 ..... 01.3736 16.94 450647 ..... 02.0240 19.98 450758 ..... 01.2423 ..........

450152 ..... 01.2645 16.04 450292 ..... 01.2051 20.15 450473 ..... 01.0047 17.83 450648 ..... 01.0382 11.36 450760 ..... 01.2068 16.97

450153 ..... 01.5803 17.10 450293 ..... 00.9746 13.55 450475 ..... 01.1363 14.13 450649 ..... 01.0756 14.64 450761 ..... 01.0642 09.63
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27519

PAGE 15 OF 16

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450763 ..... 01.0163 15.68 460047 ..... 01.7740 19.49 490067 ..... 01.2062 14.95 500029 ..... 00.9339 14.30 500141 ..... 01.3258 21.93

450766 ..... 02.3234 14.24 460049 ..... 01.9207 17.05 490069 ..... 01.3990 15.10 500030 ..... 01.4753 22.13 500143 ..... 00.7662 14.92

450769 ..... 01.0378 13.28 460050 ..... 01.3106 20.35 490071 ..... 01.4398 17.56 500031 ..... 01.2905 20.19 500146 ..... 01.0318 ..........

450770 ..... 00.9496 13.59 460051 ..... 01.1901 .......... 490073 ..... 01.3538 21.49 500033 ..... 01.2047 18.05 510001 ..... 01.7139 17.08

450771 ..... 01.9690 17.01 470001 ..... 01.2043 17.11 490074 ..... 01.3343 16.00 500036 ..... 01.3185 19.11 510002 ..... 01.2708 16.31

450774 ..... 00.9708 23.99 470003 ..... 01.8136 17.82 490075 ..... 01.3332 16.62 500037 ..... 01.1216 17.63 510004 ..... 00.9183 12.62

450775 ..... 01.1940 19.26 470004 ..... 01.1118 14.18 490077 ..... 01.1636 16.87 500039 ..... 01.3772 21.32 510005 ..... 01.0028 13.71

450776 ..... 00.9251 .......... 470005 ..... 01.2608 18.71 490079 ..... 01.3187 14.30 500041 ..... 01.2872 22.09 510006 ..... 01.2565 17.08

450777 ..... 01.0014 15.01 470006 ..... 01.1898 17.05 490083 ..... 00.6451 14.63 500042 ..... 01.3735 20.95 510007 ..... 01.4707 17.81

450779 ..... 01.3450 20.59 470008 ..... 01.2516 15.41 490084 ..... 01.2535 15.96 500043 ..... 01.2939 16.56 510008 ..... 01.1226 15.33

450780 ..... 01.6140 19.78 470010 ..... 01.1804 18.58 490085 ..... 01.2071 13.36 500044 ..... 01.8920 20.56 510012 ..... 01.0670 14.26

450781 ..... 01.4783 16.23 470011 ..... 01.1610 19.30 490088 ..... 01.2024 13.97 500045 ..... 01.1167 20.65 510013 ..... 01.1365 15.10

450785 ..... 01.0516 26.08 470012 ..... 01.2651 17.52 490089 ..... 01.0748 14.37 500048 ..... 00.9122 16.01 510015 ..... 00.9706 12.51

450788 ..... 01.4208 .......... 470013 ..... 01.1682 18.28 490090 ..... 01.1783 14.25 500049 ..... 01.4708 19.34 510016 ..... 00.9917 11.27

450792 ..... 01.3306 .......... 470015 ..... 01.0806 16.29 490091 ..... 01.2045 20.14 500050 ..... 01.4079 20.41 510018 ..... 01.1351 14.40

450793 ..... 01.6623 .......... 470018 ..... 01.1930 17.37 490092 ..... 01.2038 14.32 500051 ..... 01.6292 22.71 510020 ..... 01.0494 10.16

450794 ..... 01.4602 .......... 470020 ..... 00.9884 14.50 490093 ..... 01.2927 15.31 500052 ..... 01.2781 .......... 510022 ..... 01.7998 19.52

450795 ..... 00.8520 .......... 470023 ..... 01.2947 17.20 490094 ..... 01.0700 14.57 500053 ..... 01.2686 20.10 510023 ..... 01.1454 15.14

450797 ..... 00.6382 .......... 470024 ..... 01.1136 17.08 490095 ..... 01.4745 16.13 500054 ..... 01.8788 20.41 510024 ..... 01.4093 17.94

450798 ..... 00.8871 .......... 490001 ..... 01.0799 19.41 490097 ..... 01.1333 13.69 500055 ..... 01.0886 20.32 510026 ..... 00.9392 12.19

450799 ..... 01.3895 .......... 490002 ..... 01.0625 13.61 490098 ..... 01.3132 11.69 500057 ..... 01.3490 16.24 510027 ..... 00.9669 13.86

450800 ..... 01.3919 .......... 490003 ..... 00.6018 17.55 490099 ..... 00.9348 15.29 500058 ..... 01.5095 19.82 510028 ..... 01.0731 14.90

450801 ..... 01.4818 .......... 490004 ..... 01.2303 16.67 490100 ..... 01.3757 16.69 500059 ..... 01.1588 20.02 510029 ..... 01.2953 16.69

450802 ..... 01.2487 .......... 490005 ..... 01.5364 16.10 490101 ..... 01.1933 23.64 500060 ..... 01.4869 20.70 510030 ..... 01.0968 14.87

450803 ..... 00.8537 .......... 490006 ..... 01.1569 13.27 490104 ..... 00.9110 14.46 500061 ..... 00.9842 17.95 510031 ..... 01.3367 16.27

450804 ..... 01.5293 .......... 490007 ..... 02.0310 17.19 490105 ..... 00.7427 16.55 500062 ..... 01.0856 17.16 510033 ..... 01.2624 14.42

450805 ..... 01.1693 .......... 490009 ..... 01.8204 18.08 490106 ..... 00.9047 14.86 500064 ..... 01.5371 21.69 510035 ..... 01.1467 16.46

450807 ..... 00.9104 .......... 490010 ..... 01.0912 17.08 490107 ..... 01.3155 22.64 500065 ..... 01.3049 17.67 510036 ..... 01.0129 09.34

450809 ..... 01.6570 .......... 490011 ..... 01.4170 17.03 490108 ..... 00.8737 13.78 500068 ..... 01.0186 17.17 510038 ..... 01.1610 13.71

450897 ..... 04.8548 .......... 490012 ..... 01.1990 15.55 490109 ..... 00.9185 14.09 500069 ..... 01.1665 18.62 510039 ..... 01.3580 15.02

460001 ..... 01.7866 19.82 490013 ..... 01.2514 14.82 490110 ..... 01.3986 15.90 500071 ..... 01.3666 19.46 510043 ..... 00.9310 11.33

460003 ..... 01.7210 18.38 490014 ..... 01.3584 21.04 490111 ..... 01.2348 16.79 500072 ..... 01.1952 21.19 510046 ..... 01.2605 15.26

460004 ..... 01.7712 20.68 490015 ..... 01.4630 17.30 490112 ..... 01.7326 19.07 500073 ..... 01.0859 16.85 510047 ..... 01.2074 17.37

460005 ..... 01.5499 18.80 490017 ..... 01.3623 16.44 490113 ..... 01.3003 20.96 500074 ..... 01.1671 14.80 510048 ..... 01.0733 17.39

460006 ..... 01.4322 18.21 490018 ..... 01.2580 16.83 490114 ..... 01.0988 15.00 500075 ..... 03.7376 20.25 510050 ..... 01.4642 15.34

460007 ..... 01.5450 19.27 490019 ..... 01.2006 15.60 490115 ..... 01.2451 14.25 500077 ..... 01.3913 21.63 510053 ..... 01.0396 13.50

460008 ..... 01.3609 16.02 490020 ..... 01.1565 14.16 490116 ..... 01.2251 15.61 500079 ..... 01.4055 19.87 510055 ..... 01.2246 19.41

460009 ..... 01.8852 18.11 490021 ..... 01.1505 17.11 490117 ..... 01.1729 13.62 500080 ..... 00.8427 11.56 510058 ..... 01.2002 16.23

460010 ..... 01.9161 20.15 490022 ..... 01.4063 17.59 490118 ..... 01.7642 21.32 500084 ..... 01.1439 20.05 510059 ..... 01.2290 13.65

460011 ..... 01.3884 16.16 490023 ..... 01.2234 17.03 490119 ..... 01.3467 16.41 500085 ..... 01.0619 17.19 510060 ..... 01.1538 15.36

460013 ..... 01.5056 18.54 490024 ..... 01.7803 17.06 490120 ..... 01.3270 16.88 500086 ..... 01.4244 18.48 510061 ..... 01.0749 12.59

460014 ..... 01.0358 15.38 490027 ..... 01.1310 13.11 490122 ..... 01.5152 20.86 500088 ..... 01.3586 22.86 510062 ..... 01.1797 15.38

460015 ..... 01.2592 19.75 490028 ..... 01.3516 18.42 490123 ..... 01.1414 14.80 500089 ..... 00.9469 13.99 510063 ..... 01.0126 10.63

460016 ..... 00.8970 13.58 490030 ..... 01.1033 11.16 490124 ..... 01.1521 16.99 500090 ..... 01.1042 12.60 510065 ..... 01.0089 12.04

460017 ..... 01.4549 16.52 490031 ..... 01.1369 12.61 490126 ..... 01.3837 14.72 500092 ..... 01.0798 15.65 510066 ..... 01.1288 12.02

460018 ..... 00.9760 13.59 490032 ..... 01.7249 19.08 490127 ..... 01.0179 14.44 500094 ..... 00.9177 15.53 510067 ..... 01.2496 15.91

460019 ..... 01.1515 12.90 490033 ..... 01.1854 15.21 490130 ..... 01.3118 16.58 500096 ..... 01.0950 17.13 510068 ..... 01.1196 14.01

460020 ..... 01.0589 14.21 490035 ..... 01.2179 09.64 490131 ..... 01.0427 14.06 500097 ..... 01.1371 16.12 510070 ..... 01.2210 16.05

460021 ..... 01.3873 19.20 490037 ..... 01.1278 13.27 500001 ..... 01.3342 20.92 500098 ..... 00.9192 13.66 510071 ..... 01.2767 14.49

460022 ..... 00.9374 19.41 490038 ..... 01.2195 12.54 500002 ..... 01.4828 18.75 500101 ..... 01.0080 17.84 510072 ..... 01.0650 13.50

460023 ..... 01.1831 20.75 490040 ..... 01.4100 .......... 500003 ..... 01.4073 21.28 500102 ..... 00.9391 18.43 510077 ..... 01.1079 14.36

460024 ..... 00.8662 13.51 490041 ..... 01.3633 16.88 500005 ..... 01.8398 22.52 500104 ..... 01.2622 18.71 510080 ..... 01.1530 09.35

460025 ..... 00.8105 12.63 490042 ..... 01.3475 15.18 500007 ..... 01.4207 20.14 500106 ..... 00.9247 15.53 510081 ..... 01.0320 13.19

460026 ..... 01.0881 16.98 490043 ..... 01.3704 16.74 500008 ..... 01.8411 22.88 500107 ..... 01.1321 15.58 510082 ..... 01.0578 12.08

460027 ..... 00.9430 18.61 490044 ..... 01.3658 16.65 500009 ..... 01.2857 21.07 500108 ..... 01.6669 21.40 510084 ..... 00.9741 12.87

460029 ..... 01.0255 15.71 490045 ..... 01.1319 18.60 500011 ..... 01.3718 21.44 500110 ..... 01.2887 18.75 510085 ..... 01.2422 17.99

460030 ..... 01.2141 15.78 490046 ..... 01.4645 17.24 500012 ..... 01.5217 20.94 500118 ..... 01.1240 20.88 510086 ..... 01.0448 15.65

460032 ..... 01.0120 19.00 490047 ..... 01.0663 16.34 500014 ..... 01.5715 22.36 500119 ..... 01.3333 20.48 520002 ..... 01.2873 17.24

460033 ..... 00.9450 18.22 490048 ..... 01.4906 17.53 500015 ..... 01.3714 20.92 500122 ..... 01.1925 20.27 520003 ..... 01.1635 15.19

460035 ..... 00.9610 10.93 490050 ..... 01.4363 20.06 500016 ..... 01.4877 22.76 500123 ..... 00.8543 14.78 520004 ..... 01.1581 16.53

460036 ..... 00.9397 19.41 490052 ..... 01.6013 15.06 500019 ..... 01.3295 19.82 500124 ..... 01.3292 22.39 520006 ..... 01.0583 18.05

460037 ..... 01.0502 15.92 490053 ..... 01.2501 14.14 500021 ..... 01.5380 20.77 500125 ..... 00.9834 10.72 520007 ..... 01.2469 14.14

460039 ..... 01.0976 21.08 490054 ..... 01.1101 13.91 500023 ..... 01.1763 19.09 500129 ..... 01.7339 22.41 520008 ..... 01.5546 20.54

460041 ..... 01.2179 18.29 490057 ..... 01.5486 17.02 500024 ..... 01.6324 21.06 500132 ..... 01.0006 19.79 520009 ..... 01.5961 16.88

460042 ..... 01.4657 16.14 490059 ..... 01.5727 18.24 500025 ..... 01.8715 21.69 500134 ..... 00.7903 15.75 520010 ..... 01.1768 19.39

460043 ..... 00.9888 20.44 490060 ..... 01.0661 16.72 500026 ..... 01.4324 22.42 500137 ..... 00.7110 19.99 520011 ..... 01.2031 16.46

460044 ..... 01.2018 19.41 490063 ..... 01.6611 22.34 500027 ..... 01.5334 23.68 500138 ..... 03.4209 .......... 520013 ..... 01.2909 17.88

460046 ..... 00.7432 10.23 490066 ..... 01.2178 17.42 500028 ..... 01.0839 14.76 500139 ..... 01.4763 21.33 520014 ..... 01.2083 15.55
27520 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

PAGE 16 OF 16

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

520015 ..... 01.1174 16.65 520107 ..... 01.2599 17.46 530026 ..... 01.0473 14.63

520016 ..... 01.0872 12.75 520109 ..... 00.9937 17.25 530027 ..... 00.8416 09.56

520017 ..... 01.1927 16.87 520110 ..... 01.1756 16.47 530029 ..... 00.9590 13.49

520018 ..... 01.0801 15.88 520111 ..... 00.9841 14.44 530031 ..... 00.8745 10.95

520019 ..... 01.2873 16.65 520112 ..... 01.0805 18.15 530032 ..... 01.1558 17.33

520021 ..... 01.3538 19.16 520113 ..... 01.1645 17.80

520024 ..... 01.0377 13.33 520114 ..... 01.1037 12.61

520025 ..... 01.1242 15.19 520115 ..... 01.3222 15.89

520026 ..... 01.1051 17.48 520116 ..... 01.2576 17.66

520027 ..... 01.2244 19.22 520117 ..... 01.0303 15.40

520028 ..... 01.3261 17.60 520118 ..... 00.9469 10.95

520029 ..... 00.9657 16.70 520120 ..... 00.8647 11.95

520030 ..... 01.6772 20.19 520121 ..... 00.9763 14.18

520031 ..... 01.1054 16.11 520122 ..... 00.9894 13.96

520032 ..... 01.1683 14.56 520123 ..... 01.1427 16.55

520033 ..... 01.1820 15.91 520124 ..... 01.1255 14.34

520034 ..... 01.1271 17.17 520130 ..... 01.0776 12.60

520035 ..... 01.2587 14.67 520131 ..... 01.0620 15.82

520037 ..... 01.6518 18.23 520132 ..... 01.1878 14.31

520038 ..... 01.4916 17.14 520134 ..... 01.0269 15.14

520039 ..... 00.9998 16.24 520135 ..... 00.9427 13.84

520040 ..... 01.4327 20.05 520136 ..... 01.4778 18.87

520041 ..... 01.1487 14.54 520138 ..... 01.8773 18.18

520042 ..... 01.0742 16.25 520139 ..... 01.2893 18.50

520044 ..... 01.3803 16.09 520140 ..... 01.6143 19.31

520045 ..... 01.6794 17.97 520141 ..... 01.1223 15.63

520047 ..... 01.0211 14.50 520142 ..... 00.9152 12.48

520048 ..... 01.4410 17.67 520144 ..... 01.0302 16.10

520049 ..... 01.9925 17.97 520145 ..... 00.9155 16.57

520051 ..... 02.0296 19.41 520146 ..... 01.0749 13.71

520053 ..... 01.1007 14.78 520148 ..... 01.1668 15.34

520054 ..... 01.0919 16.40 520149 ..... 00.9581 13.31

520056 ..... 01.3164 17.77 520151 ..... 01.0803 14.43

520057 ..... 01.1308 16.08 520152 ..... 01.1177 16.38

520058 ..... 01.0511 17.87 520153 ..... 00.9775 13.19

520059 ..... 01.3130 18.17 520154 ..... 01.1520 16.15

520060 ..... 01.2970 15.15 520156 ..... 01.1216 16.37

520062 ..... 01.2707 16.18 520157 ..... 00.9447 13.70

520063 ..... 01.2571 17.61 520159 ..... 00.9412 16.25

520064 ..... 01.7132 18.60 520160 ..... 01.7643 17.77

520066 ..... 01.4169 17.73 520161 ..... 01.0283 14.76

520068 ..... 00.8891 15.82 520170 ..... 01.2367 18.51

520069 ..... 01.1915 16.75 520171 ..... 00.9904 13.69

520070 ..... 01.6012 16.93 520173 ..... 01.1609 17.36

520071 ..... 01.1175 17.71 520174 ..... 01.3641 20.57

520074 ..... 01.1086 14.96 520177 ..... 01.6458 20.33

520075 ..... 01.4753 17.44 520178 ..... 01.0634 14.61

520076 ..... 01.1296 14.40 520186 ..... 02.5906 ..........

520077 ..... 01.0286 14.50 530002 ..... 01.1932 18.07

520078 ..... 01.5021 17.89 530003 ..... 00.9310 12.59

520082 ..... 01.3454 15.25 530004 ..... 01.0270 13.17

520083 ..... 01.5871 21.59 530005 ..... 01.1389 13.19

520084 ..... 01.0883 15.73 530006 ..... 01.1268 16.83

520087 ..... 01.6162 17.16 530007 ..... 01.0516 11.52

520088 ..... 01.2469 17.56 530008 ..... 01.2810 17.75

520089 ..... 01.5230 18.79 530009 ..... 00.9688 20.60

520090 ..... 01.2710 16.16 530010 ..... 01.2195 16.30

520091 ..... 01.3709 17.25 530011 ..... 01.0899 15.27

520092 ..... 01.1124 15.11 530012 ..... 01.5874 17.25

520094 ..... 01.0158 16.07 530014 ..... 01.3289 15.01

520095 ..... 01.3510 18.56 530015 ..... 01.1500 19.22

520096 ..... 01.4979 17.78 530016 ..... 01.2060 11.87

520097 ..... 01.3308 17.90 530017 ..... 01.0038 16.09

520098 ..... 01.7143 19.40 530018 ..... 01.0645 14.57

520100 ..... 01.2350 15.91 530019 ..... 00.9449 14.32

520101 ..... 01.0947 15.75 530022 ..... 01.1147 15.94

520102 ..... 01.2141 19.00 530023 ..... 00.8514 17.76

520103 ..... 01.3242 17.70 530025 ..... 01.3686 18.12

Note: Case mix indexes do not include discharges from PPS-exempt units. Case mix indexes include cases received in HCFA central office through December

1995.
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27521

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

0040 Abilene, TX ........ 0.8055 0.8623

Taylor, TX

0060 Aguadilla, PR ..... 0.4430 0.5726

Aguada, PR

Aguadilla, PR

Moca, PR

0080 Akron, OH .......... 0.9875 0.9914

Portage, OH

Summit, OH

0120 Albany, GA ........ 0.8353 0.8841

Dougherty, GA

Lee, GA

0160 Albany-Schenectady-Troy, NY ............ 0.8510 0.8954

Albany, NY

Montgomery, NY

Rensselaer, NY

Saratoga, NY

Schenectady, NY

Schoharie, NY

0200 Albuquerque, NM 0.9390 0.9578

Bernalillo, NM

Sandoval, NM

Valencia, NM

0220 Alexandria, LA ... 0.8213 0.8739

Rapides, LA

0240 Allentown-Bethlehem-Easton, PA ..... 1.0014 1.0160

Carbon, PA

Lehigh, PA

Northampton, PA

0280 Altoona, PA ....... 0.9531 0.9676

Blair, PA

0320 Amarillo, TX ....... 0.8557 0.8988

Potter, TX

Randall, TX

0380 Anchorage, AK 1.3285 1.3104

Anchorage, AK

0440 Ann Arbor, MI .... 1.1688 1.1218

Lenawee, MI

Livingston, MI

Washtenaw, MI

0450 Anniston, AL ...... 0.7848 0.8471

Calhoun, AL

0460 Appleton-Oshkosh-Neenah, WI ....... 0.8910 0.9240

Calumet, WI

Outagamie, WI

Winnebago, WI

0470 Arecibo, PR ....... 0.4631 0.5903

Arecibo, PR

Camuy, PR

Hatillo, PR

0480 Asheville, NC ..... 0.9365 0.9561

Buncombe, NC

Madison, NC

0500 Athens, GA ........ 0.9259 0.9771

Clarke, GA

Madison, GA

Oconee, GA

0520 *Atlanta, GA ....... 1.0089 1.0363

Barrow, GA

Bartow, GA

Carroll, GA

Cherokee, GA

Clayton, GA

Cobb, GA

Coweta, GA

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

DeKalb, GA

Douglas, GA

Fayette, GA

Forsyth, GA

Fulton, GA

Gwinnett, GA

Henry, GA

Newton, GA

Paulding, GA

Pickens, GA

Rockdale, GA

Spalding, GA

Walton, GA

0560 Atlantic-Cape

May, NJ ..................... 1.1102 1.0742

Atlantic, NJ

Cape May, NJ

0600 Augusta-Aiken,

GA–SC ...................... 0.8849 0.9197

Columbia, GA

McDuffie, GA

Richmond, GA

Aiken, SC

Edgefield, SC

0640 Austin-San

Marcos, TX ................ 0.9252 0.9482

Bastrop, TX

Caldwell, TX

Hays, TX

Travis, TX

Williamson, TX

0680 Bakersfield, CA 1.0202 1.0168

Kern, CA

0720 *Baltimore, MD 0.9820 1.0173

Anne Arundel, MD

Baltimore, MD

Baltimore City, MD

Carroll, MD

Harford, MD

Howard, MD

Queen Anne’s, MD

0733 Bangor, ME ....... 0.9412 0.9594

Penobscot, ME

0743 Barnstable-Yarmouth, MA ................. 1.3682 1.2395

Barnstable, MA

0760 Baton Rouge, LA 0.8442 0.8905

Ascension, LA

East Baton Rouge, LA

Livingston, LA

West Baton Rouge,

LA

0840 Beaumont-Port

Arthur, TX .................. 0.8578 0.9003

Hardin, TX

Jefferson, TX

Orange, TX

0860 Bellingham, WA 1.1342 1.0901

Whatcom, WA

0870 Benton Harbor,

MI ............................... 0.8553 0.8985

Berrien, MI

0875 *Bergen-Passaic,

NJ .............................. 1.1717 1.1146

Bergen, NJ

Passaic, NJ

0880 Billings, MT ........ 0.8903 0.9235

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

Yellowstone, MT

0920 Biloxi-GulfportPascagoula, MS ........ 0.8573 0.8999

Hancock, MS

Harrison, MS

Jackson, MS

0960 Binghamton, NY 0.8842 0.9192

Broome, NY

Tioga, NY

1000 Birmingham, AL 0.9047 0.9337

Blount, AL

Jefferson, AL

St. Clair, AL

Shelby, AL

1010 Bismarck, ND .... 0.7976 0.8565

Burleigh, ND

Morton, ND

1020 Bloomington, IN 0.8619 0.9303

Monroe, IN

1040 Bloomington-Normal, IL ........................ 0.8921 0.9248

McLean, IL

1080 Boise City, ID .... 0.9269 0.9493

Ada, ID

Canyon, ID

1123 *Boston-Worcester-Lawrence-LowellBrockton, MA–NH ...... 1.1639 1.1428

Bristol, MA

Essex, MA

Middlesex, MA

Norfolk, MA

Plymouth, MA

Suffolk, MA

Worcester, MA

Hillsborough, NH

Merrimack, NH

Rockingham, NH

Strafford, NH

1125 BoulderLongmont, CO ........... 0.9383 0.9573

Boulder, CO

1145 Brazoria, TX ...... 0.8865 0.9208

Brazoria, TX

1150 Bremerton, WA 1.0926 1.0625

Kitsap, WA

1240 Brownsville-Harlingen-San Benito, TX 0.8561 0.8991

Cameron, TX

1260 Bryan-College

Station, TX ................. 0.8760 0.9133

Brazos, TX

1280 *Buffalo-Niagara

Falls, NY .................... 0.9123 0.9673

Erie, NY

Niagara, NY

1303 Burlington, VT .... 0.9126 0.9393

Chittenden, VT

Franklin, VT

Grand Isle, VT

1310 Caguas, PR ....... 0.4661 0.5929

Caguas, PR

Cayey, PR

Cidra, PR

Gurabo, PR

San Lorenzo, PR
27522 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

1320 CantonMassillon, OH ............ 0.8667 0.9067

Carroll, OH

Stark, OH

1350 Casper, WY ....... 0.8841 0.9191

Natrona, WY

1360 Cedar Rapids, IA 0.8477 0.8930

Linn, IA

1400 Champaign-Urbana, IL ..................... 0.9413 0.9594

Champaign, IL

1440 Charleston-North

Charleston, SC .......... 0.8984 0.9293

Berkeley, SC

Charleston, SC

Dorchester, SC

1480 Charleston, WV 0.9547 0.9688

Kanawha, WV

Putnam, WV

1520 *Charlotte-Gastonia-Rock Hill, NC–SC 0.9631 1.0038

Cabarrus, NC

Gaston, NC

Lincoln, NC

Mecklenburg, NC

Rowan, NC

Union, NC

York, SC

1540 Charlottesville,

VA .............................. 0.9175 0.9427

Albemarle, VA

Charlottesville City,

VA

Fluvanna, VA

Greene, VA

1560 Chattanooga,

TN-GA ....................... 0.8867 0.9210

Catoosa, GA

Dade, GA

Walker, GA

Hamilton, TN

Marion, TN

1580 Cheyenne, WY 0.7695 0.8357

Laramie, WY

1600 *Chicago, IL ....... 1.0756 1.0827

Cook, IL

DeKalb, IL

DuPage, IL

Grundy, IL

Kane, IL

Kendall, IL

Lake, IL

McHenry, IL

Will, IL

1620 Chico-Paradise,

CA .............................. 1.0441 1.0300

Butte, CA

1640 *Cincinnati, OH–

KY–IN ........................ 0.9477 0.9928

Dearborn, IN

Ohio, IN

Boone, KY

Campbell, KY

Gallatin, KY

Grant, KY

Kenton, KY

Pendleton, KY

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

Brown, OH

Clermont, OH

Hamilton, OH

Warren, OH

1660 Clarksville-Hopkinsville, TN–KY ........ 0.7733 0.8386

Christian, KY

Montgomery, TN

1680 *Cleveland-Lorain-Elyria, OH ........... 0.9908 1.0235

Ashtabula, OH

Cuyahoga, OH

Geauga, OH

Lake, OH

Lorain, OH

Medina, OH

1720 Colorado

Springs, CO ............... 0.9456 0.9624

El Paso, CO

1740 Columbia, MO ... 0.8919 0.9246

Boone, MO

1760 Columbia, SC .... 0.9178 0.9430

Lexington, SC

Richland, SC

1800 Columbus, GA–

AL .............................. 0.7655 0.8328

Russell, AL

Chattanoochee, GA

Harris, GA

Muscogee, GA

1840 *Columbus, OH 0.9699 1.0087

Delaware, OH

Fairfield, OH

Franklin, OH

Licking, OH

Madison, OH

Pickaway, OH

1880 Corpus Christi,

TX .............................. 0.8641 0.9048

Nueces, TX

San Patricio, TX

1900 Cumberland,

MD–WV ..................... 0.8613 0.9028

Allegany, MD

Mineral, WV

1920 *Dallas, TX ........ 0.9530 0.9966

Collin, TX

Dallas, TX

Denton, TX

Ellis, TX

Henderson, TX

Hunt, TX

Kaufman, TX

Rockwall, TX

1950 Danville, VA ....... 0.8516 0.8958

Danville City, VA

Pittsylvania, VA

1960 Davenport-Moline-Rock Island, IA–

IL ................................ 0.8407 0.8880

Scott, IA

Henry, IL

Rock Island, IL

2000 Dayton-Springfield, OH .................... 0.9582 0.9858

Clark, OH

Greene, OH

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

Miami, OH

Montgomery, OH

2020 Daytona Beach,

FL .............................. 0.8891 0.9296

Flagler, FL

Volusia, FL

2030 Decatur, AL ....... 0.8403 0.8877

Lawrence, AL

Morgan, AL

2040 Decatur, IL ......... 0.7866 0.8484

Macon, IL

2080 *Denver, CO ...... 1.0291 1.0504

Adams, CO

Arapahoe, CO

Denver, CO

Douglas, CO

Jefferson, CO

2120 Des Moines, IA 0.8772 0.9142

Dallas, IA

Polk, IA

Warren, IA

2160 *Detroit, MI ........ 1.0748 1.0822

Lapeer, MI

Macomb, MI

Monroe, MI

Oakland, MI

St. Clair, MI

Wayne, MI

2180 Dothan, AL ........ 0.7758 0.8404

Dale, AL

Houston, AL

2190 Dover, DE .......... 0.9017 0.9595

Kent, DE

2200 Dubuque, IA ...... 0.8149 0.8692

Dubuque, IA

2240 Duluth-Superior,

MN–WI ....................... 0.9437 0.9611

St. Louis, MN

Douglas, WI

2281 Dutchess County, NY ......................... 1.0604 1.0488

Dutchess, NY

2290 Eau Claire, WI ... 0.8698 0.9089

Chippewa, WI

Eau Claire, WI

2320 El Paso, TX ....... 0.9486 0.9645

El Paso, TX

2330 Elkhart-Goshen,

IN ............................... 0.8820 0.9176

Elkhart, IN

2335 Elmira, NY ......... 0.8436 0.8901

Chemung, NY

2340 Enid, OK ............ 0.7879 0.8494

Garfield, OK

2360 Erie, PA ............. 0.9137 0.9401

Erie, PA

2400 Eugene-Springfield, OR .................... 1.1503 1.1006

Lane, OR

2440 Evansville-Henderson, IN–KY ........... 0.8990 0.9297

Posey, IN

Vanderburgh, IN

Warrick, IN

Henderson, KY

2520 Fargo-Moorhead,

ND–MN ...................... 0.9010 0.9311
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27523

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

Clay, MN

Cass, ND

2560 Fayetteville, NC 0.9025 0.9322

Cumberland, NC

2580 FayettevilleSpringdale-Rogers,

AR .............................. 0.7236 0.8013

Benton, AR

Washington, AR

2620 Flagstaff, AZ–UT 0.9039 0.9331

Coconino, AZ

Kane, UT

2640 Flint, MI .............. 1.1273 1.0964

Genesee, MI

2650 Florence, AL ...... 0.8157 0.8698

Colbert, AL

Lauderdale, AL

2655 Florence, SC ..... 0.8614 0.9029

Florence, SC

2670 Fort CollinsLoveland, CO ............ 1.0628 1.0426

Larimer, CO

2680 *Ft. Lauderdale,

FL .............................. 1.0968 1.0973

Broward, FL

2700 Fort Myers-Cape

Coral, FL .................... 0.9093 0.9370

Lee, FL

2710 Fort Pierce-Port

St. Lucie, FL .............. 1.0192 1.0131

Martin, FL

St. Lucie, FL

2720 Fort Smith, AR–

OK ............................. 0.7885 0.8498

Crawford, AR

Sebastian, AR

Sequoyah, OK

2750 Fort Walton

Beach, FL .................. 0.9186 0.9435

Okaloosa, FL

2760 Fort Wayne, IN 0.8819 0.9175

Adams, IN

Allen, IN

DeKalb, IN

Huntington, IN

Wells, IN

Whitley, IN

2800 *Forth Worth-Arlington, TX ................. 1.0095 1.0367

Hood, TX

Johnson, TX

Parker, TX

Tarrant, TX

2840 Fresno, CA ........ 1.1202 1.0808

Fresno, CA

Madera, CA

2880 Gadsden, AL ..... 0.8901 0.9234

Etowah, AL

2900 Gainesville, FL ... 0.9455 0.9623

Alachua, FL

2920 Galveston-Texas

City, TX ...................... 1.1022 1.0796

Galveston, TX

2960 Gary, IN ............. 0.9176 0.9428

Lake, IN

Porter, IN

2975 Glens Falls, NY 0.8560 0.8990

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

Warren, NY

Washington, NY

2980 Goldsboro, NC ... 0.8412 0.8883

Wayne, NC

2985 Grand Forks,

ND–MN ...................... 0.9228 0.9465

Polk, MN

Grand Forks, ND

2995 Grand Junction,

CO ............................. 0.8847 0.9195

Mesa, CO

3000 Grand RapidsMuskegon-Holland, MI 1.0088 1.0060

Allegan, MI

Kent, MI

Muskegon, MI

Ottawa, MI

3040 Great Falls, MT 0.9007 0.9309

Cascade, MT

3060 Greeley, CO ...... 0.9712 0.9802

Weld, CO

3080 Green Bay, WI ... 0.9387 0.9576

Brown, WI

3120 *GreensboroWinston-Salem-High

Point, NC ................... 0.9327 0.9820

Alamance, NC

Davidson, NC

Davie, NC

Forsyth, NC

Guilford, NC

Randolph, NC

Stokes, NC

Yadkin, NC

3150 Greenville, NC ... 0.9098 0.9373

Pitt, NC

3160 GreenvilleSpartanburg-Anderson, SC ...................... 0.8947 0.9266

Anderson, SC

Cherokee, SC

Greenville, SC

Pickens, SC

Spartanburg, SC

3180 Hagerstown, MD 0.9195 0.9441

Washington, MD

3200 Hamilton-Middletown, OH ................... 0.9515 0.9665

Butler, OH

3240 Harrisburg-Lebanon-Carlisle, PA ...... 1.0181 1.0124

Cumberland, PA

Dauphin, PA

Lebanon, PA

Perry, PA

3283 *Hartford, CT ..... 1.2395 1.1931

Hartford, CT

Litchfield, CT

Middlesex, CT

Tolland, CT

3285 Hattiesburg, MS 0.7269 0.8038

Forrest, MS

Lamar, MS

3290 Hickory-Morganton-Lenoir, NC ........... 0.7945 0.8542

Alexander, NC

Burke, NC

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

Caldwell, NC

Catawba, NC

3320 Honolulu, HI ....... 1.1487 1.1776

Honolulu, HI

3350 Houma, LA ........ 0.7843 0.8518

Lafourche, LA

Terrebonne, LA

3360 *Houston, TX ..... 0.9790 1.0151

Chambers, TX

Fort Bend, TX

Harris, TX

Liberty, TX

Montgomery, TX

Waller, TX

3400 Huntington-Ashland, WV–KY–OH ...... 0.9194 0.9441

Boyd, KY

Carter, KY

Greenup, KY

Lawrence, OH

Cabell, WV

Wayne, WV

3440 Huntsville, AL .... 0.8145 0.8689

Limestone, AL

Madison, AL

3480 *Indianapolis, IN 0.9950 1.0265

Boone, IN

Hamilton, IN

Hancock, IN

Hendricks, IN

Johnson, IN

Madison, IN

Marion, IN

Morgan, IN

Shelby, IN

3500 Iowa City, IA ...... 0.9382 0.9573

Johnson, IA

3520 Jackson, MI ....... 0.9066 0.9351

Jackson, MI

3560 Jackson, MS ...... 0.7906 0.8514

Hinds, MS

Madison, MS

Rankin, MS

3580 Jackson, TN ...... 0.8340 0.8831

Madison, TN

3605 Jacksonville, FL 0.9018 0.9317

Clay, FL

Duval, FL

Nassau, FL

St. Johns, FL

3605 Jacksonville, NC 0.7071 0.7887

Onslow, NC

3610 Jamestown, NY 0.7679 0.8346

Chautaqua, NY

3620 Janesville-Beloit,

WI .............................. 0.8664 0.9065

Rock, WI

3640 Jersey City, NJ 1.1408 1.1236

Hudson, NJ

3660 Johnson CityKingsport-Bristol, TN–

VA .............................. 0.8921 0.9248

Carter, TN

Hawkins, TN

Sullivan, TN

Unicoi, TN

Washington, TN
27524 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

Bristol City, VA

Scott, VA

Washington, VA

3680 Johnstown, PA 0.8417 0.8887

Cambria, PA

Somerset, PA

3710 Joplin, MO ......... 0.7409 0.8144

Jasper, MO

Newton, MO

3720 KalamazooBattlecreek, MI .......... 1.0565 1.0384

Calhoun, MI

Kalamazoo, MI

Van Buren, MI

3740 Kankakee, IL ..... 0.8998 0.9582

Kankakee, IL

3760 *Kansas City,

KS–MO ...................... 0.9522 0.9960

Johnson, KS

Leavenworth, KS

Miami, KS

Wyandotte, KS

Cass, MO

Clay, MO

Clinton, MO

Jackson, MO

Lafayette, MO

Platte, MO

Ray, MO

3800 Kenosha, WI ...... 0.9166 0.9421

Kenosha, WI

3810 Killeen-Temple,

TX .............................. 1.0415 1.0282

Bell, TX

Coryell, TX

3840 Knoxville, TN ..... 0.8520 0.8961

Anderson, TN

Blount, TN

Knox, TN

Loudon, TN

Sevier, TN

Union, TN

3850 Kokomo, IN ........ 0.8609 0.9025

Howard, IN

Tipton, IN

3870 La Crosse, WI–

MN ............................. 0.8638 0.9046

Houston, MN

La Crosse, WI

3880 Lafayette, LA ..... 0.8183 0.8717

Acadia, LA

Lafayette, LA

St. Landry, LA

St. Martin, LA

3920 Lafayette, IN ...... 0.8824 0.9179

Clinton, IN

Tippecanoe, IN

3960 Lake Charles, LA 0.8052 0.8621

Calcasieu, LA

3980 Lakeland-Winter

Haven, FL .................. 0.8677 0.9074

Polk, FL

4000 Lancaster, PA .... 0.9605 0.9786

Lancaster, PA

4040 Lansing-East

Lansing, MI ................ 1.0016 1.0011

Clinton, MI

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

Eaton, MI

Ingham, MI

4080 Laredo, TX ......... 0.7092 0.7903

Webb, TX

4100 Las Cruces, NM 0.8516 0.8958

Dona Ana, NM

4120 *Las Vegas, NV–

AZ .............................. 1.0894 1.0922

Mohave, AZ

Clark, NV

Nye, NV

4150 Lawrence, KS .... 0.8616 0.9301

Douglas, KS

4200 Lawton, OK ........ 0.8339 0.8830

Comanche, OK

4243 Lewiston-Auburn,

ME ............................. 0.9431 0.9607

Androscoggin, ME

4280 Lexington, KY .... 0.8387 0.8865

Bourbon, KY

Clark, KY

Fayette, KY

Jessamine, KY

Madison, KY

Scott, KY

Woodford, KY

4320 Lima, OH ........... 0.8752 0.9128

Allen, OH

Auglaize, OH

4360 Lincoln, NE ........ 0.9193 0.9440

Lancaster, NE

4400 Little Rock-North

Little Rock, AR .......... 0.8616 0.9030

Faulkner, AR

Lonoke, AR

Pulaski, AR

Saline, AR

4420 Longview-Marshall, TX .................... 0.8633 0.9042

Gregg, TX

Harrison, TX

Upshur, TX

4480 *Los AngelesLong Beach, CA ........ 1.2396 1.1932

Los Angeles, CA

4520 Louisville, KY–IN 0.9445 0.9617

Clark, IN

Floyd, IN

Harrison, IN

Scott, IN

Bullitt, KY

Jefferson, KY

Oldham, KY

4600 Lubbock, TX ...... 0.8525 0.8965

Lubbock, TX

4640 Lynchburg, VA ... 0.8036 0.8609

Amherst, VA

Bedford, VA

Bedford City, VA

Campbell, VA

Lynchburg City, VA

4680 Macon, GA ........ 0.8836 0.9187

Bibb, GA

Houston, GA

Jones, GA

Peach, GA

Twiggs, GA

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

4720 Madison, WI ...... 1.0048 1.0033

Dane, WI

4800 Mansfield, OH .... 0.8543 0.8978

Crawford, OH

Richland, OH

4840 Mayaguez, PR ... 0.4186 0.5508

Anasco, PR

Cabo Rojo, PR

Hormigueros, PR

Mayaguez, PR

Sabana Grande, PR

San German, PR

4880 McAllen-Edinburg-Mission, TX ....... 0.8502 0.8948

Hidalgo, TX

4890 Medford-Ashland, OR .................... 1.0213 1.0145

Jackson, OR

4900 MelbourneTitusville-Palm Bay,

FL .............................. 0.9089 0.9507

Brevard, FL

4920 *Memphis, TN–

AR–MS ...................... 0.8185 0.8980

Crittenden, AR

DeSoto, MS

Fayette, TN

Shelby, TN

Tipton, TN

4940 Merced, CA ....... 1.0684 1.0463

Merced, CA

5000 *Miami, FL ......... 0.9240 0.9757

Dade, FL

5015 *Middlesex-Somerset-Hunterdon, NJ 1.0777 1.0842

Hunterdon, NJ

Middlesex, NJ

Somerset, NJ

5080 *MilwaukeeWaukesha, WI ........... 0.9667 1.0064

Milwaukee, WI

Ozaukee, WI

Washington, WI

Waukesha, WI

5120 *Minneapolis-St.

Paul, MN–WI ............. 1.0785 1.0847

Anoka, MN

Carver, MN

Chisago, MN

Dakota, MN

Hennepin, MN

Isanti, MN

Ramsey, MN

Scott, MN

Sherburne, MN

Washington, MN

Wright, MN

Pierce, WI

St. Croix, WI

5160 Mobile, AL ......... 0.7999 0.8582

Baldwin, AL

Mobile, AL

5170 Modesto, CA ...... 1.0135 1.0092

Stanislaus, CA

5190 *MonmouthOcean, NJ ................. 1.0842 1.0569

Monmouth, NJ
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27525

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

Ocean, NJ

5200 Monroe, LA ........ 0.8234 0.8754

Ouachita, LA

5240 Montgomery, AL 0.7949 0.8545

Autauga, AL

Elmore, AL

Montgomery, AL

5280 Muncie, IN ......... 0.9736 1.0113

Delaware, IN

5330 Myrtle Beach,

SC .............................. 0.7798 0.8434

Horry, SC

5345 Naples, FL ......... 1.0222 1.0151

Collier, FL

5360 *Nashville, TN .... 0.9065 0.9630

Cheatham, TN

Davidson, TN

Dickson, TN

Robertson, TN

Rutherford TN

Sumner, TN

Williamson, TN

Wilson, TN

5380 *Nassau-Suffolk,

NY .............................. 1.2852 1.2231

Nassau, NY

Suffolk, NY

5483 *New HavenBridgeport-StamfordWaterbury- ................. 1.2778 1.2183

Danbury, CT

Fairfield, CT

New Haven, CT

5523 New LondonNorwich, CT ............... 1.2345 1.1898

New London, CT

5560 *New Orleans,

LA .............................. 0.9434 0.9897

Jefferson, LA

Orleans, LA

Plaquemines, LA

St. Bernard, LA

St. Charles, LA

St. James, LA

St. John The Baptist,

LA

St. Tammany, LA

5600 *New York, NY 1.4041 1.2995

Bronx, NY

Kings, NY

New York, NY

Putnam, NY

Queens, NY

Richmond, NY

Rockland, NY

Westchester, NY

5640 *Newark, NJ ...... 1.1057 1.1034

Essex, NJ

Morris, NJ

Sussex, NJ

Union, NJ

Warren, NJ

5660 Newburgh, NY–

PA .............................. 1.0829 1.0561

Orange, NY

Pike, PA

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

5720 *Norfolk-Virginia

Beach-Newport News,

VA–NC ....................... 0.8326 0.9086

Currituck, NC

Chesapeake City, VA

Gloucester, VA

Hampton City, VA

Isle of Wight, VA

James City, VA

Mathews, VA

Newport News City,

VA

Norfolk City, VA

Poquoson City, VA

Portsmouth City, VA

Suffolk City, VA

Virginia Beach City,

VA

Williamsburg City, VA

York, VA

5775 *Oakland, CA ..... 1.5113 1.3666

Alameda, CA

Contra Costa, CA

5790 Ocala, FL ........... 0.8999 0.9303

Marion, FL

5800 Odessa-Midland,

TX .............................. 0.8552 0.8984

Ector, TX

Midland, TX

5880 *Oklahoma City,

OK ............................. 0.8463 0.9188

Canadian, OK

Cleveland, OK

Logan, OK

McClain, OK

Oklahoma, OK

Pottawatomie, OK

5910 Olympia, WA ..... 1.0713 1.0483

Thurston, WA

5920 Omaha, NE–IA 0.9425 0.9603

Pottawattamie, IA

Cass, NE

Douglas, NE

Sarpy, NE

Washington, NE

5945 *Orange County,

CA .............................. 1.1929 1.1622

Orange, CA

5960 *Orlando, FL ...... 0.9491 0.9938

Lake, FL

Orange, FL

Osceola, FL

Seminole, FL

5990 Owensboro, KY 0.7578 0.8270

Daviess, KY

6015 Panama City, FL 0.8080 0.8642

Bay, FL

6020 ParkersburgMarietta, WV–OH ...... 0.7895 0.8506

Washington, OH

Wood, WV

6080 Pensacola, FL ... 0.8212 0.8738

Escambia, FL

Santa Rosa, FL

6120 Peoria-Pekin, IL 0.8923 0.9249

Peoria, IL

Tazewell, IL

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

Woodford, IL

6160 *Philadelphia,

PA–NJ ....................... 1.1197 1.1129

Burlington, NJ

Camden, NJ

Gloucester, NJ

Salem, NJ

Bucks, PA

Chester, PA

Delaware, PA

Montgomery, PA

Philadelphia, PA

6200 *Phoenix-Mesa,

AZ .............................. 0.9832 1.0181

Maricopa, AZ

Pinal, AZ

6240 Pine Bluff, AR .... 0.7904 0.8512

Jefferson, AR

6280 *Pittsburgh, PA 0.9726 1.0106

Allegheny, PA

Beaver, PA

Butler, PA

Fayette, PA

Washington, PA

Westmoreland, PA

6323 Pittsfield, MA ..... 1.0570 1.0387

Berkshire, MA

6360 Ponce, PR ......... 0.4500 0.5788

Guayanilla, PR

Juana Diaz, PR

Penuelas, PR

Ponce, PR

Villalba, PR

Yauco, PR

6403 Portland, ME ...... 0.9615 0.9735

Cumberland, ME

Sagadahoc, ME

York, ME

6440 *Portland-Vancouver, OR–WA ........ 1.1267 1.1177

Clackamas, OR

Columbia, OR

Multnomah, OR

Washington, OR

Yamhill, OR

Clark, WA

6483 Providence-Warwick-Pawtucket, RI .... 1.1116 1.0751

Bristol, RI

Kent, RI

Newport, RI

Providence, RI

Washington, RI

6520 Provo-Orem, UT 1.0139 1.0095

Utah, UT

6560 Pueblo, CO ........ 0.8302 0.8804

Pueblo, CO

6580 Punta Gorda, FL 0.8284 0.8790

Charlotte, FL

6600 Racine, WI ......... 0.8855 0.9201

Racine, WI

6640 Raleigh-DurhamChapel Hill, NC .......... 0.9740 0.9821

Chatham, NC

Durham, NC

Franklin, NC

Johnston, NC
27526 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

Orange, NC

Wake, NC

6660 Rapid City, SD ... 0.8493 0.8942

Pennington, SD

6680 Reading, PA ...... 0.9467 0.9728

Berks, PA

6690 Redding, CA ...... 1.1631 1.1090

Shasta, CA

6720 Reno, NV ........... 1.1043 1.0703

Washoe, NV

6740 RichlandKennewick-Pasco,

WA ............................. 0.9993 0.9995

Benton, WA

Franklin, WA

6760 Richmond-Petersburg, VA .............. 0.9189 0.9437

Charles City County,

VA

Chesterfield, VA

Colonial Heights City,

VA

Dinwiddie, VA

Goochland, VA

Hanover, VA

Henrico, VA

Hopewell City, VA

New Kent, VA

Petersburg City, VA

Powhatan, VA

Prince George, VA

Richmond City, VA

6780 *Riverside-San

Bernardino, CA .......... 1.1251 1.1166

Riverside, CA

San Bernardino, CA

6800 Roanoke, VA ..... 0.8721 0.9105

Botetourt, VA

Roanoke, VA

Roanoke City, VA

Salem City, VA

6820 Rochester, MN 1.0452 1.0307

Olmsted, MN

6840 *Rochester, NY 0.9611 1.0024

Genesee, NY

Livingston, NY

Monroe, NY

Ontario, NY

Orleans, NY

Wayne, NY

6880 Rockford, IL ....... 0.9015 0.9315

Boone, IL

Ogle, IL

Winnebago, IL

6895 Rocky Mount,

NC ............................. 0.8951 0.9269

Edgecombe, NC

Nash, NC

6920 *Sacramento, CA 1.2382 1.1923

El Dorado, CA

Placer, CA

Sacramento, CA

6960 Saginaw-Bay

City-Midland, MI ........ 0.9605 0.9728

Bay, MI

Midland, MI

Saginaw, MI

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

6980 St. Cloud, MN .... 0.9478 0.9640

Benton, MN

Stearns, MN

7000 St. Joseph, MO 0.8570 0.8997

Andrews, MO

Buchanan, MO

7040 *St. Louis, MO–

IL ................................ 0.8926 0.9529

Clinton, IL

Jersey, IL

Madison, IL

Monroe, IL

St. Clair, IL

Franklin, MO

Jefferson, MO

Lincoln, MO

St. Charles, MO

St. Louis, MO

St. Louis City, MO

Warren, MO

7080 Salem, OR ......... 0.9749 0.9901

Marion, OR

Polk, OR

7120 Salinas, CA ........ 1.3835 1.2489

Monterey, CA

7160 *Salt Lake CityOgden, UT ................. 0.9677 1.0071

Davis, UT

Salt Lake, UT

Weber, UT

7200 San Angelo, TX 0.7594 0.8282

Tom Green, TX

7240 *San Antonio, TX 0.8365 0.9115

Bexar, TX

Comal, TX

Guadalupe, TX

Wilson, TX

7320 *San Diego, CA 1.2183 1.1791

San Diego, CA

7360 *San Francisco,

CA .............................. 1.4210 1.3102

Marin, CA

San Francisco, CA

San Mateo, CA

7400 *San Jose, CA ... 1.4435 1.3244

Santa Clara, CA

7440 *San Juan-Bayamon, PR .................... 0.4616 0.6066

Aguas Buenas, PR

Barceloneta, PR

Bayamon, PR

Canovanas, PR

Carolina, PR

Catano, PR

Ceiba, PR

Comerio, PR

Corozal, PR

Dorado, PR

Fajardo, PR

Florida, PR

Guaynabo, PR

Humacao, PR

Juncos, PR

Los Piedras, PR

Loiza, PR

Luguillo, PR

Manati, PR

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

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 ................ 1.1587 1.1061

San Luis Obispo, CA

7480 Santa BarbaraSanta Maria-Lompoc,

CA .............................. 1.1267 1.0851

Santa Barbara, CA

7485 Santa CruzWatsonville, CA ......... 1.3551 1.2313

Santa Cruz, CA

7490 Santa Fe, NM .... 1.0847 1.0573

Los Alamos, NM

Santa Fe, NM

7500 Santa Rosa, CA 1.2558 1.1688

Sonoma, CA

7510 Sarasota-Bradenton, FL ................. 0.9770 0.9842

Manatee, FL

Sarasota, FL

7520 Savannah, GA ... 1.0089 1.0061

Bryan, GA

Chatham, GA

Effingham, GA

7560 Scranton–WilkesBarre–Hazleton, PA ... 0.8767 0.9138

Columbia, PA

Lackawanna, PA

Luzerne, PA

Wyoming, PA

7600 *Seattle-Bellevue-Everett, WA ........ 1.1410 1.1274

Island, WA

King, WA

Snohomish, WA

7610 Sharon, PA ........ 0.8764 0.9136

Mercer, PA

7620 Sheboygan, WI 0.7782 0.8422

Sheboygan, WI

7640 ShermanDenison, TX ............... 0.8650 0.9055

Grayson, TX

7680 Shreveport-Bossier City, LA ............... 0.9379 0.9570

Bossier, LA

Caddo, LA

Webster, LA

7720 Sioux City, IA–

NE .............................. 0.8331 0.8825

Woodbury, IA

Dakota, NE

7760 Sioux Falls, SD 0.8606 0.9023

Lincoln, SD

Minnehaha, SD

7800 South Bend, IN 0.9957 0.9971

St. Joseph, IN
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27527

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

7840 Spokane, WA .... 1.0548 1.0372

Spokane, WA

7880 Springfield, IL .... 0.8783 0.9150

Menard, IL

Sangamon, IL

7920 Springfield, MO 0.7840 0.8465

Christian, MO

Greene, MO

Webster, MO

8003 Springfield, MA 1.0609 1.0552

Hampden, MA

Hampshire, MA

8050 State College,

PA .............................. 0.8875 0.9215

Centre, PA

8080 SteubenvilleWeirton, OH–WV ....... 0.8244 0.9024

Jefferson, OH

Brooke, WV

Hancock, WV

8120 Stockton-Lodi,

CA .............................. 1.1417 1.0997

San Joaquin, CA

8140 Sumter, SC ........ 0.7716 0.8373

Sumter, SC

8160 Syracuse, NY .... 0.9406 0.9589

Cayuga, NY

Madison, NY

Onondaga, NY

Oswego, NY

8200 Tacoma, WA ...... 1.0891 1.0655

Pierce, WA

8240 Tallahassee, FL 0.8332 0.8825

Gadsden, FL

Leon, FL

8280 *Tampa-St. Petersburg-Clearwater,

FL .............................. 0.9322 0.9817

Hernando, FL

Hillsborough, FL

Pasco, FL

Pinellas, FL

8320 Terre Haute, IN 0.8611 0.9027

Clay, IN

Vermillion, IN

Vigo, IN

8360 Texarkana, ARTexarkana, TX ........... 0.8484 0.8935

Miller, AR

Bowie, TX

8400 Toledo, OH ........ 1.0383 1.0445

Fulton, OH

Lucas, OH

Wood, OH

8440 Topeka, KS ........ 1.0108 1.0074

Shawnee, KS

8480 Trenton, NJ ........ 1.0572 1.0388

Mercer, NJ

8520 Tucson, AZ ........ 0.9050 0.9339

Pima, AZ

8560 Tulsa, OK .......... 0.8113 0.8666

Creek, OK

Osage, OK

Rogers, OK

Tulsa, OK

Wagoner, OK

8600 Tuscaloosa, AL 0.7723 0.8378

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

Tuscaloosa, AL

8640 Tyler, TX ............ 1.0158 1.0108

Smith, TX

8680 Utica-Rome, NY 0.8421 0.8890

Herkimer, NY

Oneida, NY

8720 Vallejo-FairfieldNapa, CA ................... 1.3483 1.2271

Napa, CA

Solano, CA

8735 Ventura, CA ....... 1.1169 1.0786

Ventura, CA

8750 Victoria, TX ........ 0.8478 0.8931

Victoria, TX

8760 Vineland-MillvilleBridgeton, NJ ............. 1.0015 1.0010

Cumberland, NJ

8780 Visalia-TularePorterville, CA ........... 1.0174 1.0119

Tulare, CA

8800 Waco, TX ........... 0.7789 0.8427

McLennan, TX

8840 *Washington,

DC–MD–VA–WV ....... 1.0842 1.0886

District of Columbia,

DC

Calvert, MD

Charles, MD

Frederick, MD

Montgomery, MD

Prince Georges, MD

Alexandria City, VA

Arlington, VA

Clarke, VA

Culpepper, VA

Fairfax, VA

Fairfax City, VA

Falls Church City, VA

Fauquier, VA

Fredericksburg City,

VA

King George, VA

Loudoun, VA

Manassas City, VA

Manassas Park City,

VA

Prince William, VA

Spotsylvania, VA

Stafford, VA

Warren, VA

Berkeley, WV

Jefferson, WV

8920 Waterloo-Cedar

Falls, IA ..................... 0.8724 0.9108

Black Hawk, IA

8940 Wausau, WI ....... 1.0347 1.0236

Marathon, WI

8960 West Palm

Beach-Boca Raton,

FL .............................. 1.0016 1.0036

Palm Beach, FL

9000 Wheeling, OH–

WV ............................. 0.7580 0.8313

Belmont, OH

Marshall, WV

Ohio, WV

9040 Wichita, KS ........ 0.9447 0.9618

TABLE 4A.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR URBAN AREAS—Continued

Urban area (constituent

counties or county

equivalents)

Wage

index GAF

Butler, KS

Harvey, KS

Sedgwick, KS

9080 Wichita Falls, TX 0.8070 0.8634

Archer, TX

Wichita, TX

9140 Williamsport, PA 0.8487 0.8937

Lycoming, PA

9160 Wilmington-Newark, DE–MD ............... 1.1341 1.1063

New Castle, DE

Cecil, MD

9200 Wilmington, NC 0.9072 0.9355

New Hanover, NC

Brunswick, NC

9260 Yakima, WA ....... 1.0049 1.0034

Yakima, WA

9270 Yolo, CA ............ 1.1470 1.0985

Yolo, CA

9280 York, PA ............ 0.9124 0.9391

York, PA

9320 YoungstownWarren, OH ............... 0.9764 0.9838

Columbiana, OH

Mahoning, OH

Trumbull, OH

9340 Yuba City, CA .... 1.0437 1.0297

Sutter, CA

Yuba, CA

9360 Yuma, AZ .......... 0.9518 0.9667

Yuma, AZ

* Large Urban Area

TABLE 4B.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR RURAL AREAS

Nonurban area Wage

index GAF

Alabama ........................ 0.7160 0.7955

Alaska ........................... 1.2472 1.2550

Arizona .......................... 0.7946 0.8543

Arkansas ....................... 0.7000 0.7833

California ....................... 0.9991 1.0010

Colorado ........................ 0.8156 0.8697

Connecticut ................... 1.2788 1.2189

Delaware ....................... 0.9464 0.9630

Florida ........................... 0.8677 0.9084

Georgia ......................... 0.7659 0.8331

Hawaii ........................... 1.0268 1.0771

Idaho ............................. 0.8356 0.8843

Illinois ............................ 0.7567 0.8286

Indiana .......................... 0.8119 0.8718

Iowa ............................... 0.7394 0.8132

Kansas .......................... 0.7113 0.7922

Kentucky ....................... 0.7772 0.8419

Louisiana ....................... 0.7284 0.8055

Maine ............................ 0.8335 0.8827

Maryland ....................... 0.8446 0.8908

Massachusetts .............. 1.0794 1.0537

Michigan ........................ 0.8837 0.9188

Minnesota ...................... 0.8161 0.8704

Mississippi ..................... 0.6808 0.7685

Missouri ......................... 0.7249 0.8044
27528 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 4B.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR RURAL AREAS—Continued

Nonurban area Wage

index GAF

Montana ........................ 0.8137 0.8683

Nebraska ....................... 0.7245 0.8020

Nevada .......................... 0.8795 0.9158

New Hampshire ............ 0.9776 0.9895

New Jersey 1 ................. .............. ..............

New Mexico .................. 0.7873 0.8489

New York ...................... 0.8565 0.8994

North Carolina ............... 0.7945 0.8565

North Dakota ................. 0.7370 0.8114

Ohio ............................... 0.8349 0.8909

Oklahoma ...................... 0.6963 0.7805

Oregon .......................... 0.9715 0.9813

Pennsylvania ................. 0.8480 0.8939

Puerto Rico ................... 0.4182 0.5505

Rhode Island 1 ............... .............. ..............

South Carolina .............. 0.7679 0.8356

South Dakota ................ 0.7085 0.7898

Tennessee .................... 0.7372 0.8116

Texas ............................ 0.7430 0.8166

Utah ............................... 0.8854 0.9200

Vermont ......................... 0.8941 0.9287

Virginia .......................... 0.7760 0.8422

Washington ................... 0.9956 0.9978

West Virginia ................. 0.7943 0.8541

Wisconsin ...................... 0.8449 0.8914

Wyoming ....................... 0.8202 0.8731

1All counties within the State are classified

as urban.

TABLE 4C.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR HOSPITALS THAT ARE

RECLASSIFIED

Area reclassified to Wage

index GAF

Abilene, TX ................... 0.8055 0.8623

Albuquerque, NM .......... 0.9390 0.9578

Alexandria, LA ............... 0.8213 0.8739

Amarillo, TX .................. 0.8557 0.8988

Anchorage, AK .............. 1.3285 1.2147

Asheville, NC ................ 0.9365 0.9561

Atlanta, GA .................... 0.9986 0.9990

Bangor, ME ................... 0.9412 0.9594

Baton Rouge, LA .......... 0.8442 0.8905

Benton Harbor, MI ........ 0.8553 0.8985

Benton Harbor, MI

(Rural Michigan

Hosp.) ........................ 0.8837 0.9188

Billings, MT ................... 0.8903 0.9235

Birmingham, AL ............ 0.9047 0.9337

Bismarck, ND ................ 0.7976 0.8565

Boise City, ID ................ 0.9269 0.9493

Boston-Worcester-Lawrence-Lowell-Brockton, MA–NH ............... 1.1639 1.1095

Caguas, PR ................... 0.4661 0.5929

Champaign-Urbana, IL 0.8999 0.9303

Charleston-North

Charleston, SC .......... 0.8984 0.9293

Charlotte-Gastonia-Rock

Hill, NC–SC ............... 0.9631 0.9746

Charlottesville, VA ......... 0.9006 0.9308

Chattanooga, TN–GA ... 0.8867 0.9210

Chicago, IL .................... 1.0653 1.0443

TABLE 4C.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR HOSPITALS THAT ARE

RECLASSIFIED—Continued

Area reclassified to Wage

index GAF

Cincinnati, OH–KY–IN 0.9477 0.9639

Cleveland-Lorain-Elyria,

OH ............................. 0.9908 0.9937

Columbia, MO ............... 0.8919 0.9246

Columbus, OH .............. 0.9699 0.9793

Dallas, TX ..................... 0.9530 0.9676

Davenport-Moline-Rock

Island, IA–IL .............. 0.8407 0.8880

Denver, CO ................... 1.0291 1.0198

Des Moines, IA ............. 0.8772 0.9142

Duluth-Superior, MN–WI 0.9437 0.9611

Dutchess County, NY ... 1.0309 1.0211

Elkhart-Goshen, IN ....... 0.8820 0.9176

Eugene-Springfield, OR 1.1503 1.1006

Fargo-Moorhead, ND–

MN ............................. 0.8860 0.9205

Fayetteville, NC ............. 0.8658 0.9060

Flagstaff, AR–UT .......... 0.8848 0.9196

Flint, MI ......................... 1.1273 1.0855

Florence, AL .................. 0.8157 0.8698

Florence, SC ................. 0.8614 0.9029

Fort Lauderdale, FL ...... 1.0968 1.0653

Fort Pierce-Port St.

Lucie, FL .................... 1.0049 1.0034

Fort Smith, AR–OK ....... 0.7885 0.8498

Fort Walton Beach, FL 0.8978 0.9288

Fort Worth-Arlington, TX 1.0095 1.0065

Gadsden, AL ................. 0.8901 0.9234

Gary, IN ......................... 0.9176 0.9428

Grand Forks, ND–MN ... 0.9228 0.9465

Grand Junction, CO ...... 0.8847 0.9195

Grand Rapids-Muskegon-Holland, MI ......... 1.0088 1.0060

Great Falls, MT ............. 0.9007 0.9309

Greeley, CO .................. 0.9409 0.9591

Green Bay, WI .............. 0.9387 0.9576

Greensboro-WinstonSalem-High Point, NC 0.9327 0.9534

Greenville-SpartanburgAnderson, SC ............ 0.8947 0.9266

Hartford, CT .................. 1.2218 1.1470

Honolulu, HI .................. 1.1487 1.0996

Houston, TX .................. 0.9790 0.9856

Huntington-Ashland,

WV–KY–OH ............... 0.9194 0.9441

Huntsville, AL ................ 0.8040 0.8612

Indianapolis, IN ............. 0.9833 0.9885

Jackson, MS ................. 0.7906 0.8514

Jacksonville, FL ............ 0.9018 0.9317

Johnson City-KingsportBristol, TN–VA ........... 0.8921 0.9248

Joplin, MO ..................... 0.7409 0.8144

Kalamazoo-Battlecreek,

MI ............................... 1.0462 1.0314

Kansas City, KS–MO .... 0.9522 0.9670

Knoxville, TN ................. 0.8520 0.8961

Lafayette, LA ................. 0.8183 0.8717

Lansing-East Lansing,

MI ............................... 1.0016 1.0011

Las Vegas, NV–AZ ....... 1.0894 1.0604

Lexington, KY ................ 0.8387 0.8865

Lima, OH ....................... 0.8752 0.9128

Lincoln, NE .................... 0.9059 0.9346

Little Rock-North Little

Rock, AR ................... 0.8616 0.9030

Longview-Marshall, TX 0.8495 0.8943

Los Angeles-Long

Beach, CA ................. 1.2396 1.1585

TABLE 4C.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR HOSPITALS THAT ARE

RECLASSIFIED—Continued

Area reclassified to Wage

index GAF

Louisville, KY–IN ........... 0.9445 0.9617

Macon, GA .................... 0.8460 0.8918

Madison, WI .................. 1.0048 1.0033

Mansfield, OH ............... 0.8543 0.8978

Medford-Ashland, OR ... 1.0213 1.0145

Memphis, TN–AR–MS 0.8185 0.8718

Middlesex-SomersetHunterdon, NJ ........... 1.0777 1.0526

Milwaukee-Waukesha,

WI .............................. 0.9667 0.9771

Minneapolis-St. Paul,

MN–WI ....................... 1.0785 1.0531

Modesto, CA ................. 1.0135 1.0092

Monmouth-Ocean, NJ ... 1.0572 1.0388

Montgomery, AL ............ 0.7949 0.8545

Nashville, TN ................. 0.9065 0.9350

New Haven-BridgeportStamford-WaterburyDanbury, CT .............. 1.2778 1.1828

New London-Norwich,

CT .............................. 1.2345 1.1552

New Orleans, LA ........... 0.9434 0.9609

New York, NY ............... 1.4041 1.2616

Newark, NJ ................... 1.0956 1.0645

Oakland, CA .................. 1.5113 1.3268

Odessa-Midland, TX ..... 0.8552 0.8984

Oklahoma City, OK ....... 0.8463 0.8920

Omaha, NE–IA .............. 0.9425 0.9603

Orange County, CA ...... 1.1929 1.1284

Peoria-Pekin, IL ............ 0.8923 0.9249

Philadelphia, PA–NJ ..... 1.1197 1.0805

Pittsburgh, PA ............... 0.9564 0.9699

Portland, ME ................. 0.9615 0.9735

Portland-Vancouver,

OR–WA ..................... 1.1267 1.0851

Provo-Orem, UT ............ 1.0139 1.0095

Raleigh-Durham-Chapel

Hill, NC ...................... 0.9615 0.9735

Rapid City, SD .............. 0.8493 0.8942

Roanoke, VA ................. 0.8721 0.9105

Rochester, MN .............. 1.0452 1.0307

Rockford, IL ................... 0.9015 0.9315

Sacramento, CA ............ 1.2382 1.1576

Saginaw-Bay City-Midland, MI ...................... 0.9605 0.9728

St. Cloud, MN ............... 0.9478 0.9640

St. Louis, MO–IL ........... 0.8926 0.9251

Salt Lake City-Ogden,

UT .............................. 0.9677 0.9778

San Diego, CA .............. 1.2183 1.1448

San Francisco, CA ........ 1.4210 1.2720

San Jose, CA ................ 1.4435 1.2858

Santa Rosa, CA ............ 1.2430 1.1606

Sarasota-Bradenton, FL 0.9770 0.9842

Seattle-Bellevue-Everett,

WA ............................. 1.1410 1.0945

Sharon, PA .................... 0.8764 0.9136

Sherman-Denison, TX 0.8650 0.9055

Sioux Falls, SD ............. 0.8606 0.9023

South Bend, IN ............. 0.9957 0.9971

Springfield, IL ................ 0.8783 0.9150

Springfield, MO ............. 0.7840 0.8465

Stockton-Lodi, CA ......... 1.1417 1.0950

Syracuse, NY ................ 0.9406 0.9589

Tacoma, WA ................. 1.0891 1.0602

Tampa-St. PetersburgClearwater, FL ........... 0.9322 0.9531
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27529

TABLE 4C.—WAGE INDEX AND CAPITAL

GEOGRAPHIC ADJUSTMENT FACTOR

(GAF) FOR HOSPITALS THAT ARE

RECLASSIFIED—Continued

Area reclassified to Wage

index GAF

Texarkana, AR-Texarkana, TX ................. 0.8484 0.8935

Toledo, OH .................... 1.0383 1.0261

Topeka, KS ................... 0.9817 0.9874

Tucson, AZ .................... 0.9050 0.9339

Tulsa, OK ...................... 0.8113 0.8666

Tyler, TX ....................... 0.9717 0.9805

Victoria, TX ................... 0.8259 0.8772

Washington, DC–MD–

VA–WV ...................... 1.0842 1.0569

Waterloo-Cedar Falls, IA 0.8601 0.9019

Wausau, WI .................. 0.9720 0.9807

Wichita, KS ................... 0.9282 0.9503

Rural Alabama .............. 0.7160 0.7955

Rural Florida ................. 0.8677 0.9074

Rural Kentucky .............. 0.7772 0.8415

Rural Louisiana ............. 0.7284 0.8049

Rural Michigan .............. 0.8837 0.9188

Rural Minnesota ............ 0.8161 0.8701

Rural New Hampshire ... 0.9776 0.9846

Rural North Carolina ..... 0.7945 0.8542

Rural Virginia ................ 0.7760 0.8406

Rural Washington ......... 0.9956 0.9970

Rural West Virginia ....... 0.7943 0.8541

Rural Wyoming ............. 0.8202 0.8731

TABLE 4D.—AVERAGE HOURLY WAGE

FOR URBAN AREAS

Urban area

Average

hourly

wage

Abilene, TX ................................... 15.4795

Aguadilla, PR ................................ 8.6418

Akron, OH ..................................... 19.2662

Albany, GA .................................... 16.2968

Albany-Schenectady-Troy, NY ..... 16.6016

Albuquerque, NM .......................... 18.3100

Alexandria, LA .............................. 15.8746

Allentown-Bethlehem-Easton, PA 19.5376

Altoona, PA ................................... 18.5951

Amarillo, TX .................................. 16.6936

Anchorage, AK .............................. 25.8567

Ann Arbor, MI ............................... 22.8035

Anniston, AL ................................. 15.3104

Appleton-Oshkosh-Neenah, WI .... 17.3835

Arecibo, PR ................................... 9.0343

Asheville, NC ................................ 18.2517

Athens, GA ................................... 18.0640

Atlanta, GA ................................... 19.6832

Atlantic-Cape May, NJ .................. 21.6594

Augusta-Aiken, GA–SC ................ 17.2642

Austin-San Marcos, TX ................. 18.0500

Bakersfield, CA ............................. 19.9031

Baltimore, MD ............................... 19.1581

Bangor, ME ................................... 18.3630

Barnstable-Yarmouth, MA ............ 26.6928

Baton Rouge, LA .......................... 16.4700

Beaumont-Port Arthur, TX ............ 16.7355

Bellingham, WA ............................ 22.1285

Benton Harbor, MI ........................ 16.5971

Bergen-Passaic, NJ ...................... 22.8591

Billings, MT ................................... 17.3702

Biloxi-Gulfport-Pascagoula, MS .... 16.7252

Binghamton, NY ............................ 17.2505

Birmingham, AL ............................ 17.6503

TABLE 4D.—AVERAGE HOURLY WAGE

FOR URBAN AREAS—Continued

Urban area

Average

hourly

wage

Bismarck, ND ................................ 15.0933

Bloomington, IN ............................ 16.8155

Bloomington-Normal, IL ................ 17.4035

Boise City, ID ................................ 18.0695

Boston-Worcester-Lawrence-Lowell-Brockton, MA–NH ................. 22.7069

Boulder-Longmont, CO ................. 18.3061

Brazoria, TX .................................. 17.9908

Bremerton, WA ............................. 21.3152

Brownsville-Harlingen-San Benito,

TX .............................................. 16.7030

Bryan-College Station, TX ............ 17.0898

Buffalo-Niagara Falls, NY ............. 17.7977

Burlington, VT ............................... 17.8037

Caguas, PR .................................. 9.0488

Canton-Massillon, OH ................... 16.9098

Casper, WY .................................. 17.2484

Cedar Rapids, IA .......................... 16.5386

Champaign-Urbana, IL ................. 18.3634

Charleston-North Charleston, SC 17.5265

Charleston, WV ............................. 18.6261

Charlotte-Gastonia-Rock Hill, NC–

SC ............................................. 18.7900

Charlottesville, VA ........................ 17.9005

Chattanooga, TN–GA ................... 17.2991

Cheyenne, WY .............................. 15.0126

Chicago, IL .................................... 20.9843

Chico-Paradise, CA ...................... 20.3689

Cincinnati, OH–KY–IN .................. 18.4886

Clarksville-Hopkinsville, TN–KY ... 15.0873

Cleveland-Lorain-Elyria, OH ......... 19.3306

Colorado Springs, CO .................. 18.4479

Columbia, MO ............................... 17.4002

Columbia, SC ................................ 17.9066

Columbus, GA–AL ........................ 14.9336

Columbus, OH .............................. 18.9232

Corpus Christi, TX ........................ 16.8587

Cumberland, MD–WV ................... 16.8031

Dallas, TX ..................................... 18.5928

Danville, VA .................................. 16.6152

Davenport-Moline-Rock Island,

IA–IL .......................................... 16.4021

Dayton-Springfield, OH ................. 18.6930

Daytona Beach, FL ....................... 17.3459

Decatur, AL ................................... 16.3934

Decatur, IL .................................... 15.3452

Denver, CO ................................... 20.0780

Des Moines, IA ............................. 17.1139

Detroit, MI ..................................... 20.9694

Dothan, AL .................................... 15.1351

Dover, DE ..................................... 17.5916

Dubuque, IA .................................. 15.8987

Duluth-Superior, MN–WI ............... 18.4105

Dutchess County, NY ................... 20.6881

Eau Claire, WI .............................. 16.9692

El Paso, TX ................................... 18.5059

Elkhart-Goshen, IN ....................... 17.2083

Elmira, NY ..................................... 16.4576

Enid, OK ....................................... 15.3724

Erie, PA ......................................... 17.8263

Eugene-Springfield, OR ................ 22.0384

Evansville, Henderson, IN–KY ..... 17.5397

Fargo-Moorhead, ND–MN ............ 17.5775

Fayetteville, NC ............................ 17.6077

Fayetteville-Springdale-Rogers,

AR ............................................. 14.1177

Flagstaff, AZ–UT ........................... 17.6344

Flint, MI ......................................... 21.9933

Florence, AL ................................. 15.5886

TABLE 4D.—AVERAGE HOURLY WAGE

FOR URBAN AREAS—Continued

Urban area

Average

hourly

wage

Florence, SC ................................. 16.8047

Fort Collins-Loveland, CO ............ 20.7345

Fort Lauderdale, FL ...................... 20.5796

Fort Myers-Cape Coral, FL ........... 17.7400

Fort Pierce-Port St. Lucie, FL ....... 19.8836

Fort Smith, AR–OK ....................... 15.3772

Fort Walton Beach, FL ................. 17.9217

Fort Wayne, IN ............................. 17.2046

Fort Worth-Arlington, TX ............... 19.6953

Fresno, CA .................................... 21.8549

Gadsden, AL ................................. 17.3656

Gainesville, FL .............................. 18.4465

Galveston-Texas City, TX ............. 21.5032

Gary, IN ........................................ 18.8135

Glens Falls, NY ............................. 16.6999

Goldsboro, NC .............................. 16.4109

Grand Forks, ND–MN ................... 17.6200

Grand Junction, CO ...................... 16.2899

Grand Rapids-Muskegon-Holland,

MI .............................................. 19.6810

Great Falls, MT ............................. 16.9748

Greeley, CO .................................. 18.9481

Green Bay, WI .............................. 17.6730

Greensboro-Winston-Salem-High

Point, NC ................................... 18.1974

Greenville, NC .............................. 17.7503

Greenville-Spartanburg-Anderson,

SC ............................................. 17.4547

Hagerstown, MD ........................... 17.9394

Hamilton-Middletown, OH ............. 18.5631

Harrisburg-Lebanon-Carlisle, PA 19.8630

Hartford, CT .................................. 24.1823

Hattiesburg, MS ............................ 14.1809

Hickory-Morganton-Lenoir, NC ..... 16.8672

Honolulu, HI .................................. 22.4099

Houma, LA .................................... 15.3009

Houston, TX .................................. 19.1004

Huntington-Ashland, WV–KY–OH 17.9378

Huntsville, AL ................................ 15.8903

Indianapolis, IN ............................. 19.4109

Iowa City, IA ................................. 18.3037

Jackson, MI ................................... 17.6864

Jackson, MS ................................. 15.3259

Jackson, TN .................................. 16.2704

Jacksonville, FL ............................ 17.5917

Jacksonville, NC ........................... 13.7955

Jamestown, NY ............................. 14.9815

Janesville-Beloit, WI ..................... 16.9030

Jersey City, NJ ............................. 22.2562

Johnson City-Kingsport-Bristol,

TN–VA ....................................... 17.3717

Johnstown, PA .............................. 16.4213

Joplin, MO ..................................... 14.3989

Kalamazoo-Battlecreek, MI ........... 20.6127

Kankakee, IL ................................. 17.5542

Kansas City, KS–MO .................... 18.5772

Kenosha, WI ................................. 17.8819

Killeen-Temple, TX ....................... 20.3189

Knoxville, TN ................................. 16.6222

Kokomo, IN ................................... 16.7962

La Crosse, WI–MN ....................... 16.8513

Lafayette, LA ................................. 15.9607

Lafayette, IN ................................. 17.1635

Lake Charles, LA .......................... 15.7084

Lakeland-Winter Haven, FL .......... 17.1559

Lancaster, PA ............................... 18.7384

Lansing-East Lansing, MI ............. 19.5408

Laredo, TX .................................... 13.8360

Las Cruces, NM ............................ 16.6145
27530 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 4D.—AVERAGE HOURLY WAGE

FOR URBAN AREAS—Continued

Urban area

Average

hourly

wage

Las Vegas, NV–AZ ....................... 21.2545

Lawrence, KS ............................... 16.8098

Lawton, OK ................................... 16.2681

Lewiston-Auburn, ME ................... 18.3998

Lexington, KY ............................... 16.3501

Lima, OH ....................................... 17.0746

Lincoln, NE ................................... 17.9352

Little Rock-North Little Rock, AR 16.8095

Longview-Marshall, TX ................. 16.8433

Los Angeles-Long Beach, CA ...... 24.1067

Louisville, KY–IN ........................... 18.4271

Lubbock, TX .................................. 16.6316

Lynchburg, VA .............................. 15.6776

Macon, GA .................................... 17.2388

Madison, WI .................................. 19.6027

Mansfield, OH ............................... 16.6677

Mayaguez, PR .............................. 8.1673

McAllen-Edinburg-Mission, TX ..... 16.5870

Medford-Ashland, OR ................... 19.6857

Melbourne-Titusville-Palm Bay, FL 17.7314

Memphis, TN–AR–MS .................. 15.9681

Merced, CA ................................... 20.8439

Miami, FL ...................................... 19.3734

Middlesex-Somerset-Hunterdon,

NJ .............................................. 21.0732

Milwaukee-Waukesha, WI ............ 18.8591

Minneapolis-St. Paul, MN–WI ....... 21.0411

Mobile, AL ..................................... 15.6052

Modesto, CA ................................. 20.7262

Monmouth-Ocean, NJ ................... 21.1523

Monroe, LA ................................... 16.0633

Montgomery, AL ........................... 15.5087

Muncie, IN ..................................... 18.9936

Myrtle Beach, SC .......................... 15.2138

Naples, FL .................................... 19.9423

Nashville, TN ................................ 17.6844

Nassau-Suffolk, NY ...................... 26.4295

New Haven-Bridgeport-StamfordWaterbury-Danbury, CT ............ 24.8405

New London-Norwich, CT ............ 23.9754

New Orleans, LA .......................... 18.4047

New York, NY ............................... 27.3928

Newark, NJ ................................... 22.9650

Newburgh, NY–PA ........................ 21.1274

Norfolk-Virginia Beach-Newport

News, VA–NC ........................... 16.2433

Oakland, CA ................................. 29.3295

Ocala, FL ...................................... 17.5573

Odessa-Midland, TX ..................... 16.5854

Oklahoma City, OK ....................... 16.5112

Olympia, WA ................................. 20.9003

Omaha, NE–IA .............................. 18.3867

Orange County, CA ...................... 23.3969

Orlando, FL ................................... 18.5157

Owensboro, KY ............................. 14.7838

Panama City, FL ........................... 15.7629

Parkersburg-Marietta, WV–OH ..... 15.4018

Pensacola, FL ............................... 16.0203

Peoria-Pekin, IL ............................ 17.4092

Philadelphia, PA–NJ ..................... 21.8450

Phoenix-Mesa, AZ ........................ 19.1821

Pine Bluff, AR ............................... 15.4205

Pittsburgh, PA ............................... 18.9757

Pittsfield, MA ................................. 20.6216

Ponce, PR ..................................... 8.7784

Portland, ME ................................. 18.7580

Portland-Vancouver, OR–WA ....... 21.9821

Providence-Warwick, RI ............... 21.6876

Provo-Orem, UT ........................... 19.7809

TABLE 4D.—AVERAGE HOURLY WAGE

FOR URBAN AREAS—Continued

Urban area

Average

hourly

wage

Pueblo, CO ................................... 16.1970

Punta Gorda, FL ........................... 16.1612

Racine, WI .................................... 17.2751

Raleigh-Durham-Chapel Hill, NC 19.0031

Rapid City, SD .............................. 16.5325

Reading, PA .................................. 18.4690

Redding, CA ................................. 22.6922

Reno, NV ...................................... 21.5443

Richland-Kennewick-Pasco, WA 19.4956

Richmond-Petersburg, VA ............ 17.9271

Riverside-San Bernardino, CA ..... 22.2324

Roanoke, VA ................................. 17.0151

Rochester, MN .............................. 20.3908

Rochester, NY .............................. 18.7505

Rockford, IL .................................. 17.5872

Rocky Mount, NC ......................... 17.4626

Sacramento, CA ........................... 24.1558

Saginaw-Bay City-Midland, MI ..... 18.5818

St. Cloud, MN ............................... 18.4907

St. Joseph, MO ............................. 16.7196

St. Louis, MO–IL ........................... 17.4144

Salem, OR .................................... 19.0205

Salinas, CA ................................... 26.9904

Salt Lake City-Ogden, UT ............ 18.8799

San Angelo, TX ............................ 14.8158

San Antonio, TX ........................... 16.3206

San Diego, CA .............................. 23.7299

San Francisco, CA ........................ 27.8220

San Jose, CA ................................ 28.2911

San Juan-Bayamon, PR ............... 9.0059

San Luis Obispo-Atascadero-Paso

Robles, CA ................................ 22.6053

Santa Barbara-Santa MariaLompoc, CA .............................. 21.9816

Santa Cruz-Watsonville, CA ......... 26.4364

Santa Fe, NM ............................... 21.1622

Santa Rosa, CA ............................ 24.4999

Sarasota-Bradenton, FL ............... 19.0607

Savannah, GA .............................. 19.6834

Scranton-Wilkes Barre-Hazleton,

PA .............................................. 17.1047

Seattle-Bellevue-Everett, WA ....... 22.2595

Sharon, PA ................................... 17.0979

Sheboygan, WI ............................. 15.1817

Sherman-Denison, TX .................. 16.8423

Shreveport-Bossier City, LA ......... 18.2987

Sioux City, IA–NE ......................... 16.2539

Sioux Falls, SD ............................. 16.7892

South Bend, IN ............................. 19.4248

Spokane, WA ................................ 20.5788

Springfield, IL ................................ 17.1355

Springfield, MO ............................. 15.2957

Springfield, MA ............................. 20.6983

State College, PA ......................... 17.3139

Steubenville-Weirton, OH–WV ..... 16.0839

Stockton-Lodi, CA ......................... 22.1532

Sumter, SC ................................... 15.0540

Syracuse, NY ................................ 18.3462

Tacoma, WA ................................. 21.2353

Tallahassee, FL ............................ 16.2555

Tampa-St. Petersburg-Clearwater,

FL .............................................. 18.0837

Terre Haute, IN ............................. 16.7989

Texarkana, AR-Texarkana, TX ..... 16.5261

Toledo, OH ................................... 20.2562

Topeka, KS ................................... 19.7210

Trenton, NJ ................................... 20.6250

Tucson, AZ ................................... 17.6383

Tulsa, OK ...................................... 15.8281

TABLE 4D.—AVERAGE HOURLY WAGE

FOR URBAN AREAS—Continued

Urban area

Average

hourly

wage

Tuscaloosa, AL ............................. 15.0679

Tyler, TX ....................................... 19.8177

Utica-Rome, NY ............................ 16.4296

Vallejo-Fairfield-Napa, CA ............ 27.2883

Ventura, CA .................................. 22.5369

Victoria, TX ................................... 16.5405

Vineland-Millville-Bridgeton, NJ .... 19.5394

Visalia-Tulare-Porterville, CA ........ 19.8483

Waco, TX ...................................... 15.1959

Washington, DC–MD–VA–WV ..... 21.1518

Waterloo-Cedar Falls, IA .............. 17.0208

Wausau, WI .................................. 20.1856

West Palm Beach-Boca Raton, FL 19.9482

Wheeling, OH–WV ........................ 14.7877

Wichita, KS ................................... 18.4305

Wichita Falls, TX ........................... 15.7442

Williamsport, PA ........................... 16.5567

Wilmington-Newark, DE–MD ........ 22.1249

Wilmington, NC ............................. 17.6987

Yakima, WA .................................. 19.6049

Yolo, CA ........................................ 22.3769

York, PA ........................................ 17.8006

Youngstown-Warren, OH .............. 19.0484

Yuba City, CA ............................... 20.3622

Yuma, AZ ...................................... 18.5693

TABLE 4E.—AVERAGE HOURLY WAGE

FOR RURAL AREAS

Nonurban area

Average

hourly

wage

Alabama ........................................ 13.9126

Alaska ........................................... 24.3314

Arizona .......................................... 15.5017

Arkansas ....................................... 13.6566

California ....................................... 19.4927

Colorado ....................................... 15.9126

Connecticut ................................... 24.9480

Delaware ....................................... 18.4636

Florida ........................................... 16.9290

Georgia ......................................... 14.9414

Hawaii ........................................... 20.0330

Idaho ............................................. 16.3016

Illinois ............................................ 14.7630

Indiana .......................................... 15.8402

Iowa .............................................. 14.4246

Kansas .......................................... 13.8771

Kentucky ....................................... 15.1633

Louisiana ....................................... 14.1714

Maine ............................................ 16.2618

Maryland ....................................... 16.4778

Massachusetts .............................. 21.0582

Michigan ........................................ 17.2254

Minnesota ..................................... 15.9225

Mississippi ..................................... 13.2817

Missouri ......................................... 14.1433

Montana ........................................ 15.8750

Nebraska ....................................... 14.1342

Nevada .......................................... 17.1588

New Hampshire ............................ 19.0608

New Jersey 1 ................................. ................

New Mexico .................................. 15.3596

New York ...................................... 16.7103

North Carolina ............................... 15.4962

North Dakota ................................. 14.3775

Ohio .............................................. 16.2883
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27531

TABLE 4E.—AVERAGE HOURLY WAGE

FOR RURAL AREAS—Continued

Nonurban area

Average

hourly

wage

Oklahoma ...................................... 13.5853

Oregon .......................................... 18.9527

Pennsylvania ................................. 16.5230

Puerto Rico ................................... 8.1591

Rhode Island 1 .............................. ................

South Carolina .............................. 14.9812

TABLE 4E.—AVERAGE HOURLY WAGE

FOR RURAL AREAS—Continued

Nonurban area

Average

hourly

wage

South Dakota ................................ 13.8219

Tennessee .................................... 14.3822

Texas ............................................ 14.4957

Utah .............................................. 17.2737

Vermont ........................................ 17.4440

Virginia .......................................... 15.1073

TABLE 4E.—AVERAGE HOURLY WAGE

FOR RURAL AREAS—Continued

Nonurban area

Average

hourly

wage

Washington ................................... 19.4229

West Virginia ................................. 15.4577

Wisconsin ...................................... 16.4842

Wyoming ....................................... 16.0015

1All counties within the State are classified

as urban.

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC MEAN LENGTH

OF STAY, AND LENGTH OF STAY OUTLIER CUTOFF POINTS USED IN THE PROSPECTIVE PAYMENT SYSTEM

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

Outlier

threshold

1 ....... 01 SURG CRANIOTOMY AGE >17 EXCEPT FOR TRAUMA .............. 3.0445 7.7 11.1 32

2 ....... 01 SURG CRANIOTOMY FOR TRAUMA AGE >17 .............................. 3.0241 8.4 11.5 32

3 ....... 01 SURG *CRANIOTOMY AGE 0–17 .................................................... 1.9159 12.7 12.7 37

4 ....... 01 SURG SPINAL PROCEDURES ........................................................ 2.3330 5.9 9.1 30

5 ....... 01 SURG EXTRACRANIAL VASCULAR PROCEDURES ..................... 1.5149 3.3 4.4 26

6 ....... 01 SURG CARPAL TUNNEL RELEASE ................................................ .7359 2.4 3.4 25

7 ....... 01 SURG PERIPH & CRANIAL NERVE & OTHER NERV SYST

PROC W CC.

2.4935 8.2 12.6 32

8 ....... 01 SURG PERIPH & CRANIAL NERVE & OTHER NERV SYST

PROC W/O CC.

1.1419 2.8 4.1 27

9 ....... 01 MED SPINAL DISORDERS & INJURIES ....................................... 1.2522 5.4 7.7 29

10 ..... 01 MED NERVOUS SYSTEM NEOPLASMS W CC ........................... 1.2209 5.7 8.1 30

11 ..... 01 MED NERVOUS SYSTEM NEOPLASMS W/O CC ....................... .8020 3.5 5.0 28

12 ..... 01 MED DEGENERATIVE NERVOUS SYSTEM DISORDERS .......... .9435 5.4 7.6 29

13 ..... 01 MED MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA .............. .7799 5.0 6.3 29

14 ..... 01 MED SPECIFIC CEREBROVASCULAR DISORDERS EXCEPT

TIA.

1.2003 5.5 7.5 30

15 ..... 01 MED TRANSIENT ISCHEMIC ATTACK & PRECEREBRAL OCCLUSIONS..7232 3.5 4.4 27

16 ..... 01 MED NONSPECIFIC CEREBROVASCULAR DISORDERS W CC 1.0390 4.9 6.6 29

17 ..... 01 MED NONSPECIFIC CEREBROVASCULAR DISORDERS W/O

CC.

.6308 3.0 4.0 26

18 ..... 01 MED CRANIAL & PERIPHERAL NERVE DISORDERS W CC ..... .9345 4.8 6.4 29

19 ..... 01 MED CRANIAL & PERIPHERAL NERVE DISORDERS W/O CC .6258 3.4 4.5 27

20 ..... 01 MED NERVOUS SYSTEM INFECTION EXCEPT VIRAL MENINGITIS.2.4782 8.5 11.5 33

21 ..... 01 MED VIRAL MENINGITIS ............................................................... 1.4972 5.8 7.9 30

22 ..... 01 MED HYPERTENSIVE ENCEPHALOPATHY ................................ .8356 3.8 4.9 28

23 ..... 01 MED NONTRAUMATIC STUPOR & COMA ................................... .8053 3.6 5.1 28

24 ..... 01 MED SEIZURE & HEADACHE AGE >17 W CC ............................ .9707 4.2 5.8 28

25 ..... 01 MED SEIZURE & HEADACHE AGE >17 W/O CC ........................ .5791 3.0 3.9 24

26 ..... 01 MED SEIZURE & HEADACHE AGE 0–17 ..................................... .7381 3.3 4.6 27

27 ..... 01 MED TRAUMATIC STUPOR & COMA, COMA >1 HR .................. 1.3186 3.7 6.3 28

28 ..... 01 MED TRAUMATIC STUPOR & COMA, COMA <1 HR AGE >17

W CC.

1.2075 4.8 7.2 29

29 ..... 01 MED TRAUMATIC STUPOR & COMA, COMA <1 HR AGE >17

W/O CC.

.6382 3.0 4.1 27

30 ..... 01 MED *TRAUMATIC STUPOR & COMA, COMA <1 HR AGE 0–17 .3240 2.0 2.0 17

31 ..... 01 MED CONCUSSION AGE >17 W CC ............................................ .8367 3.7 5.4 28

32 ..... 01 MED CONCUSSION AGE >17 W/O CC ........................................ .4887 2.3 3.2 21

33 ..... 01 MED *CONCUSSION AGE 0–17 .................................................... .2036 1.6 1.6 9

34 ..... 01 MED OTHER DISORDERS OF NERVOUS SYSTEM W CC ........ 1.0639 4.6 6.5 29

35 ..... 01 MED OTHER DISORDERS OF NERVOUS SYSTEM ...................

W/O CC ..................................................................................

.6112 3.2 4.3 27

36 ..... 02 SURG RETINAL PROCEDURES ...................................................... .6156 1.3 1.6 6

37 ..... 02 SURG ORBITAL PROCEDURES ..................................................... .9280 2.7 4.0 27

38 ..... 02 SURG PRIMARY IRIS PROCEDURES ............................................ .4217 1.8 2.5 16

39 ..... 02 SURG LENS PROCEDURES WITH OR WITHOUT VITRECTOMY .5162 1.5 2.0 10

40 ..... 02 SURG EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE

>17.

.7094 2.2 3.4 26

41 ..... 02 SURG *EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE 0–

17.

.3298 1.6 1.6 7

42 ..... 02 SURG INTRAOCULAR PROCEDURES EXCEPT RETINA, IRIS &

LENS.

.5821 1.6 2.2 13

43 ..... 02 MED HYPHEMA .............................................................................. .4448 3.2 4.1 27
27532 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC MEAN LENGTH

OF STAY, AND LENGTH OF STAY OUTLIER CUTOFF POINTS USED IN THE PROSPECTIVE PAYMENT SYSTEM—Continued

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

Outlier

threshold

44 ..... 02 MED ACUTE MAJOR EYE INFECTIONS ...................................... .6234 4.7 5.7 29

45 ..... 02 MED NEUROLOGICAL EYE DISORDERS .................................... .6514 3.1 3.8 22

46 ..... 02 MED OTHER DISORDERS OF THE EYE AGE >17 W CC .......... .7595 4.0 5.5 28

47 ..... 02 MED OTHER DISORDERS OF THE EYE AGE >17 W/O CC ...... .4703 2.8 3.8 27

48 ..... 02 MED *OTHER DISORDERS OF THE EYE AGE 0–17 .................. .2906 2.9 2.9 27

49 ..... 03 SURG MAJOR HEAD & NECK PROCEDURES .............................. 1.7253 4.1 5.6 28

50 ..... 03 SURG SIALOADENECTOMY ........................................................... .7677 1.7 2.1 9

51 ..... 03 SURG SALIVARY GLAND PROCEDURES EXCEPT

SIALOADENECTOMY.

.7358 1.9 3.0 21

52 ..... 03 SURG CLEFT LIP & PALATE REPAIR ............................................ 1.0971 2.1 3.6 26

53 ..... 03 SURG SINUS & MASTOID PROCEDURES AGE >17 ..................... 1.0116 2.2 3.6 26

54 ..... 03 SURG *SINUS & MASTOID PROCEDURES AGE 0–17 ................. .4711 3.2 3.2 22

55 ..... 03 SURG MISCELLANEOUS EAR, NOSE, MOUTH & THROAT PROCEDURES..7844 1.9 3.0 22

56 ..... 03 SURG RHINOPLASTY ...................................................................... .8247 2.1 2.8 18

57 ..... 03 SURG T&A PROC, EXCEPT TONSILLECTOMY &/OR

ADENOIDECTOMY ONLY, AGE >17.

.9413 2.7 4.1 27

58 ..... 03 SURG *T&A PROC, EXCEPT TONSILLECTOMY &/OR

ADENOIDECTOMY ONLY, AGE 0–17.

.2674 1.5 1.5 4

59 ..... 03 SURG TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE

>17.

.7521 2.3 3.7 26

60 ..... 03 SURG *TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE

0–17.

.2037 1.5 1.5 4

61 ..... 03 SURG MYRINGOTOMY W TUBE INSERTION AGE >17 ................ 1.2155 2.7 5.3 27

62 ..... 03 SURG *MYRINGOTOMY W TUBE INSERTION AGE 0–17 ............ .2884 1.3 1.3 5

63 ..... 03 SURG OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES.1.2217 3.2 4.7 27

64 ..... 03 MED EAR, NOSE, MOUTH & THROAT MALIGNANCY ................ 1.1699 4.7 7.5 29

65 ..... 03 MED DYSEQUILIBRIUM ................................................................. .5192 2.7 3.4 20

66 ..... 03 MED EPISTAXIS ............................................................................. .5358 2.9 3.6 21

67 ..... 03 MED EPIGLOTTITIS ....................................................................... .8452 3.4 4.2 24

68 ..... 03 MED OTITIS MEDIA & URI AGE >17 W CC ................................. .7075 3.8 4.8 27

69 ..... 03 MED OTITIS MEDIA & URI AGE >17 W/O CC ............................. .5244 3.1 3.8 20

70 ..... 03 MED OTITIS MEDIA & URI AGE 0–17 .......................................... .3839 2.6 3.1 15

71 ..... 03 MED LARYNGOTRACHEITIS ........................................................ .7959 3.1 4.2 27

72 ..... 03 MED NASAL TRAUMA & DEFORMITY ......................................... .6466 3.1 4.4 27

73 ..... 03 MED OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES

AGE >17.

.7483 3.7 5.0 28

74 ..... 03 MED *OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES

AGE 0–17.

.3276 2.1 2.1 20

75 ..... 04 SURG MAJOR CHEST PROCEDURES ........................................... 3.1904 8.8 11.1 33

76 ..... 04 SURG OTHER RESP SYSTEM O.R. PROCEDURES W CC .......... 2.6018 9.1 12.5 33

77 ..... 04 SURG OTHER RESP SYSTEM O.R. PROCEDURES W/O CC ...... 1.1577 3.8 5.5 28

78 ..... 04 MED PULMONARY EMBOLISM .................................................... 1.4291 7.0 8.3 31

79 ..... 04 MED RESPIRATORY INFECTIONS & INFLAMMATIONS AGE

>17 W CC.

1.6310 7.2 9.3 31

80 ..... 04 MED RESPIRATORY INFECTIONS & INFLAMMATIONS AGE

>17 W/O CC.

.9481 5.4 6.6 29

81 ..... 04 MED *RESPIRATORY INFECTIONS & INFLAMMATIONS AGE

0–17.

.9716 6.1 6.1 30

82 ..... 04 MED RESPIRATORY NEOPLASMS .............................................. 1.3347 5.7 7.9 30

83 ..... 04 MED MAJOR CHEST TRAUMA W CC .......................................... .9738 4.9 6.4 29

84 ..... 04 MED MAJOR CHEST TRAUMA W/O CC ...................................... .5335 2.9 3.7 24

85 ..... 04 MED PLEURAL EFFUSION W CC ................................................. 1.2229 5.6 7.4 30

86 ..... 04 MED PLEURAL EFFUSION W/O CC ............................................. .7175 3.4 4.5 27

87 ..... 04 MED PULMONARY EDEMA & RESPIRATORY FAILURE ............ 1.3587 5.1 6.8 29

88 ..... 04 MED CHRONIC OBSTRUCTIVE PULMONARY DISEASE ........... .9831 4.9 6.1 29

89 ..... 04 MED SIMPLE PNEUMONIA & PLEURISY AGE >17 W CC .......... 1.1158 5.8 7.1 30

90 ..... 04 MED SIMPLE PNEUMONIA & PLEURISY AGE >17 W/O CC ...... .6995 4.3 5.1 24

91 ..... 04 MED SIMPLE PNEUMONIA & PLEURISY AGE 0–17 ................... .7883 3.7 4.7 28

92 ..... 04 MED INTERSTITIAL LUNG DISEASE W CC ................................. 1.2053 5.6 7.3 30

93 ..... 04 MED INTERSTITIAL LUNG DISEASE W/O CC ............................. .7551 4.0 5.0 28

94 ..... 04 MED PNEUMOTHORAX W CC ...................................................... 1.1764 5.3 7.1 29

95 ..... 04 MED PNEUMOTHORAX W/O CC .................................................. .6035 3.3 4.1 25

96 ..... 04 MED BRONCHITIS & ASTHMA AGE >17 W CC .......................... .8254 4.5 5.5 29

97 ..... 04 MED BRONCHITIS & ASTHMA AGE >17 W/O CC ....................... .6013 3.6 4.3 22

98 ..... 04 MED BRONCHITIS & ASTHMA AGE 0–17 ................................... .8036 3.1 4.5 27

99 ..... 04 MED RESPIRATORY SIGNS & SYMPTOMS W CC ..................... .6868 2.7 3.5 22

100 ... 04 MED RESPIRATORY SIGNS & SYMPTOMS W/O CC ................. .5126 2.0 2.4 12

101 ... 04 MED OTHER RESPIRATORY SYSTEM DIAGNOSES W CC ...... .8735 3.8 5.2 28
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27533

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC MEAN LENGTH

OF STAY, AND LENGTH OF STAY OUTLIER CUTOFF POINTS USED IN THE PROSPECTIVE PAYMENT SYSTEM—Continued

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

Outlier

threshold

102 ... 04 MED OTHER RESPIRATORY SYSTEM DIAGNOSES W/O CC ... .5330 2.4 3.1 20

103 ... 05 SURG HEART TRANSPLANT .......................................................... 15.2952 28.1 39.4 52

104 ... 05 SURG CARDIAC VALVE PROCEDURES W CARDIAC CATH ....... 7.3389 12.0 14.6 36

105 ... 05 SURG CARDIAC VALVE PROCEDURES W/O CARDIAC CATH ... 5.6012 9.0 10.9 33

106 ... 05 SURG CORONARY BYPASS W CARDIAC CATH .......................... 5.5599 10.3 11.7 34

107 ... 05 SURG CORONARY BYPASS W/O CARDIAC CATH ...................... 4.0741 7.8 8.8 32

108 ... 05 SURG OTHER CARDIOTHORACIC PROCEDURES ...................... 5.9226 9.8 12.6 34

109 ... ............ NO LONGER VALID .............................................................. .0000 .0 .0 0

110 ... 05 SURG MAJOR CARDIOVASCULAR PROCEDURES W CC ........... 4.1674 8.2 10.9 32

111 ... 05 SURG MAJOR CARDIOVASCULAR PROCEDURES W/O CC ....... 2.2863 5.9 6.7 30

112 ... 05 SURG PERCUTANEOUS CARDIOVASCULAR PROCEDURES .... 2.0962 3.5 4.7 27

113 ... 05 SURG AMPUTATION FOR CIRC SYSTEM DISORDERS EXCEPT

UPPER LIMB & TOE.

2.6919 10.6 14.4 35

114 ... 05 SURG UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM

DISORDERS.

1.5122 6.8 9.5 31

115 ... 05 SURG PERM CARDIAC PACEMAKER IMPLANT W AMI, HEART

FAILURE OR SHOCK.

3.6844 9.1 11.4 33

116 ... 05 SURG OTH PERM CARDIAC PACEMAKER IMPLANT OR AICD

LEAD OR GENERATOR PROC.

2.4158 3.9 5.4 28

117 ... 05 SURG CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT.1.1774 2.7 4.1 27

118 ... 05 SURG CARDIAC PACEMAKER DEVICE REPLACEMENT ............. 1.5782 2.1 3.2 25

119 ... 05 SURG VEIN LIGATION & STRIPPING ............................................. 1.1378 3.3 5.5 27

120 ... 05 SURG OTHER CIRCULATORY SYSTEM O.R. PROCEDURES ..... 1.9321 5.4 9.2 29

121 ... 05 MED CIRCULATORY DISORDERS W AMI & C.V. COMP DISCH

ALIVE.

1.6473 6.4 7.8 30

122 ... 05 MED CIRCULATORY DISORDERS W AMI W/O C.V. COMP

DISCH ALIVE.

1.1617 4.4 5.3 28

123 ... 05 MED CIRCULATORY DISORDERS W AMI, EXPIRED ................. 1.4519 2.7 4.7 27

124 ... 05 MED CIRCULATORY DISORDERS EXCEPT AMI, W CARD

CATH & COMPLEX DIAG.

1.3264 3.8 5.0 28

125 ... 05 MED CIRCULATORY DISORDERS EXCEPT AMI, W CARD

CATH W/O COMPLEX DIAG.

.9259 2.3 3.1 20

126 ... 05 MED ACUTE & SUBACUTE ENDOCARDITIS ............................... 2.5380 11.0 14.3 35

127 ... 05 MED HEART FAILURE & SHOCK ................................................. 1.0268 4.8 6.2 29

128 ... 05 MED DEEP VEIN THROMBOPHLEBITIS ...................................... .7861 5.9 6.7 27

129 ... 05 MED CARDIAC ARREST, UNEXPLAINED .................................... 1.1239 2.0 3.4 26

130 ... 05 MED PERIPHERAL VASCULAR DISORDERS W CC ................... .9357 5.3 6.7 29

131 ... 05 MED PERIPHERAL VASCULAR DISORDERS W/O CC ............... .6045 4.3 5.2 28

132 ... 05 MED ATHEROSCLEROSIS W CC ................................................. .6834 2.9 3.6 20

133 ... 05 MED ATHEROSCLEROSIS W/O CC ............................................. .5543 2.3 2.9 16

134 ... 05 MED HYPERTENSION ................................................................... .5799 3.0 3.9 23

135 ... 05 MED CARDIAC CONGENITAL & VALVULAR DISORDERS AGE

>17 W CC.

.8797 3.7 5.0 28

136 ... 05 MED CARDIAC CONGENITAL & VALVULAR DISORDERS AGE

>17 W/O CC.

.5597 2.6 3.2 18

137 ... 05 MED *CARDIAC CONGENITAL & VALVULAR DISORDERS AGE

0–17.

.7996 3.3 3.3 27

138 ... 05 MED CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS

W CC.

.8009 3.5 4.6 27

139 ... 05 MED CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS

W/O CC.

.4975 2.4 2.9 16

140 ... 05 MED ANGINA PECTORIS .............................................................. .6210 2.8 3.5 20

141 ... 05 MED SYNCOPE & COLLAPSE W CC ........................................... .7129 3.4 4.5 27

142 ... 05 MED SYNCOPE & COLLAPSE W/O CC ....................................... .5289 2.5 3.2 18

143 ... 05 MED CHEST PAIN .......................................................................... .5233 2.1 2.6 14

144 ... 05 MED OTHER CIRCULATORY SYSTEM DIAGNOSES W CC ...... 1.0850 4.1 5.7 28

145 ... 05 MED OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC ... .6217 2.5 3.3 20

146 ... 06 SURG RECTAL RESECTION W CC ................................................ 2.6401 9.8 11.3 34

147 ... 06 SURG RECTAL RESECTION W/O CC ............................................ 1.6115 6.7 7.4 27

148 ... 06 SURG MAJOR SMALL & LARGE BOWEL PROCEDURES W CC 3.3693 11.2 13.4 35

149 ... 06 SURG MAJOR SMALL & LARGE BOWEL PROCEDURES W/O

CC.

1.6038 7.1 7.7 25

150 ... 06 SURG PERITONEAL ADHESIOLYSIS W CC .................................. 2.6786 9.5 11.7 34

151 ... 06 SURG PERITONEAL ADHESIOLYSIS W/O CC .............................. 1.2959 5.2 6.5 29

152 ... 06 SURG MINOR SMALL & LARGE BOWEL PROCEDURES W CC 1.9381 7.6 9.0 32

153 ... 06 SURG MINOR SMALL & LARGE BOWEL PROCEDURES W/O

CC.

1.1550 5.6 6.2 24

154 ... 06 SURG STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES

AGE >17 W CC.

4.1880 11.6 15.0 36
27534 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC MEAN LENGTH

OF STAY, AND LENGTH OF STAY OUTLIER CUTOFF POINTS USED IN THE PROSPECTIVE PAYMENT SYSTEM—Continued

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

Outlier

threshold

155 ... 06 SURG STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES

AGE >17 W/O CC.

1.4070 4.6 5.9 29

156 ... 06 SURG *STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE 0–17..8235 6.0 6.0 30

157 ... 06 SURG ANAL & STOMAL PROCEDURES W CC ............................. 1.1331 4.2 5.8 28

158 ... 06 SURG ANAL & STOMAL PROCEDURES W/O CC ......................... .6106 2.3 2.9 18

159 ... 06 SURG HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL

AGE >17 W CC.

1.2263 4.0 5.3 28

160 ... 06 SURG HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL

AGE >17 W/O CC.

.7032 2.4 3.0 16

161 ... 06 SURG INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17

W CC.

1.0089 3.0 4.4 27

162 ... 06 SURG INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17

W/O CC.

.5710 1.7 2.2 11

163 ... 06 SURG *HERNIA PROCEDURES AGE 0–17 .................................... .7703 2.1 2.1 11

164 ... 06 SURG APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W

CC.

2.3299 8.0 9.3 32

165 ... 06 SURG APPENDECTOMY W COMPLICATED PRINCIPAL DIAG

W/O CC.

1.2576 5.1 5.8 25

166 ... 06 SURG APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG

W CC.

1.4512 4.5 5.7 29

167 ... 06 SURG APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG

W/O CC.

.8496 2.8 3.2 15

168 ... 03 SURG MOUTH PROCEDURES W CC ............................................. 1.0951 3.2 4.9 27

169 ... 03 SURG MOUTH PROCEDURES W/O CC ......................................... .6828 2.0 2.6 15

170 ... 06 SURG OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC 2.7448 8.5 12.5 33

171 ... 06 SURG OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W/O

CC.

1.1297 4.0 5.4 28

172 ... 06 MED DIGESTIVE MALIGNANCY W CC ........................................ 1.2934 5.7 8.2 30

173 ... 06 MED DIGESTIVE MALIGNANCY W/O CC .................................... .6736 3.0 4.3 27

174 ... 06 MED G.I. HEMORRHAGE W CC ................................................... .9962 4.4 5.6 28

175 ... 06 MED G.I. HEMORRHAGE W/O CC ............................................... .5492 2.9 3.5 17

176 ... 06 MED COMPLICATED PEPTIC ULCER .......................................... 1.0874 4.7 6.2 29

177 ... 06 MED UNCOMPLICATED PEPTIC ULCER W CC .......................... .8353 4.0 5.0 28

178 ... 06 MED UNCOMPLICATED PEPTIC ULCER W/O CC ...................... .6122 3.0 3.6 19

179 ... 06 MED INFLAMMATORY BOWEL DISEASE .................................... 1.1219 5.5 7.2 30

180 ... 06 MED G.I. OBSTRUCTION W CC ................................................... .9202 4.7 6.1 29

181 ... 06 MED G.I. OBSTRUCTION W/O CC ............................................... .5346 3.3 4.0 22

182 ... 06 MED ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17 W CC..7791 3.8 5.0 28

183 ... 06 MED ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17 W/O CC..5570 2.8 3.5 20

184 ... 06 MED ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE 0–17..5366 2.7 3.8 26

185 ... 03 MED DENTAL & ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE >17..8467 3.7 5.2 28

186 ... 03 MED *DENTAL & ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE 0–17..3139 2.9 2.9 23

187 ... 03 MED DENTAL EXTRACTIONS & RESTORATIONS ..................... .7211 3.1 4.3 27

188 ... 06 MED OTHER DIGESTIVE SYSTEM DIAGNOSES AGE >17 W

CC.

1.0593 4.5 6.1 28

189 ... 06 MED OTHER DIGESTIVE SYSTEM DIAGNOSES AGE >17 W/O

CC.

.5629 2.7 3.7 27

190 ... 06 MED OTHER DIGESTIVE SYSTEM DIAGNOSES AGE 0–17 ...... .8364 3.9 4.9 28

191 ... 07 SURG PANCREAS, LIVER & SHUNT PROCEDURES W CC ........ 4.4227 12.0 16.2 36

192 ... 07 SURG PANCREAS, LIVER & SHUNT PROCEDURES W/O CC ..... 1.8016 6.2 8.0 30

193 ... 07 SURG BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W

OR W/O C.D.E. W CC.

3.2582 11.4 13.9 35

194 ... 07 SURG BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W

OR W/O C.D.E. W/O CC.

1.7596 6.8 8.4 31

195 ... 07 SURG CHOLECYSTECTOMY W C.D.E. W CC ............................... 2.6806 8.8 10.5 33

196 ... 07 SURG CHOLECYSTECTOMY W C.D.E. W/O CC ........................... 1.6252 5.9 6.8 30

197 ... 07 SURG CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O

C.D.E. W CC.

2.2636 7.5 9.1 31

198 ... 07 SURG CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O

C.D.E. W/O CC.

1.1769 4.3 5.0 23

199 ... 07 SURG HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR MALIGNANCY.2.3744 8.3 11.1 32

200 ... 07 SURG HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR NONMALIGNANCY.2.9783 7.6 11.9 32
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27535

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC MEAN LENGTH

OF STAY, AND LENGTH OF STAY OUTLIER CUTOFF POINTS USED IN THE PROSPECTIVE PAYMENT SYSTEM—Continued

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

Outlier

threshold

201 ... 07 SURG OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES.3.6216 12.1 16.6 36

202 ... 07 MED CIRRHOSIS & ALCOHOLIC HEPATITIS .............................. 1.3286 5.7 7.7 30

203 ... 07 MED MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS.1.2511 5.5 7.7 30

204 ... 07 MED DISORDERS OF PANCREAS EXCEPT MALIGNANCY ...... 1.2003 5.1 6.7 29

205 ... 07 MED DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA

W CC.

1.2099 5.3 7.3 29

206 ... 07 MED DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA

W/O CC.

.7211 3.6 4.8 28

207 ... 07 MED DISORDERS OF THE BILIARY TRACT W CC .................... 1.0500 4.4 5.8 28

208 ... 07 MED DISORDERS OF THE BILIARY TRACT W/O CC ................. .6053 2.6 3.5 21

209 ... 08 SURG MAJOR JOINT & LIMB REATTACHMENT PROCEDURES

OF LOWER EXTREMITY.

2.2617 5.9 6.7 23

210 ... 08 SURG HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT

AGE >17 W CC.

1.8458 7.2 8.5 31

211 ... 08 SURG HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT

AGE >17 W/O CC.

1.2747 5.6 6.3 23

212 ... 08 SURG *HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT

AGE 0–17.

1.1483 11.1 11.1 35

213 ... 08 SURG AMPUTATION FOR MUSCULOSKELETAL SYSTEM &

CONN TISSUE DISORDERS.

1.7045 7.0 9.6 31

214 ... 08 SURG BACK & NECK PROCEDURES W CC ................................. 1.9259 4.9 6.5 29

215 ... 08 SURG BACK & NECK PROCEDURES W/O CC .............................. 1.1135 3.0 3.7 20

216 ... 08 SURG BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE.2.0775 7.9 11.1 32

217 ... 08 SURG WND DEBRID & SKN GRFT EXCEPT HAND,FOR

MUSCSKELET & CONN TISS DIS.

2.8715 10.2 15.3 34

218 ... 08 SURG LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT,

FEMUR AGE >17 W CC.

1.4562 4.8 6.2 29

219 ... 08 SURG LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT,

FEMUR AGE >17 W/O CC.

.9560 3.1 3.8 19

220 ... 08 SURG *LOWER EXTREM & HUMER PROC EXCEPT HIP, FOOT,

FEMUR AGE 0–17.

.5704 5.3 5.3 29

221 ... 08 SURG KNEE PROCEDURES W CC ................................................ 1.8379 5.8 8.2 30

222 ... 08 SURG KNEE PROCEDURES W/O CC ............................................ 1.0223 3.1 4.1 27

223 ... 08 SURG MAJOR SHOULDER/ELBOW PROC, OR OTHER UPPER

EXTREMITY PROC W CC.

.8726 2.2 2.9 16

224 ... 08 SURG SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR

JOINT PROC, W/O CC.

.7418 1.9 2.3 10

225 ... 08 SURG FOOT PROCEDURES ........................................................... 1.0019 3.3 5.0 27

226 ... 08 SURG SOFT TISSUE PROCEDURES W CC .................................. 1.3708 4.4 6.7 28

227 ... 08 SURG SOFT TISSUE PROCEDURES W/O CC .............................. .7458 2.3 3.0 18

228 ... 08 SURG MAJOR THUMB OR JOINT PROC, OR OTH HAND OR

WRIST PROC W CC.

.9381 2.3 3.6 26

229 ... 08 SURG HAND OR WRIST PROC, EXCEPT MAJOR JOINT PROC,

W/O CC.

.6495 1.8 2.4 14

230 ... 08 SURG LOCAL EXCISION & REMOVAL OF INT FIX DEVICES OF

HIP & FEMUR.

1.0592 3.3 5.2 27

231 ... 08 SURG LOCAL EXCISION & REMOVAL OF INT FIX DEVICES EXCEPT HIP & FEMUR.1.2285 3.3 5.1 27

232 ... 08 SURG ARTHROSCOPY .................................................................... 1.0901 2.6 4.5 27

233 ... 08 SURG OTHER MUSCULOSKELET SYS & CONN TISS O.R.

PROC W CC.

1.9951 6.4 9.0 30

234 ... 08 SURG OTHER MUSCULOSKELET SYS & CONN TISS O.R.

PROC W/O CC.

1.0684 3.1 4.2 27

235 ... 08 MED FRACTURES OF FEMUR ..................................................... .8353 4.6 6.9 29

236 ... 08 MED FRACTURES OF HIP & PELVIS ........................................... .7613 4.7 6.4 29

237 ... 08 MED SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS

& THIGH.

.5622 3.3 4.4 27

238 ... 08 MED OSTEOMYELITIS .................................................................. 1.3857 7.6 10.1 32

239 ... 08 MED PATHOLOGICAL FRACTURES & MUSCULOSKELETAL &

CONN TISS MALIGNANCY.

1.0096 5.8 7.6 30

240 ... 08 MED CONNECTIVE TISSUE DISORDERS W CC ........................ 1.2107 5.5 7.5 30

241 ... 08 MED CONNECTIVE TISSUE DISORDERS W/O CC .................... .6063 3.5 4.6 28

242 ... 08 MED SEPTIC ARTHRITIS .............................................................. 1.0535 5.8 7.7 30

243 ... 08 MED MEDICAL BACK PROBLEMS ............................................... .7241 4.3 5.6 28

244 ... 08 MED BONE DISEASES & SPECIFIC ARTHROPATHIES W CC .7221 4.3 5.8 28

245 ... 08 MED BONE DISEASES & SPECIFIC ARTHROPATHIES W/O

CC.

.4965 3.2 4.2 27
27536 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC MEAN LENGTH

OF STAY, AND LENGTH OF STAY OUTLIER CUTOFF POINTS USED IN THE PROSPECTIVE PAYMENT SYSTEM—Continued

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

Outlier

threshold

246 ... 08 MED NON-SPECIFIC ARTHROPATHIES ...................................... .5901 3.6 4.6 28

247 ... 08 MED SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM

& CONN TISSUE.

.5539 2.9 4.0 27

248 ... 08 MED TENDONITIS, MYOSITIS & BURSITIS ................................. .7363 3.9 5.3 28

249 ... 08 MED AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE..6514 2.9 4.3 27

250 ... 08 MED FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT

AGE >17 W CC.

.6808 3.5 4.9 28

251 ... 08 MED FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT

AGE >17 W/O CC.

.4625 2.5 3.3 22

252 ... 08 MED *FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT

AGE 0–17.

.2478 1.8 1.8 15

253 ... 08 MED FX, SPRN, STRN & DISL OF UPARM, LOWLEG EX FOOT

AGE >17 W CC.

.7438 4.3 5.8 28

254 ... 08 MED FX, SPRN, STRN & DISL OF UPARM, LOWLEG EX FOOT

AGE >17 W/O CC.

.4433 2.9 3.9 25

255 ... 08 MED *FX, SPRN, STRN & DISL OF UPARM, LOWLEG EX

FOOT AGE 0–17.

.2885 2.9 2.9 27

256 ... 08 MED OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE

TISSUE DIAGNOSES.

.7724 4.0 5.7 28

257 ... 09 SURG TOTAL MASTECTOMY FOR MALIGNANCY W CC ............. .9021 2.8 3.4 17

258 ... 09 SURG TOTAL MASTECTOMY FOR MALIGNANCY W/O CC ......... .7099 2.2 2.5 10

259 ... 09 SURG SUBTOTAL MASTECTOMY FOR MALIGNANCY W CC ..... .8673 2.3 3.5 26

260 ... 09 SURG SUBTOTAL MASTECTOMY FOR MALIGNANCY W/O CC .6083 1.6 1.9 8

261 ... 09 SURG BREAST PROC FOR NON-MALIGNANCY EXCEPT BIOPSY & LOCAL EXCISION..8342 1.9 2.4 12

262 ... 09 SURG BREAST BIOPSY & LOCAL EXCISION FOR NON-MALIGNANCY..7694 2.7 3.9 27

263 ... 09 SURG SKIN GRAFT &/OR DEBRID FOR SKN ULCER OR

CELLULITIS W CC.

2.1157 9.8 13.9 34

264 ... 09 SURG SKIN GRAFT &/OR DEBRID FOR SKN ULCER OR

CELLULITIS W/O CC.

1.1308 6.0 8.4 30

265 ... 09 SURG SKIN GRAFT &/OR DEBRID EXCEPT FOR SKIN ULCER

OR CELLULITIS W CC.

1.4949 4.8 7.7 29

266 ... 09 SURG SKIN GRAFT &/OR DEBRID EXCEPT FOR SKIN ULCER

OR CELLULITIS W/O CC.

.7650 2.6 3.7 27

267 ... 09 SURG PERIANAL & PILONIDAL PROCEDURES ........................... .8086 2.7 4.1 27

268 ... 09 SURG SKIN, SUBCUTANEOUS TISSUE & BREAST PLASTIC

PROCEDURES.

.9935 2.5 4.0 27

269 ... 09 SURG OTHER SKIN, SUBCUT TISS & BREAST PROC W CC ..... 1.6361 6.2 9.1 30

270 ... 09 SURG OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC .7016 2.4 3.4 26

271 ... 09 MED SKIN ULCERS ....................................................................... 1.0791 6.6 8.5 31

272 ... 09 MED MAJOR SKIN DISORDERS W CC ........................................ 1.0212 5.6 7.5 30

273 ... 09 MED MAJOR SKIN DISORDERS W/O CC .................................... .6358 4.1 5.5 28

274 ... 09 MED MALIGNANT BREAST DISORDERS W CC ......................... 1.0713 5.3 7.8 29

275 ... 09 MED MALIGNANT BREAST DISORDERS W/O CC ...................... .4984 2.5 3.6 27

276 ... 09 MED NON-MALIGANT BREAST DISORDERS .............................. .6443 3.9 5.1 28

277 ... 09 MED CELLULITIS AGE >17 W CC ................................................ .8532 5.5 6.7 29

278 ... 09 MED CELLULITIS AGE >17 W/O CC ............................................ .5775 4.3 5.1 25

279 ... 09 MED *CELLULITIS AGE 0–17 ........................................................ .7187 4.2 4.2 24

280 ... 09 MED TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE

>17 W CC.

.6765 3.7 5.1 28

281 ... 09 MED TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE

>17 W/O CC.

.4566 2.7 3.7 24

282 ... 09 MED *TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE

0–17.

.2508 2.2 2.2 19

283 ... 09 MED MINOR SKIN DISORDERS W CC ........................................ .7034 4.1 5.5 28

284 ... 09 MED MINOR SKIN DISORDERS W/O CC .................................... .4375 2.9 3.9 27

285 ... 10 SURG AMPUTAT OF LOWER LIMB FOR ENDOCRINE, NUTRIT,

& METABOL DISORDERS.

2.1948 9.5 13.5 34

286 ... 10 SURG ADRENAL & PITUITARY PROCEDURES ............................ 2.3858 6.6 8.7 31

287 ... 10 SURG SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT

& METAB DISORDERS.

1.9722 9.4 13.4 33

288 ... 10 SURG O.R. PROCEDURES FOR OBESITY .................................... 2.0537 5.3 7.0 29

289 ... 10 SURG PARATHYROID PROCEDURES ........................................... 1.0231 2.7 3.9 27

290 ... 10 SURG THYROID PROCEDURES ..................................................... .8827 2.1 2.8 15

291 ... 10 SURG THYROGLOSSAL PROCEDURES ....................................... .5221 1.4 1.8 8

292 ... 10 SURG OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W

CC.

2.6435 8.4 12.7 32
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27537

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC MEAN LENGTH

OF STAY, AND LENGTH OF STAY OUTLIER CUTOFF POINTS USED IN THE PROSPECTIVE PAYMENT SYSTEM—Continued

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

Outlier

threshold

293 ... 10 SURG OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W/O

CC.

1.2415 4.4 6.4 28

294 ... 10 MED DIABETES AGE >35 .............................................................. .7604 4.3 5.7 28

295 ... 10 MED DIABETES AGE 0–35 ............................................................ .7171 3.3 4.3 27

296 ... 10 MED NUTRITIONAL & MISC METABOLIC DISORDERS AGE

>17 W CC.

.8939 4.7 6.4 29

297 ... 10 MED NUTRITIONAL & MISC METABOLIC DISORDERS AGE

>17 W/O CC.

.5374 3.3 4.3 26

298 ... 10 MED NUTRITIONAL & MISC METABOLIC DISORDERS AGE 0–

17.

.5036 2.3 3.0 19

299 ... 10 MED INBORN ERRORS OF METABOLISM .................................. .8211 3.8 5.4 28

300 ... 10 MED ENDOCRINE DISORDERS W CC ........................................ 1.1005 5.5 7.3 30

301 ... 10 MED ENDOCRINE DISORDERS W/O CC .................................... .6193 3.4 4.4 27

302 ... 11 SURG KIDNEY TRANSPLANT ......................................................... 3.9210 10.4 12.3 34

303 ... 11 SURG KIDNEY, URETER & MAJOR BLADDER PROCEDURES

FOR NEOPLASM.

2.6364 8.4 10.2 32

304 ... 11 SURG KIDNEY, URETER & MAJOR BLADDER PROC FOR NONNEOPL W CC.2.3744 7.5 10.3 31

305 ... 11 SURG KIDNEY, URETER & MAJOR BLADDER PROC FOR NONNEOPL W/O CC.1.1797 3.9 4.9 28

306 ... 11 SURG PROSTATECTOMY W CC .................................................... 1.2243 4.3 6.2 28

307 ... 11 SURG PROSTATECTOMY W/O CC ................................................ .6709 2.4 3.0 15

308 ... 11 SURG MINOR BLADDER PROCEDURES W CC ............................ 1.5260 4.6 7.0 29

309 ... 11 SURG MINOR BLADDER PROCEDURES W/O CC ........................ .8858 2.3 3.0 18

310 ... 11 SURG TRANSURETHRAL PROCEDURES W CC .......................... 1.0013 3.1 4.6 27

311 ... 11 SURG TRANSURETHRAL PROCEDURES W/O CC ....................... .5663 1.8 2.2 11

312 ... 11 SURG URETHRAL PROCEDURES, AGE >17 W CC ..................... .9118 3.1 4.8 27

313 ... 11 SURG URETHRAL PROCEDURES, AGE >17 W/O CC .................. .5211 1.7 2.3 13

314 ... 11 SURG *URETHRAL PROCEDURES, AGE 0–17 ............................. .4835 2.3 2.3 26

315 ... 11 SURG OTHER KIDNEY & URINARY TRACT O.R. PROCEDURES 2.0606 5.3 9.3 29

316 ... 11 MED RENAL FAILURE ................................................................... 1.3066 5.4 7.6 29

317 ... 11 MED ADMIT FOR RENAL DIALYSIS ............................................. .4837 2.0 2.8 19

318 ... 11 MED KIDNEY & URINARY TRACT NEOPLASMS W CC ............. 1.1233 5.0 7.2 29

319 ... 11 MED KIDNEY & URINARY TRACT NEOPLASMS W/O CC .......... .5801 2.3 3.2 24

320 ... 11 MED KIDNEY & URINARY TRACT INFECTIONS AGE >17 W

CC.

.9052 5.1 6.4 29

321 ... 11 MED KIDNEY & URINARY TRACT INFECTIONS AGE >17 W/O

CC.

.6094 3.9 4.7 24

322 ... 11 MED KIDNEY & URINARY TRACT INFECTIONS AGE 0–17 ....... .5265 3.6 4.4 24

323 ... 11 MED URINARY STONES W CC, &/OR ESW LITHOTRIPSY ....... .7490 2.7 3.6 24

324 ... 11 MED URINARY STONES W/O CC ................................................ .4161 1.7 2.1 10

325 ... 11 MED KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE

>17 W CC.

.6397 3.4 4.6 27

326 ... 11 MED KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE

>17 W/O CC.

.4346 2.4 3.5 19

327 ... 11 MED *KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE

0–17.

.2340 3.1 3.1 27

328 ... 11 MED URETHRAL STRICTURE AGE >17 W CC ........................... .6929 3.1 4.3 27

329 ... 11 MED URETHRAL STRICTURE AGE >17 W/O CC ....................... .4536 2.1 2.8 16

330 ... 11 MED *URETHRAL STRICTURE AGE 0–17 ................................... .3114 1.6 1.6 9

331 ... 11 MED OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE

>17 W CC.

.9926 4.6 6.2 29

332 ... 11 MED OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE

>17 W/O CC.

.6170 2.8 3.9 27

333 ... 11 MED OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE

0–17.

.8641 4.3 5.9 28

334 ... 12 SURG MAJOR MALE PELVIC PROCEDURES W CC .................... 1.6656 5.3 6.0 23

335 ... 12 SURG MAJOR MALE PELVIC PROCEDURES W/O CC ................. 1.2596 4.1 4.6 17

336 ... 12 SURG TRANSURETHRAL PROSTATECTOMY W CC ................... .8859 3.2 4.1 24

337 ... 12 SURG TRANSURETHRAL PROSTATECTOMY W/O CC ................ .6149 2.3 2.7 11

338 ... 12 SURG TESTES PROCEDURES, FOR MALIGNANCY .................... 1.0534 3.5 5.3 27

339 ... 12 SURG TESTES PROCEDURES, NON-MALIGNANCY AGE >17 .... 1.0213 3.1 4.9 27

340 ... 12 SURG *TESTES PROCEDURES, NON-MALIGNANCY AGE 0–17 .2768 2.4 2.4 13

341 ... 12 SURG PENIS PROCEDURES .......................................................... 1.0701 2.3 3.2 21

342 ... 12 SURG CIRCUMCISION AGE >17 ..................................................... .7579 2.6 4.0 27

343 ... 12 SURG *CIRCUMCISION AGE 0–17 ................................................. .1503 1.7 1.7 6

344 ... 12 SURG OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY.1.0086 2.3 3.5 25

345 ... 12 SURG OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXCEPT FOR MALIGNANCY..8396 2.7 4.0 27
27538 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC MEAN LENGTH

OF STAY, AND LENGTH OF STAY OUTLIER CUTOFF POINTS USED IN THE PROSPECTIVE PAYMENT SYSTEM—Continued

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

Outlier

threshold

346 ... 12 MED MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W CC .9564 4.8 6.8 29

347 ... 12 MED MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W/O

CC.

.5161 2.4 3.4 26

348 ... 12 MED BENIGN PROSTATIC HYPERTROPHY W CC .................... .7102 3.5 4.9 28

349 ... 12 MED BENIGN PROSTATIC HYPERTROPHY W/O CC ................. .4048 2.2 3.0 21

350 ... 12 MED INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM..6631 3.9 4.8 24

351 ... 12 MED *STERILIZATION, MALE ....................................................... .2309 1.3 1.3 5

352 ... 12 MED OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES .... .5889 2.8 4.0 27

353 ... 13 SURG PELVIC EVISCERATION, RADICAL HYSTERECTOMY &

RADICAL VULVECTOMY.

1.9266 6.7 8.4 31

354 ... 13 SURG UTERINE, ADNEXA PROC FOR NON-OVARIAN/

ADNEXAL MALIG W CC.

1.4646 5.2 6.3 28

355 ... 13 SURG UTERINE, ADNEXA PROC FOR NON-OVARIAN/

ADNEXAL MALIG W/O CC.

.9065 3.6 3.9 11

356 ... 13 SURG FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE

PROCEDURES.

.7377 2.6 3.0 12

357 ... 13 SURG UTERINE & ADNEXA PROC FOR OVARIAN OR

ADNEXAL MALIGNANCY.

2.3847 8.0 9.8 32

358 ... 13 SURG UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W

CC.

1.1713 4.0 4.7 19

359 ... 13 SURG UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/

O CC.

.8289 3.0 3.3 10

360 ... 13 SURG VAGINA, CERVIX & VULVA PROCEDURES ....................... .8470 2.9 3.5 17

361 ... 13 SURG LAPAROSCOPY & INCISIONAL TUBAL INTERRUPTION 1.1284 2.5 3.5 23

362 ... 13 SURG *ENDOSCOPIC TUBAL INTERRUPTION ............................. .2950 1.4 1.4 5

363 ... 13 SURG D&C, CONIZATION & RADIO-IMPLANT, FOR MALIGNANCY..6887 2.6 3.5 20

364 ... 13 SURG D&C, CONIZATION EXCEPT FOR MALIGNANCY .............. .6823 2.6 3.6 27

365 ... 13 SURG OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES.1.7253 5.3 8.1 29

366 ... 13 MED MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC 1.1948 5.3 7.7 29

367 ... 13 MED MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W/O

CC.

.5173 2.3 3.3 24

368 ... 13 MED INFECTIONS, FEMALE REPRODUCTIVE SYSTEM ........... 1.0303 5.3 6.9 29

369 ... 13 MED MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS..5504 2.6 3.8 27

370 ... 14 SURG CESAREAN SECTION W CC ............................................... 1.0444 4.3 5.6 26

371 ... 14 SURG CESAREAN SECTION W/O CC ............................................ .6865 3.2 3.6 11

372 ... 14 MED VAGINAL DELIVERY W COMPLICATING DIAGNOSES ..... .5471 2.4 3.3 19

373 ... 14 MED VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES .3584 1.6 1.9 7

374 ... 14 SURG VAGINAL DELIVERY W STERILIZATION &/OR D&C .......... .6083 2.0 2.4 9

375 ... 14 SURG *VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/

OR D&C.

.6696 4.4 4.4 28

376 ... 14 MED POSTPARTUM & POST ABORTION DIAGNOSES W/O

O.R. PROCEDURE.

.5972 2.4 3.5 26

377 ... 14 SURG POSTPARTUM & POST ABORTION DIAGNOSES W O.R.

PROCEDURE.

.8078 2.0 3.2 26

378 ... 14 MED ECTOPIC PREGNANCY ....................................................... .8157 2.5 3.0 15

379 ... 14 MED THREATENED ABORTION ................................................... .3573 2.0 2.9 20

380 ... 14 MED ABORTION W/O D&C ........................................................... .4988 1.8 2.3 13

381 ... 14 SURG ABORTION W D&C, ASPIRATION CURETTAGE OR

HYSTEROTOMY.

.5212 1.6 2.3 14

382 ... 14 MED FALSE LABOR ....................................................................... .2100 1.3 1.7 7

383 ... 14 MED OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS..4672 2.8 4.1 27

384 ... 14 MED OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL

COMPLICATIONS.

.4140 1.9 3.3 24

385 ... 15 *NEONATES, DIED OR TRANSFERRED TO ANOTHER

ACUTE CARE FACILITY.

1.3437 1.8 1.8 26

386 ... 15 *EXTREME IMMATURITY OR RESPIRATORY DISTRESS

SYNDROME, NEONATE.

4.4311 17.9 17.9 42

387 ... 15 *PREMATURITY W MAJOR PROBLEMS ............................. 3.0264 13.3 13.3 37

388 ... 15 *PREMATURITY W/O MAJOR PROBLEMS ......................... 1.8261 8.6 8.6 33

389 ... 15 FULL TERM NEONATE W MAJOR PROBLEMS ................. 2.2247 8.0 10.7 32

390 ... 15 NEONATE W OTHER SIGNIFICANT PROBLEMS ............... 1.4188 3.8 5.0 28

391 ... 15 *NORMAL NEWBORN ........................................................... .1489 3.1 3.1 11

392 ... 16 SURG SPLENECTOMY AGE >17 .................................................... 3.2602 8.9 11.7 33

393 ... 16 SURG *SPLENECTOMY AGE 0–17 ................................................. 1.3163 9.1 9.1 33
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27539

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC MEAN LENGTH

OF STAY, AND LENGTH OF STAY OUTLIER CUTOFF POINTS USED IN THE PROSPECTIVE PAYMENT SYSTEM—Continued

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

Outlier

threshold

394 ... 16 SURG OTHER O.R. PROCEDURES OF THE BLOOD AND

BLOOD FORMING ORGANS.

1.5902 4.5 7.9 28

395 ... 16 MED RED BLOOD CELL DISORDERS AGE >17 ......................... .8360 3.9 5.4 28

396 ... 16 MED RED BLOOD CELL DISORDERS AGE 0–17 ....................... .7226 2.8 3.9 27

397 ... 16 MED COAGULATION DISORDERS ............................................... 1.2574 4.4 6.1 28

398 ... 16 MED RETICULOENDOTHELIAL & IMMUNITY DISORDERS W

CC.

1.2106 5.2 6.6 29

399 ... 16 MED RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O

CC.

.7061 3.5 4.4 27

400 ... 17 SURG LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE 2.5606 6.6 10.3 31

401 ... 17 SURG LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R.

PROC W CC.

2.4945 8.5 12.4 32

402 ... 17 SURG LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R.

PROC W/O CC.

1.0299 3.1 4.7 27

403 ... 17 MED LYMPHOMA & NON-ACUTE LEUKEMIA W CC .................. 1.6925 6.5 9.3 30

404 ... 17 MED LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC ............... .8070 3.7 5.1 28

405 ... 17 *ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE

0–17.

1.8661 4.9 4.9 29

406 ... 17 SURG MYELOPROLIF DISORD OR POORLY DIFF NEOPL W

MAJ O.R. PROC W CC.

2.6923 8.1 11.2 32

407 ... 17 SURG MYELOPROLIF DISORD OR POORLY DIFF NEOPL W

MAJ O.R. PROC W/O CC.

1.1822 3.8 4.9 28

408 ... 17 SURG MYELOPROLIF DISORD OR POORLY DIFF NEOPL W

OTHER O.R. PROC.

1.7412 5.0 8.2 29

409 ... 17 MED RADIOTHERAPY ................................................................... .9708 4.7 6.7 29

410 ... 17 MED CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS..7524 2.6 3.4 20

411 ... 17 MED HISTORY OF MALIGNANCY W/O ENDOSCOPY ................ .3780 2.1 2.6 14

412 ... 17 MED HISTORY OF MALIGNANCY W ENDOSCOPY .................... .4133 2.2 3.1 24

413 ... 17 MED OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL

DIAG W CC.

1.3263 5.9 8.3 30

414 ... 17 MED OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL

DIAG W/O CC.

.7442 3.8 5.2 28

415 ... 18 SURG O.R. PROCEDURE FOR INFECTIOUS & PARASITIC DISEASES.3.4473 11.4 15.7 35

416 ... 18 MED SEPTICEMIA AGE >17 .......................................................... 1.4862 6.2 8.2 30

417 ... 18 MED SEPTICEMIA AGE 0–17 ........................................................ .7936 3.7 4.7 28

418 ... 18 MED POSTOPERATIVE & POST-TRAUMATIC INFECTIONS ..... .9678 5.3 6.8 29

419 ... 18 MED FEVER OF UNKNOWN ORIGIN AGE >17 W CC ................ .8993 4.4 5.7 28

420 ... 18 MED FEVER OF UNKNOWN ORIGIN AGE >17 W/O CC ............ .6253 3.5 4.3 24

421 ... 18 MED VIRAL ILLNESS AGE >17 ..................................................... .7157 3.6 4.6 28

422 ... 18 MED VIRAL ILLNESS & FEVER OF UNKNOWN ORIGIN AGE

0–17.

.5217 2.9 3.7 23

423 ... 18 MED OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES.1.5864 6.3 8.7 30

424 ... 19 SURG O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS.2.3596 10.9 17.8 35

425 ... 19 MED ACUTE ADJUST REACT & DISTURBANCES OF

PSYCHOSOCIAL DYSFUNCTION.

.7078 3.5 4.9 27

426 ... 19 MED DEPRESSIVE NEUROSES ................................................... .5715 4.0 5.5 28

427 ... 19 MED NEUROSES EXCEPT DEPRESSIVE ................................... .5544 3.7 5.3 28

428 ... 19 MED DISORDERS OF PERSONALITY & IMPULSE CONTROL .7352 5.2 8.5 29

429 ... 19 MED ORGANIC DISTURBANCES & MENTAL RETARDATION ... .9063 5.9 8.9 30

430 ... 19 MED PSYCHOSES ......................................................................... .8422 6.9 9.8 31

431 ... 19 MED CHILDHOOD MENTAL DISORDERS .................................... .6694 5.0 7.5 29

432 ... 19 MED OTHER MENTAL DISORDER DIAGNOSES ........................ .7228 3.9 6.3 28

433 ... 20 ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA .3007 2.5 3.4 24

434 ... 20 ALC/DRUG ABUSE OR DEPEND, DETOX OR OTH

SYMPT TREAT W CC.

.7152 4.4 5.8 28

435 ... 20 ALC/DRUG ABUSE OR DEPEND, DETOX OR OTH

SYMPT TREAT W/O CC.

.4178 3.8 4.8 28

436 ... 20 ALC/DRUG DEPENDENCE W REHABILITATION THERAPY..8199 12.1 14.8 36

437 ... 20 ALC/DRUG DEPENDENCE, COMBINED REHAB & DETOX

THERAPY.

.7714 9.2 10.9 33

438 ... ............ NO LONGER VALID .............................................................. .0000 .0 .0 0

439 ... 21 SURG SKIN GRAFTS FOR INJURIES ............................................. 1.6153 5.8 8.9 30

440 ... 21 SURG WOUND DEBRIDEMENTS FOR INJURIES ......................... 1.7631 6.3 9.8 30

441 ... 21 SURG HAND PROCEDURES FOR INJURIES ................................ .9344 2.4 4.4 26

442 ... 21 SURG OTHER O.R. PROCEDURES FOR INJURIES W CC .......... 2.1659 5.6 8.7 30
27540 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC MEAN LENGTH

OF STAY, AND LENGTH OF STAY OUTLIER CUTOFF POINTS USED IN THE PROSPECTIVE PAYMENT SYSTEM—Continued

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

Outlier

threshold

443 ... 21 SURG OTHER O.R. PROCEDURES FOR INJURIES W/O CC ....... .8851 2.5 3.5 26

444 ... 21 MED TRAUMATIC INJURY AGE >17 W CC ................................. .7310 4.0 5.3 28

445 ... 21 MED TRAUMATIC INJURY AGE >17 W/O CC ............................. .4754 2.8 3.8 24

446 ... 21 MED *TRAUMATIC INJURY AGE 0–17 ......................................... .2893 2.4 2.4 22

447 ... 21 MED ALLERGIC REACTIONS AGE >17 ....................................... .4908 2.1 2.8 17

448 ... 21 MED ALLERGIC REACTIONS AGE 0–17 ..................................... .0759 1.0 1.0 1

449 ... 21 MED POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W

CC.

.7907 3.0 4.4 27

450 ... 21 MED POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W/

O CC.

.4276 1.8 2.3 13

451 ... 21 MED *POISONING & TOXIC EFFECTS OF DRUGS AGE 0–17 .2569 2.1 2.1 17

452 ... 21 MED COMPLICATIONS OF TREATMENT W CC ......................... .9448 3.8 5.4 28

453 ... 21 MED COMPLICATIONS OF TREATMENT W/O CC ...................... .4853 2.4 3.2 20

454 ... 21 MED OTHER INJURY, POISONING & TOXIC EFFECT DIAG W

CC.

.8536 3.4 5.1 27

455 ... 21 MED OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/

O CC.

.4445 2.1 2.8 18

456 ... 22 BURNS, TRANSFERRED TO ANOTHER ACUTE CARE

FACILITY.

1.8816 4.0 8.4 28

457 ... 22 MED EXTENSIVE BURNS W/O O.R. PROCEDURE .................... 1.4446 2.4 4.8 26

458 ... 22 SURG NON-EXTENSIVE BURNS W SKIN GRAFT ......................... 3.5465 12.0 17.0 36

459 ... 22 SURG NON-EXTENSIVE BURNS W WOUND DEBRIDEMENT OR

OTHER O.R. PROC.

1.6693 6.7 10.3 31

460 ... 22 MED NON-EXTENSIVE BURNS W/O O.R. PROCEDURE ........... .9554 4.6 6.6 29

461 ... 23 SURG O.R. PROC W DIAGNOSES OF OTHER CONTACT W

HEALTH SERVICES.

.9981 2.5 4.9 27

462 ... 23 MED REHABILITATION .................................................................. 1.4294 11.0 14.0 35

463 ... 23 MED SIGNS & SYMPTOMS W CC ................................................ .7074 3.8 5.2 28

464 ... 23 MED SIGNS & SYMPTOMS W/O CC ............................................ .5040 2.8 3.7 24

465 ... 23 MED AFTERCARE W HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS..5611 2.3 3.9 26

466 ... 23 MED AFTERCARE W/O HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS..5728 2.5 4.7 27

467 ... 23 MED OTHER FACTORS INFLUENCING HEALTH STATUS ........ .4588 2.4 4.1 26

468 ... ............ EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS.3.5858 10.6 15.3 35

469 ... ............ **PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS..0000 .0 .0 0

470 ... ............ **UNGROUPABLE ................................................................. .0000 .0 .0 0

471 ... 08 SURG BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF

LOWER EXTREMITY.

3.6043 6.8 8.0 31

472 ... 22 SURG EXTENSIVE BURNS W O.R. PROCEDURE ........................ 11.1357 17.3 30.7 41

473 ... 17 ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE

>17.

3.5669 8.5 14.7 32

474 ... ............ NO LONGER VALID .............................................................. .0000 .0 .0 0

475 ... 04 MED RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR

SUPPORT.

3.6736 8.6 12.3 33

476 ... ............ SURG PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS.2.2362 10.3 13.8 34

477 ... ............ SURG NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO

PRINCIPAL DIAGNOSIS.

1.7153 5.8 9.2 30

478 ... 05 SURG OTHER VASCULAR PROCEDURES W CC ......................... 2.2890 5.6 8.3 30

479 ... 05 SURG OTHER VASCULAR PROCEDURES W/O CC ..................... 1.4113 3.5 4.6 27

480 ... ............ SURG LIVER TRANSPLANT ............................................................ 12.8388 22.5 29.7 47

481 ... ............ SURG BONE MARROW TRANSPLANT .......................................... 11.2985 29.1 32.1 53

482 ... ............ SURG TRACHEOSTOMY FOR FACE, MOUTH & NECK DIAGNOSES.3.6598 11.4 15.0 35

483 ... ............ SURG TRACHEOSTOMY EXCEPT FOR FACE, MOUTH & NECK

DIAGNOSES.

16.0114 35.9 46.2 60

484 ... 24 SURG CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA ... 5.5711 10.4 15.5 34

485 ... 24 SURG LIMB REATTACHMENT, HIP AND FEMUR PROC FOR

MULTIPLE SIGNIFICANT TR.

3.1619 9.1 11.6 33

486 ... 24 SURG OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA.4.8009 9.0 13.5 33

487 ... 24 MED OTHER MULTIPLE SIGNIFICANT TRAUMA ........................ 1.9999 6.1 9.0 30

488 ... 25 SURG HIV W EXTENSIVE O.R. PROCEDURE ............................... 4.2773 12.9 17.6 37

489 ... 25 MED HIV W MAJOR RELATED CONDITION ................................ 1.7436 7.0 10.4 31

490 ... 25 MED HIV W OR W/O OTHER RELATED CONDITION ................. 1.0106 4.4 6.6 28

491 ... 08 SURG MAJOR JOINT & LIMB REATTACHMENT PROCEDURES

OF UPPER EXTREMITY.

1.6358 3.6 4.3 19
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27541

TABLE 5.—LIST OF DIAGNOSIS RELATED GROUPS (DRGS), RELATIVE WEIGHTING FACTORS, GEOMETRIC MEAN LENGTH

OF STAY, AND LENGTH OF STAY OUTLIER CUTOFF POINTS USED IN THE PROSPECTIVE PAYMENT SYSTEM—Continued

Relative

weights

Geometric

mean LOS

Arithmetic

mean LOS

Outlier

threshold

492 ... 17 MED CHEMOTHERAPY W ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS.4.0624 11.2 17.4 35

493 ... 07 SURG LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W

CC.

1.7085 4.2 5.9 28

494 ... 07 SURG LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O

CC.

.9186 1.8 2.4 15

495 ... ............ SURG LUNG TRANSPLANT ............................................................ 9.8070 18.4 23.8 42

*Medicare data have been supplemented by data from 19 states for low volume DRGS.

**DRGS 469 and 470 contain cases which could not be assigned to valid DRGS.

Note: Geometric mean is used only to determine payment for transfer cases.

Note: Arithmetic mean is used only to determine payment for outlier cases.

Note: relative weights are based on Medicare patient data and may not be appropriate for other patients.

TABLE 6A.—NEW DIAGNOSIS CODES

Diagnosis

code Description CC MDC DRG

079.6 Respiratory syncytial virus (RSV) ........................................................................ N 15 3871, 389 1

18 421, 422

291.81 Alcohol withdrawal ............................................................................................... Y 20 434, 435, 436, 437

291.89 Other specified alcoholic psychosis, not elsewhere classified ............................ Y 20 434, 435, 436, 437

293.84 Organic anxiety syndrome ................................................................................... Y 19 429

300.82 Undifferentiated somatoform disorder ................................................................. N 19 427

315.32 Receptive language disorder (mixed) .................................................................. N 19 431

414.04 Coronary atherosclerosis of artery bypass graft ................................................. N 5 132, 133

414.05 Coronary atherosclerosis of unspecified type of bypass graft ............................ N 5 132, 133

466.11 Acute bronchiolitis due to respiratory syncytial virus (RSV) ............................... N 4 96, 97, 98

466.19 Acute bronchiolitis due to other infectious organisms ......................................... N 4 96, 97, 98

483.1 Pneumonia due to Chlamydia ............................................................................. Y 4 89, 90, 91

15 387,1 3891

574.60 Calculus of gallbladder and bile duct with acute cholecystitis without mention

of obstruction.

Y 7 207, 208

574.61 Calculus of gallbladder and bile duct with acute cholecystitis with obstruction Y 7 207, 208

574.70 Calculus of gallbladder and bile duct with other cholecystitis without mention

of obstruction.

Y 7 207, 208

574.71 Calculus of gallbladder and bile duct with other cholecystitis with obstruction Y 7 207, 208

574.80 Calculus of gallbladder and bile duct with acute and chronic cholecystitis without mention of obstruction.Y 7 207, 208

574.81 Calculus of gallbladder and bile duct with acute and chronic cholecystitis with

obstruction.

Y 7 207, 208

574.90 Calculus of gallbladder and bile duct without cholecystitis without mention of

obstruction.

Y 7 207, 208

574.91 Calculus of gallbladder and bile duct without cholecystitis with obstruction ....... Y 7 207, 208

575.10 Cholecystitis, unspecified ..................................................................................... N 7 207, 208

575.11 Chronic cholecystitis ............................................................................................ N 7 207, 208

575.12 Acute and chronic cholecystitis ........................................................................... Y 7 207, 208

752.51 Undescended testis ............................................................................................. N 12 352

752.52 Retractile testis .................................................................................................... N 12 352

752.61 Hypospadias ........................................................................................................ N 12 352

752.62 Epispadias ............................................................................................................ N 12 352

752.63 Congenital chordee .............................................................................................. N 12 352

752.64 Micropenis ............................................................................................................ N 12 352

752.65 Hidden penis ........................................................................................................ N 12 352

752.69 Other penile anomalies ........................................................................................ N 12 352

753.20 Unspecified obstructive defect of renal pelvis and ureter ................................... N 11 331, 332, 333

753.21 Congenital obstruction of ureteropelvic junction .................................................. N 11 331, 332, 333

753.22 Congenital obstruction of ureterovesical junction ................................................ N 11 331, 332, 333

753.23 Congenital ureterocele ......................................................................................... N 11 331, 332, 333

753.29 Obstructive defects of renal pelvis and ureter, not elsewhere classifed ............. N 11 331, 332, 333

758.81 Other conditions due to sex chromosome anomalies ......................................... N 12 352

13 358, 359, 369

758.89 Other conditions due to chromosome anomalies, not elsewhere classified ....... N 12 352

13 358, 359, 369

922.31 Back contusion ..................................................................................................... N 9 280, 281, 282

922.32 Buttock contusion ................................................................................................. N 9 280, 281, 282

922.33 Interscapular region contusion ............................................................................. N 9 280, 281, 282

995.50 Child abuse, unspecified ...................................................................................... N 21 454, 455

995.51 Child emotional/psychological abuse ................................................................... N 21 454, 455
27542 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 6A.—NEW DIAGNOSIS CODES—Continued

Diagnosis

code Description CC MDC DRG

995.52 Child neglect (nutritional) ..................................................................................... N 21 454, 455

995.53 Child sexual abuse .............................................................................................. N 21 454, 455

995.54 Child physical abuse ............................................................................................ N 21 454, 455

995.55 Shaken infant syndrome ...................................................................................... N 21 454, 455

995.59 Child maltreatment syndrome, not elsewhere classified ..................................... N 21 454, 455

995.80 Adult maltreatment, unspecified .......................................................................... N 21 454, 455

995.82 Adult emotional/psychological abuse ................................................................... N 21 454, 455

995.83 Adult sexual abuse .............................................................................................. N 21 454, 455

995.84 Adult neglect (nutritional) ..................................................................................... N 21 454, 455

995.85 Other adult abuse and neglect ............................................................................ N 21 454, 455

998.11 Hemorrhage complicating a procedure ............................................................... Y 21 452, 453

998.12 Hematoma complicating a procedure .................................................................. Y 21 452, 453

998.13 Seroma complicating a procedure ....................................................................... Y 21 452, 453

998.51 Infected postoperative seroma ............................................................................ Y 18 418

998.59 Other postoperative infection ............................................................................... Y 18 418

998.83 Non-healing surgical wound ................................................................................ Y 21 452, 453

V15.41 History of physical abuse ..................................................................................... N 23 467

V15.42 History of emotional abuse .................................................................................. N 23 467

V15.49 Psychological trauma, not elsewhere classified .................................................. N 23 467

V61.10 Counseling for marital and partner problems, unspecified .................................. N 23 467

V61.11 Counseling for victim of spousal and partner abuse ........................................... N 23 467

V61.12 Counseling for perpetrator of spousal and partner abuse .................................. N 23 467

V61.22 Counseling for perpetrator of parental child abuse ............................................. N 23 467

V62.83 Counseling for perpetrator of physical/sexual abuse .......................................... N 23 467

V66.7 Encounter for palliative care ................................................................................ N 23 467

1 Diagnosis code is classified as a ‘‘major problem’’ in these DRGs.

TABLE 6B.—NEW PROCEDURE CODES

Procedure

code Description OR MDC DRG

36.17 Abdominal-coronary artery bypass ........................................................................ Y 5 106, 107

39.90 Insertion of non-coronary artery stent or stents .................................................... N ..................

47.01 Laparoscopic appendectomy ................................................................................. Y 6 164, 165, 166, 167

47.09 Other appendectomy ............................................................................................. Y 6 164, 165, 166, 167

47.11 Laparoscopic incidental appendectomy ................................................................ Y 13 365

21 442, 443

24 486

47.19 Other incidental appendectomy ............................................................................. Y 13 365

21 442, 443

24 486

51.21 Other partial cholecystectomy ............................................................................... Y 7 193, 194

17 400, 406,

17 407

21 442, 443

24 486

51.24 Laparoscopic partial cholecystectomy ................................................................... Y 7 193, 194

17 400, 406,

17 407,

21 442, 443

24 486

52.84 Autotransplantation of cells of Islets of Langerhans ............................................. N ..................

52.85 Allotransplantation of cells of Islets of Langerhans ............................................... N ..................

52.86 Transplantation of cells of Islets of Langerhans, not otherwise specified ............ N ..................

54.51 Laparoscopic lysis of peritoneal adhesions ........................................................... Y 6

7

150, 151

201

13 365

21 442, 443

24 486

54.59 Other lysis of peritoneal adhesions ....................................................................... Y 6 150, 151

7 201

13 365

21 442, 443

24 486

59.03 Laparoscopic lysis of perirenal or periureteral adhesions ..................................... Y 11

12

303, 304, 305

344, 345

13 365

17 400

17 406, 407
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27543

TABLE 6B.—NEW PROCEDURE CODES—Continued

Procedure

code Description OR MDC DRG

21 442, 443

24 486

59.12 Laparoscopic lysis of perivesical adhesions ......................................................... Y 11

12

308, 309

344, 345

13 365

17 400

17 406, 407

21 442, 443

24 486

65.01 Laparoscopic oophorotomy ................................................................................... Y 13 354, 355, 357, 358,

359

65.09 Other oophorotomy ................................................................................................ Y 13 354, 355, 357, 358,

359

65.13 Laparoscopic biopsy of ovary ................................................................................ Y 13 354, 355, 357, 358,

359

65.14 Other laparoscopic diagnostic procedures on ovaries .......................................... Y 13 354, 355, 357, 358,

359

65.23 Laparoscopic marsupialization of ovarian cyst ...................................................... Y 13 354, 355, 357, 358,

359

65.24 Laparoscopic wedge resection of ovary ................................................................ Y 10 292, 293

13 354, 355, 357, 358,

359

65.25 Other laparoscopic local excision or destruction of ovary .................................... Y 13 354, 355, 357, 358,

359

65.31 Laparoscopic unilateral oophorectomy .................................................................. Y 13 354, 355, 357, 358,

359

65.39 Other unilateral oophorectomy .............................................................................. Y 13 354, 355, 357, 358,

359

65.41 Laparoscopic unilateral salpingo-oophorectomy ................................................... Y 13 354, 355, 357, 358,

359

65.49 Other unilateral salpingo-oophorectomy ................................................................ Y 13 354, 355, 357, 358,

359

65.53 Laparoscopic removal of both ovaries at same operative episode ...................... Y 9 269, 270

13 354, 355,

13 357, 358, 359

65.54 Laparoscopic removal of remaining ovary ............................................................ Y 9 269, 270

13 354, 355,

13 357, 358, 359

65.63 Laparoscopic removal of both ovaries and tubes at same operative episode ..... Y 9 269, 270

13 354, 355,

13 357, 358, 359

65.64 Laparoscopic removal of remaining ovary and tube ............................................. Y 13 354, 355, 357, 358,

359

65.74 Laparoscopic simple suture of ovary ..................................................................... Y 13 354, 355,

13 357, 358,

21 359

24 442, 443, 486

65.75 Laparoscopic reimplantation of ovary .................................................................... Y 13 354, 355,

13 357, 358,

21 359

24 442, 443, 486

65.76 Laparoscopic salpingo-oophoroplasty ................................................................... Y 13 354, 355,

13 357, 358,

21 359

24 442, 443, 486

65.81 Laparoscopic lysis of adhesions of ovary and fallopian tube ............................... Y 13

13

21

24

354, 355,

357, 358,

359

442, 443, 486

65.89 Other lysis of adhesions of ovary and fallopian tube ............................................ Y 13 354, 355,

13 357, 358,

21 359

24 442, 443, 486

68.23 Endometrial ablation .............................................................................................. Y 13 354, 355, 357, 358,

359

68.51 Laparoscopically assisted vaginal hysterectomy (LAVH) ...................................... Y 13

13

14

354, 355,

357, 358,

359, 375

68.59 Other vaginal hysterectomy ................................................................................... Y 13

13

14

354, 355,

357, 358,

359, 375
27544 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 6C.—TABLE DIAGNOSIS CODES

Diagnosis

code Description CC MDC DRG

291.8 Other specified alcoholic psychosis ................................................................. Y 20 434, 435, 436, 437

466.1 Acute bronchiolitis ............................................................................................ N 4 96, 97, 98

575.1 Other cholecystitis ............................................................................................ N 7 207, 208

752.5 Undescended testicle ....................................................................................... N 12 352

752.6 Hypospadias and epispadias ........................................................................... N 12 352

753.2 Obstructive defects of renal pelvis and ureter ................................................. N 11 331, 332, 333

758.8 Other conditions due to sex chromosome anomalies ..................................... N 12

13

352

358, 359, 369

922.3 Contusion of back ............................................................................................ N 9 280, 281,

9 282

24 484, 486, 487

995.5 Child maltreatment syndrome .......................................................................... N 21 454, 455

998.1 Hemorrhage or hematoma complicating a procedure ..................................... Y 15 387 1, 389 1

21 452, 453

998.5 Postoperative infection ..................................................................................... Y 15 387 1, 389 1

18 418

V15.4 Psychological trauma ....................................................................................... N 23 467

V61.1 Marital problems ............................................................................................... N 23 467

1 Diagnosis code is classified as a ‘‘major problem’’ in these DRGs.

TABLE 6D.—INVALID PROCEDURE CODES

Procedure

code Description OR MDC DRG

47.0 Appendectomy .................................................................................................. Y 6 164, 165, 166, 167

47.1 Incidental appendectomy ................................................................................. Y 13

21

24

365,

442, 443,

486

54.5 Lysis of peritoneal adhesions ........................................................................... Y 6 150, 151

7 201

13 365

21 442, 443

24 486

59.01 Ureterolysis with freeing or repositioning of ureter for retroperitoneal fibrosis Y 11 303, 304,

11 305

12 344, 345

13 365

17 400, 406,

17 407

21 442, 443

24 486

65.0 Oophorotomy .................................................................................................... Y 13 354, 355, 357, 358,

359

65.3 Unilateral oophorectomy .................................................................................. Y 13 354, 355, 357, 358,

359

65.4 Unilateral salpingo-oophorectomy .................................................................... Y 13 354, 355, 357, 358,

359

65.8 Lysis of adhesions of ovary and fallopian tube ............................................... Y 13 354, 355,

13 357, 358,

21 359

24 442, 443, 486

68.5 Vaginal hysterectomy ....................................................................................... Y 13 354, 355,

13 357, 358,

13 359

14 375

TABLE 6E.—REVISED DIAGNOSIS CODE TITLES

Diagnosis

code Description CC MDC DRG

414.00 Coronary atherosclerosis of unspecified type of vessel, native or graft ................... N 5 132, 133

995.81 Adult physical abuse .................................................................................................. N 21 454, 455

997.60 Amputation stump complication, unspecified complication ....................................... N 8 256

997.61 Amputation stump complication, neuroma of amputation stump .............................. N 8 256

997.62 Amputation stump complication, infection (chronic) .................................................. Y 8 256

997.69 Amputation stump complication, not elsewhere classified ........................................ N 8 256
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27545

TABLE 6E.—REVISED DIAGNOSIS CODE TITLES—Continued

Diagnosis

code Description CC MDC DRG

V61.20 Counseling for parent-child problem, unspecified ..................................................... N 23 467

V61.21 Counseling for victim of child abuse .......................................................................... N 23 467

V67.4 Follow-up examination, following treatment of healed fracture ................................. N 23 465, 466

TABLE 6F.—REVISED PROCEDURE CODE TITLES

Procedure

code Description OR MDC DRG

59.11 Other lysis of perivesical adhesions ...................................................................... Y 11

12

308, 309

344, 345

13 365

17 400, 406,

17 407

21 442, 443

24 486

65.51 Other removal of both ovaries at same operative episode ................................... Y 9

13

13

269, 270

354, 355

357, 358, 359

65.52 Other removal of remaining ovary ......................................................................... Y 9

13

13

269, 270

354, 355

357, 358, 359

65.61 Other removal of both ovaries and tubes at same operative episode .................. Y 9

13

13

269, 270

354, 355,

357, 358, 359

65.62 Other removal of remaining ovary and tube ......................................................... Y 13 354, 355, 357, 358,

359

65.71 Other simple suture of ovary ................................................................................. Y 13

13

354, 355,

357, 358,

13 359

21 442, 443

24 486

65.72 Other reimplantation of ovary ................................................................................ Y 13

13

354, 355,

357, 358,

21 359

24 442, 443, 486

65.73 Other salpingo-oophoroplasty ................................................................................ Y 11

12

308, 309,

344, 345

13 365

17 400, 406,

17 407

21 442, 443

24 486
27546 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 6G.—ADDITIONS TO THE CC EXCLUSIONS LIST

PAGE 1 OF 5 PAGES

CCs that are added to the list are in Table 6G—Additions to the CC Exclusions List. Each of the principal diagnoses is shown with an asterisk,

and the revisions to the CC Exclusions List are provided in an indented column immediately following the affected principal diagnosis.

*0011 00844 *00800 00844 *0085 00844 *01133 *01182

00841 00845 00841 00845 00841 00845 4831 4831

00842 00846 00842 00846 00842 00846 *01134 *01183

00843 00847 00843 00847 00843 00847 4831 4831

00844 *0061 00844 *00841 00844 *0088 *01135 *01184

00845 00841 00845 00841 00845 00841 4831 4831

00846 00842 00846 00842 00846 00842 *01136 *01185

00847 00843 00847 00843 00847 00843 4831 4831

*0020 00844 *00801 00844 *00861 00844 *01140 *01186

00841 00845 00841 00845 00841 00845 4831 4831

00842 00846 00842 00846 00842 00846 *01141 *01190

00843 00847 00843 00847 00843 00847 4831 4831

00844 *0062 00844 *00842 00844 *0090 *01142 *01191

00845 00841 00845 00841 00845 00841 4831 4831

00846 00842 00846 00842 00846 00842 *01143 *01192

00847 00843 00847 00843 00847 00843 4831 4831

*0029 00844 *00802 00844 *00862 00844 *01144 *01193

00841 00845 00841 00845 00841 00845 4831 4831

00842 00846 00842 00846 00842 00846 *01145 *01194

00843 00847 00843 00847 00843 00847 4831 4831

00844 *0069 00844 *00843 00844 *01100 *01146 *01195

00845 00841 00845 00841 00845 4831 4831 4831

00846 00842 00846 00842 00846 *01101 *01150 *01196

00847 00843 00847 00843 00847 4831 4831 4831

*0030 00844 *00803 00844 *00863 *01102 *01151 *01200

00841 00845 00841 00845 00841 4831 4831 4831

00842 00846 00842 00846 00842 *01103 *01152 *01201

00843 00847 00843 00847 00843 4831 4831 4831

00844 *0071 00844 *00844 00844 *01104 *01153 *01202

00845 00841 00845 00841 00845 4831 4831 4831

00846 00842 00846 00842 00846 *01105 *01154 *01203

00847 00843 00847 00843 00847 4831 4831 4831

*0049 00844 *00804 00844 *00864 *01106 *01155 *01204

00841 00845 00841 00845 00841 4831 4831 4831

00842 00846 00842 00846 00842 *01110 *01156 *01205

00843 00847 00843 00847 00843 4831 4831 4831

00844 *0072 00844 *00845 00844 *01111 *01160 *01206

00845 00841 00845 00841 00845 4831 4831 4831

00846 00842 00846 00842 00846 *01112 *01161 *01210

00847 00843 00847 00843 00847 4831 4831 4831

*0050 00844 *00809 00844 *00865 *01113 *01162 *01211

00841 00845 00841 00845 00841 4831 4831 4831

00842 00846 00842 00846 00842 *01114 *01163 *01212

00843 00847 00843 00847 00843 4831 4831 4831

00844 *0073 00844 *00846 00844 *01115 *01164 *01213

00845 00841 00845 00841 00845 4831 4831 4831

00846 00842 00846 00842 00846 *01116 *01165 *01214

00847 00843 00847 00843 00847 4831 4831 4831

*0051 00844 *0081 00844 *00866 *01120 *01166 *01215

00841 00845 00841 00845 00841 4831 4831 4831

00842 00846 00842 00846 00842 *01121 *01170 *01216

00843 00847 00843 00847 00843 4831 4831 4831

00844 *0078 00844 *00847 00844 *01122 *01171 *01280

00845 00841 00845 00841 00845 4831 4831 4831

00846 00842 00846 00842 00846 *01123 *01172 *01281

00847 00843 00847 00843 00847 4831 4831 4831

*0052 00844 *0082 00844 *00867 *01124 *01173 *01282

00841 00845 00841 00845 00841 4831 4831 4831

00842 00846 00842 00846 00842 *01125 *01174 *01283

00843 00847 00843 00847 00843 4831 4831 4831

00844 *0079 00844 *00849 00844 *01126 *01175 *01284

00845 00841 00845 00841 00845 4831 4831 4831

00846 00842 00846 00842 00846 *01130 *01176 *01285

00847 00843 00847 00843 00847 4831 4831 4831

*0060 00844 *0083 00844 *00869 *01131 *01180 *01286

00841 00845 00841 00845 00841 4831 4831 4831

00842 00846 00842 00846 00842 *01132 *01181 *01480

00843 00847 00843 00847 00843 4831 4831 00841
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27547

PAGE 2 OF 5 PAGES

00842 4831 29382 29284 *29212 29383 29614 29181

00843 *11285 29383 29289 29181 29384 29634 29189

00844 00841 29384 2929 29189 7105 29644 29384

00845 00842 30300 29381 29384 *29389 29654 *30420

00846 00843 30301 29382 *2922 29181 29664 29181

00847 00844 30302 29383 29181 29189 2980 29189

*01481 00845 30390 29384 29189 29384 2983 29384

00841 00846 30391 30300 29384 *2939 2984 *30421

00842 00847 30392 30301 *29281 29181 29900 29181

00843 *11505 30400 30302 29181 29189 29910 29189

00844 4831 30401 30390 29189 29384 29980 29384

00845 *11515 30402 30391 29384 *2940 29990 *30422

00846 4831 30410 30392 *29282 29181 *30300 29181

00847 *11595 30411 30400 29181 29189 29181 29189

*01482 4831 30412 30401 29189 29384 29189 29384

00841 *1221 30420 30402 29384 *2941 29384 *30423

00842 4831 30421 30410 *29283 29181 *30301 29181

00843 *129 30422 30411 29181 29189 29181 29189

00844 00841 30440 30412 29189 29384 29189 29384

00845 00842 30441 30420 29384 *2948 29384 *30430

00846 00843 30442 30421 *29284 29181 *30302 29181

00847 00844 30450 30422 29181 29189 29181 29189

*01483 00845 30451 30440 29189 29384 29189 29384

00841 00846 30452 30441 29384 *2949 29384 *30431

00842 00847 30460 30442 *29289 29181 *30303 29181

00843 *1304 30461 30450 29181 29189 29181 29189

00844 4831 30462 30451 29189 29384 29189 29384

00845 *1363 30470 30452 29384 *30082 29384 *30432

00846 4831 30471 30460 *2929 29500 *30390 29181

00847 *2910 30472 30461 29181 29501 29181 29189

*01484 29181 30480 30462 29189 29502 29189 29384

00841 29189 30481 30470 29384 29503 29384 *30433

00842 29384 30482 30471 *2930 29504 *30391 29181

00843 *2911 30490 30472 29181 29510 29181 29189

00844 29181 30491 30480 29189 29511 29189 29384

00845 29189 30492 30481 29384 29512 29384 *30440

00846 29384 30500 30482 *2931 29513 *30392 29181

00847 *2912 30501 30490 29181 29514 29181 29189

*01485 29181 30502 30491 29189 29521 29189 29384

00841 29189 30530 30492 29384 29522 29384 *30441

00842 29384 30531 30500 *29381 29523 *30393 29181

00843 *2913 30532 30501 29181 29524 29181 29189

00844 29181 30540 30502 29189 29530 29189 29384

00845 29189 30541 30530 29384 29531 29384 *30442

00846 29384 30542 30531 *29382 29532 *30400 29181

00847 *2914 30550 30532 29181 29533 29181 29189

*01486 29181 30551 30540 29189 29534 29189 29384

00841 29189 30552 30541 29384 29540 29384 *30443

00842 29384 30560 30542 *29383 29541 *30401 29181

00843 *2915 30561 30550 29181 29542 29181 29189

00844 29181 30562 30551 29189 29543 29189 29384

00845 29189 30570 30552 29384 29544 29384 *30450

00846 29384 30571 30560 *29384 29560 *30402 29181

00847 *29181 30572 30561 2910 29561 29181 29189

*01790 2910 30590 30562 2911 29562 29189 29384

4831 2911 30591 30570 2912 29563 29384 *30451

*01791 2912 30592 30571 2913 29564 *30403 29181

4831 2913 *29189 30572 2914 29570 29181 29189

*01792 2914 2910 30590 29181 29571 29189 29384

4831 29181 2911 30591 29189 29572 29384 *30452

*01793 29189 2912 30592 2919 29573 *30410 29181

4831 2919 2913 *2919 2920 29574 29181 29189

*01794 2920 2914 29181 29211 29580 29189 29384

4831 29211 29181 29189 29212 29581 29384 *30453

*01795 29212 29189 29384 2922 29582 *30411 29181

4831 2922 2919 *2920 29281 29583 29181 29189

*01796 29281 2920 29181 29282 29584 29189 29384

4831 29282 29211 29189 29283 29590 29384 *30460

*0212 29283 29212 29384 29284 29591 *30412 29181

4831 29284 2922 *29211 29289 29592 29181 29189

*0310 29289 29281 29181 2929 29593 29189 29384

4831 2929 29282 29189 29381 29594 29384 *30461

*0391 29381 29283 29384 29382 29604 *30413 29181
27548 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

PAGE 3 OF 5 PAGES

29189 29384 *30562 29532 *48239 01180 5078 4831

29384 *30520 29181 29533 4831 01181 5080 *5062

*30462 29181 29189 29534 *4824 01182 5081 4831

29181 29189 29384 29540 4831 01183 5171 *5063

29189 29384 *30563 29541 *48281 01184 *4838 4831

29384 *30521 29181 29542 4831 01185 4831 *5064

*30463 29181 29189 29543 *48282 01186 *4841 4831

29181 29189 29384 29544 4831 01190 4831 *5069

29189 29384 *30570 29560 *48283 01191 *4843 4831

29384 *30522 29181 29561 4831 01192 4831 *5070

*30470 29181 29189 29562 *48289 01193 *4845 4831

29181 29189 29384 29563 4831 01194 4831 *5071

29189 29384 *30571 29564 *4829 01195 *4846 4831

29384 *30523 29181 29570 4831 01196 4831 *5078

*30471 29181 29189 29571 *4830 01200 *4847 4831

29181 29189 29384 29572 4831 01201 4831 *5080

29189 29384 *30572 29573 *4831 01202 *4848 4831

29384 *30530 29181 29574 01100 01203 4831 *5081

*30472 29181 29189 29580 01101 01204 *485 4831

29181 29189 29384 29581 01102 01205 4831 *5088

29189 29384 *30573 29582 01103 01206 *486 4831

29384 *30531 29181 29583 01104 01210 4831 *5089

*30473 29181 29189 29584 01105 01211 *4870 4831

29181 29189 29384 29590 01106 01212 4831 *5171

29189 29384 *30580 29591 01110 01213 *4871 4831

29384 *30532 29181 29592 01111 01214 4831 *5178

*30480 29181 29189 29593 01112 01215 *4878 4831

29181 29189 29384 29594 01113 01216 00841 *51889

29189 29384 *30581 29604 01114 0310 00842 4831

29384 *30533 29181 29614 01115 11505 00843 *5198

*30481 29181 29189 29634 01116 11515 00844 4831

29181 29189 29384 29644 01120 1304 00845 *5199

29189 29384 *30582 29654 01121 1363 00846 4831

29384 *30540 29181 29664 01122 481 00847 *53081

*30482 29181 29189 2980 01123 4820 *494 99811

29181 29189 29384 2983 01124 4821 4831 99812

29189 29384 *30583 2984 01125 4822 *4950 99813

29384 *30541 29181 29900 01126 48230 4831 *53082

*30483 29181 29189 29910 01130 48231 *4951 99811

29181 29189 29384 29980 01131 48232 4831 99812

29189 29384 *30590 29990 01132 48239 *4952 99813

29384 *30542 29181 *4560 01133 4824 4831 *53083

*30490 29181 29189 99811 01134 48281 *4953 99811

29181 29189 29384 99812 01135 48282 4831 99812

29189 29384 *30591 99813 01136 48283 *4954 99813

29384 *30543 29181 *45620 01140 48289 4831 *53089

*30491 29181 29189 99811 01141 4829 *4955 99811

29181 29189 29384 99812 01142 4830 4831 99812

29189 29384 *30592 99813 01143 4831 *4956 99813

29384 *30550 29181 *4800 01144 4838 4831 *53100

*30492 29181 29189 4831 01145 4841 *4957 99811

29181 29189 29384 *4801 01146 4843 4831 99812

29189 29384 *30593 4831 01150 4845 *4958 99813

29384 *30551 29181 *4802 01151 4846 4831 *53101

*30493 29181 29189 4831 01152 4847 *4959 99811

29181 29189 29384 *4808 01153 4848 4831 99812

29189 29384 *31532 4831 01154 485 *496 99813

29384 *30552 29500 *4809 01155 486 4831 *53120

*30500 29181 29501 4831 01156 4870 *500 99811

29181 29189 29502 *481 01160 4950 4831 99812

29189 29384 29503 4831 01161 4951 *501 99813

29384 *30553 29504 *4820 01162 4952 4831 *53121

*30501 29181 29510 4831 01163 4953 *502 99811

29181 29189 29511 *4821 01164 4954 4831 99812

29189 29384 29512 4831 01165 4955 *503 99813

29384 *30560 29513 *4822 01166 4956 4831 *53140

*30502 29181 29514 4831 01170 4957 *504 99811

29181 29189 29521 *48230 01171 4958 4831 99812

29189 29384 29522 4831 01172 4959 *505 99813

29384 *30561 29523 *48231 01173 5060 4831 *53141

*30503 29181 29524 4831 01174 5061 *5060 99811

29181 29189 29530 *48232 01175 5070 4831 99812

29189 29384 29531 4831 01176 5071 *5061 99813
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27549

PAGE 4 OF 5 PAGES

*53160 99811 00846 00843 00844 57431 57400 57400

99811 99812 00847 00844 00845 57440 57401 57401

99812 99813 *53783 00845 00846 57441 57410 57410

99813 *53401 99811 00846 00847 57450 57411 57411

*53161 99811 99812 00847 *56202 57451 57421 57421

99811 99812 99813 *5565 99811 57460 57430 57430

99812 99813 *5550 00841 99812 57461 57431 57431

99813 *53420 00841 00842 99813 57470 57440 57440

*53200 99811 00842 00843 *56203 57471 57441 57441

99811 99812 00843 00844 99811 57490 57450 57450

99812 99813 00844 00845 99812 57491 57451 57451

99813 *53421 00845 00846 99813 5750 57470 57460

*53201 99811 00846 00847 *56212 *57461 57471 57461

99811 99812 00847 *5566 99811 57400 57480 57470

99812 99813 *5551 00841 99812 57401 57481 57471

99813 *53440 00841 00842 99813 57410 57490 57480

*53220 99811 00842 00843 *56213 57411 57491 57481

99811 99812 00843 00844 99811 57421 5750 57490

99812 99813 00844 00845 99812 57430 *57490 57491

99813 *53441 00845 00846 99813 57431 57430 5750

*53221 99811 00846 00847 *5641 57440 57431 57512

99811 99812 00847 *5568 00841 57441 57440 *57512

99812 99813 *5552 00841 00842 57450 57441 57400

99813 *53460 00841 00842 00843 57451 57450 57401

*53240 99811 00842 00843 00844 57460 57451 57410

99811 99812 00843 00844 00845 57461 57470 57411

99812 99813 00844 00845 00846 57470 57471 57421

99813 *53461 00845 00846 00847 57471 57490 57430

*53241 99811 00846 00847 *5693 57490 57491 57431

99811 99812 00847 *5569 99811 57491 *57491 57440

99812 99813 *5559 00841 99812 5750 57430 57441

99813 *53501 00841 00842 99813 *57470 57431 57450

*53260 99811 00842 00843 *56985 57430 57440 57451

99811 99812 00843 00844 99811 57431 57441 57460

99812 99813 00844 00845 99812 57440 57450 57461

99813 *53511 00845 00846 99813 57441 57451 57470

*53261 99811 00846 00847 *57430 57450 57470 57471

99811 99812 00847 *5570 57470 57451 57471 57480

99812 99813 *5560 00841 57471 57470 57490 57481

99813 *53521 00841 00842 57490 57471 57491 57490

*53300 99811 00842 00843 57491 57490 *5750 57491

99811 99812 00843 00844 *57431 57491 57460 5750

99812 99813 00844 00845 57470 *57471 57461 57512

99813 *53531 00845 00846 57471 57430 57470 *5759

*53301 99811 00846 00847 57490 57431 57471 57460

99811 99812 00847 *5571 57491 57440 57480 57461

99812 99813 *5561 00841 *57440 57441 57481 57480

99813 *53541 00841 00842 57470 57450 57490 57481

*53320 99811 00842 00843 57471 57451 57491 57512

99811 99812 00843 00844 57490 57470 57512 *5768

99812 99813 00844 00845 57491 57471 *57510 57460

99813 *53551 00845 00846 *57441 57490 57400 57461

*53321 99811 00846 00847 57470 57491 57401 57470

99811 99812 00847 *5579 57471 *57480 57410 57471

99812 99813 *5562 00841 57490 57400 57411 57480

99813 *53561 00841 00842 57491 57401 57421 57481

*53340 99811 00842 00843 *57450 57410 57430 57490

99811 99812 00843 00844 57470 57411 57431 57491

99812 99813 00844 00845 57471 57421 57440 57512

99813 *5363 00845 00846 57490 57430 57441 *5769

*53341 00841 00846 00847 57491 57431 57450 57460

99811 00842 00847 *5582 *57451 57440 57451 57461

99812 00843 *5563 00841 57470 57441 57460 57470

99813 00844 00841 00842 57471 57450 57461 57471

*53360 00845 00842 00843 57490 57451 57470 57480

99811 00846 00843 00844 57491 57470 57471 57481

99812 00847 00844 00845 *57460 57471 57480 57490

99813 *5368 00845 00846 57400 57480 57481 57491

*53361 00841 00846 00847 57401 57481 57490 57512

99811 00842 00847 *5589 57410 57490 57491 *5780

99812 00843 *5564 00841 57411 57491 5750 99811

99813 00844 00841 00842 57421 5750 57512 99812

*53400 00845 00842 00843 57430 *57481 *57511 99813
27550 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

PAGE 5 OF 5 PAGES

*5781 5996 00841 99812 9971

99811 78820 00842 99813 9972

99812 78829 00843 *99813 9973

99813 *75329 00844 9585 9974

*5789 5845 00845 9954 9975

99811 5846 00846 9980 99762

99812 5847 00847 99811 99799

99813 5849 *7758 99812 9980

*74861 585 00841 99813 9982

4831 5996 00842 *99851 9983

*75261 78820 00843 99851 9984

5970 78829 00844 99859 9986

5981 *7724 00845 *99859 9987

5982 99811 00846 99851 99883

5994 99812 00847 99859 99889

*75262 99813 *7759 *99881 9989

5970 *7750 00841 99811 *99889

5981 00841 00842 99812 99811

5982 00842 00843 99813 99812

5994 00843 00844 99851 99813

*75263 00844 00845 99859 99851

5970 00845 00846 99883 99859

5981 00846 00847 *99883 99883

5982 00847 *7775 9580 *9989

5994 *7751 00841 9581 99811

*75264 00841 00842 9582 99812

5970 00842 00843 9583 99813

5981 00843 00844 9584 99851

5982 00844 00845 9585 99859

5994 00845 00846 9587 99883

*75265 00846 00847 9954

5970 00847 *7778 99600

5981 *7752 00841 99601

5982 00841 00842 99602

5994 00842 00843 99603

*75269 00843 00844 99604

5970 00844 00845 99609

5981 00845 00846 9961

5982 00846 00847 9962

5994 00847 *7903 99630

*75320 *7753 29181 99639

5845 00841 29189 9964

5846 00842 29384 99660

5847 00843 *99791 99661

5849 00844 99811 99662

585 00845 99812 99663

5996 00846 99813 99664

78820 00847 99851 99665

78829 *7754 99859 99666

*75321 00841 99883 99667

5845 00842 *99799 99669

5846 00843 99811 99670

5847 00844 99812 99671

5849 00845 99813 99672

585 00846 99851 99673

5996 00847 99859 99674

78820 *7755 99883 99675

78829 00841 *9980 99676

*75322 00842 99811 99677

5845 00843 99812 99678

5846 00844 99813 99679

5847 00845 *99811 99690

5849 00846 9585 99691

585 00847 9954 99692

5996 *7756 9980 99693

78820 00841 99811 99694

78829 00842 99812 99695

*75323 00843 99813 99696

5845 00844 *99812 99699

5846 00845 9585 99700

5847 00846 9954 99701

5849 00847 9980 99702

585 *7757 99811 99709
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27551

TABLE 6H.—DELETIONS TO THE CC EXCLUSIONS LIST

PAGE 1 OF 1 PAGE

CCs that are deleted from the list are in Table 6H—Deletions to the CC Exclusions List. Each of the principal diagnoses is shown with an

asterisk, and the revisions to the CC Exclusions List are provided in an indented column immediately following the affected principal diagnosis.

*2910 30502 2918 2918 2918 9981 57421

2918 30530 *30303 *30471 *30563 *53261 57430

*2911 30531 2918 2918 2918 9981 57431

2918 30532 *30390 *30472 *30570 *53300 57440

*2912 30540 2918 2918 2918 9981 57441

2918 30541 *30391 *30473 *30571 *53301 57450

*2913 30542 2918 2918 2918 9981 57451

2918 30550 *30392 *30480 *30572 *53320 5750

*2914 30551 2918 2918 2918 9981 *5780

2918 30552 *30393 *30481 *30573 *53321 9981

*2915 30560 2918 2918 2918 9981 *5781

2918 30561 *30400 *30482 *30580 *53340 9981

*2918 30562 2918 2918 2918 9981 *5789

2910 30570 *30401 *30483 *30581 *53341 9981

2911 30571 2918 2918 2918 9981 *7526

2912 30572 *30402 *30490 *30582 *53360 5970

2913 30590 2918 2918 2918 9981 5981

2914 30591 *30403 *30491 *30583 *53361 5982

2918 30592 2918 2918 2918 9981 5994

2919 *2919 *30410 *30492 *30590 *53400 *7532

2920 2918 2918 2918 2918 9981 5845

29211 *2920 *30411 *30493 *30591 *53401 5846

29212 2918 2918 2918 2918 9981 5847

2922 *29211 *30412 *30500 *30592 *53420 5849

29281 2918 2918 2918 2918 9981 585

29282 *29212 *30413 *30501 *30593 *53421 5996

29283 2918 2918 2918 2918 9981 78820

29284 *2922 *30420 *30502 *4560 *53440 78829

29289 2918 2918 2918 9981 9981 *7724

2929 *29281 *30421 *30503 *45620 *53441 9981

29381 2918 2918 2918 9981 9981 *7903

29382 *29282 *30422 *30520 *53081 *53460 2918

29383 2918 2918 2918 9981 9981 *99791

30300 *29283 *30423 *30521 *53082 *53461 9981

30301 2918 2918 2918 9981 9981 9985

30302 *29284 *30430 *30522 *53083 *53501 *99799

30390 2918 2918 2918 9981 9981 9981

30391 *29289 *30431 *30523 *53089 *53511 9985

30392 2918 2918 2918 9981 9981 *9980

30400 *2929 *30432 *30530 *53100 *53521 9981

30401 2918 2918 2918 9981 9981 *9981

30402 *2930 *30433 *30531 *53101 *53531 9585

30410 2918 2918 2918 9981 9981 9954

30411 *2931 *30440 *30532 *53120 *53541 9980

30412 2918 2918 2918 9981 9981 9981

30420 *29381 *30441 *30533 *53121 *53551 *9985

30421 2918 2918 2918 9981 9981 9985

30422 *29382 *30442 *30540 *53140 *53561 *99881

30440 2918 2918 2918 9981 9981 9981

30441 *29383 *30443 *30541 *53141 *53783 9985

30442 2918 2918 2918 9981 9981 *99889

30450 *29389 *30450 *30542 *53160 *56202 9981

30451 2918 2918 2918 9981 9981 9985

30452 *2939 *30451 *30543 *53161 *56203 *9989

30460 2918 2918 2918 9981 9981 9981

30461 *2940 *30452 *30550 *53200 *56212 9985

30462 2918 2918 2918 9981 9981

30470 *2941 30453 *30551 *53201 *56213

30471 2918 2918 2918 9981 9981

30472 *2948 *30460 *30552 *53220 *5693

30480 2918 2918 2918 9981 9981

30481 *2949 *30461 *30553 *53221 *56985

30482 2918 2918 2918 9981 9981

30490 *30300 *30462 *30560 *53240 *5751

30491 2918 2918 2918 9981 57400

30492 *30301 *30463 *30561 *53241 57401

30500 2918 2918 2918 9981 57410

30501 *30302 *30470 *30562 *53260 57411
27552 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY

[FY95 MEDPAR Update 12/95 Grouper V13.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

1 .................................... 32723 11.0372 3 4 8 14 23

2 .................................... 6165 11.5178 3 5 8 14 23

3 .................................... 1 10.0000 10 10 10 10 10

4 .................................... 5866 9.1202 2 3 6 11 20

5 .................................... 95896 4.4060 2 2 3 5 9

6 .................................... 444 3.3581 1 1 2 4 7

7 .................................... 10526 12.5752 3 5 8 14 25

8 .................................... 2248 4.1348 1 1 3 5 9

9 .................................... 1655 7.5287 2 3 5 9 16

10 .................................. 19194 7.9610 2 3 6 10 16

11 .................................. 2866 4.9215 1 2 4 6 10

12 .................................. 23355 7.5868 2 3 5 9 14

13 .................................. 5969 6.2406 2 4 5 7 11

14 .................................. 351205 7.4178 2 3 6 9 14

15 .................................. 138882 4.4367 1 2 3 5 8

16 .................................. 11877 6.5858 2 3 5 8 12

17 .................................. 3217 4.0258 1 2 3 5 7

18 .................................. 22783 6.3682 2 3 5 8 12

19 .................................. 7433 4.5271 1 2 4 6 8

20 .................................. 5990 11.2129 3 5 9 15 22

21 .................................. 1114 7.8905 2 3 6 10 16

22 .................................. 2585 4.8584 2 2 4 6 9

23 .................................. 5720 5.0336 1 2 4 6 10

24 .................................. 53620 5.8059 2 3 4 7 11

25 .................................. 21830 3.8592 1 2 3 5 7

26 .................................. 46 4.6087 1 2 3 6 10

27 .................................. 3475 6.2774 1 1 4 7 15

28 .................................. 11179 7.0945 1 3 5 9 14

29 .................................. 3684 4.0581 1 2 3 5 8

31 .................................. 3167 5.4436 1 2 4 6 10

32 .................................. 1723 3.1573 1 1 2 4 6

34 .................................. 16272 6.4700 2 3 5 8 12

35 .................................. 3648 4.2928 1 2 3 5 8

36 .................................. 9010 1.5970 1 1 1 2 3

37 .................................. 1878 4.0213 1 1 3 5 8

38 .................................. 234 2.5385 1 1 2 3 5

39 .................................. 3289 1.9663 1 1 1 2 4

40 .................................. 2779 3.3843 1 1 2 4 7

42 .................................. 7351 2.2049 1 1 1 2 5

43 .................................. 97 4.0928 1 2 3 5 8

44 .................................. 1614 5.7038 2 3 5 7 10

45 .................................. 2412 3.8163 1 2 3 5 7

46 .................................. 2952 5.4814 1 2 4 7 10

47 .................................. 1333 3.7802 1 2 3 5 7

49 .................................. 2139 5.6396 1 2 4 7 11

50 .................................. 3347 2.1138 1 1 2 2 3

51 .................................. 308 2.9870 1 1 1 3 7

52 .................................. 78 3.6282 1 1 2 3 8

53 .................................. 3340 3.5548 1 1 2 4 8

54 .................................. 1 1.0000 1 1 1 1 1

55 .................................. 1924 2.9569 1 1 2 3 6

56 .................................. 704 2.7514 1 1 2 3 6

57 .................................. 637 4.0973 1 1 3 5 8

59 .................................. 88 3.7045 1 1 2 4 7

60 .................................. 3 1.0000 1 1 1 1 1

61 .................................. 217 5.2535 1 1 2 7 14

62 .................................. 1 2.0000 2 2 2 2 2

63 .................................. 3996 4.6652 1 2 3 5 10

64 .................................. 3351 7.5067 1 2 5 9 16

65 .................................. 29525 3.4147 1 2 3 4 6

66 .................................. 6479 3.5658 1 2 3 4 6

67 .................................. 510 4.2039 2 2 3 5 8

68 .................................. 9443 4.7605 2 3 4 6 9

69 .................................. 3062 3.7606 1 2 3 5 7

70 .................................. 30 3.0667 1 2 3 3 5

71 .................................. 90 4.1556 1 2 3 5 8

72 .................................. 561 4.3529 1 2 3 5 9

73 .................................. 6017 4.9493 1 2 4 6 9

75 .................................. 39401 11.1088 4 6 8 14 21

76 .................................. 38785 12.4555 3 6 10 15 24
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27553

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY95 MEDPAR Update 12/95 Grouper V13.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

77 .................................. 2331 5.5268 1 2 4 8 12

78 .................................. 28979 8.2306 4 5 7 10 13

79 .................................. 207606 9.2488 3 5 7 11 17

80 .................................. 8932 6.6160 2 4 5 8 12

81 .................................. 9 7.2222 1 2 6 11 12

82 .................................. 68573 7.8881 2 3 6 10 16

83 .................................. 6976 6.3817 2 3 5 8 12

84 .................................. 1430 3.7217 1 2 3 5 7

85 .................................. 18398 7.3317 2 3 6 9 14

86 .................................. 1372 4.5117 1 2 4 6 9

87 .................................. 58612 6.7959 1 3 6 9 13

88 .................................. 345365 6.0658 2 3 5 7 11

89 .................................. 415072 7.0754 3 4 6 9 12

90 .................................. 40306 5.1392 2 3 4 6 9

91 .................................. 50 4.5800 2 2 3 6 8

92 .................................. 11849 7.2524 2 4 6 9 13

93 .................................. 1262 4.9374 1 3 4 6 9

94 .................................. 12531 7.0527 2 3 5 9 14

95 .................................. 1365 4.1341 1 2 3 5 8

96 .................................. 60887 5.5101 2 3 5 7 10

97 .................................. 25835 4.2614 2 2 4 5 7

98 .................................. 19 4.4737 1 1 3 6 10

99 .................................. 25241 3.4914 1 2 3 4 7

100 ................................ 10191 2.4244 1 1 2 3 4

101 ................................ 19810 5.1725 1 2 4 7 10

102 ................................ 4399 3.1298 1 1 2 4 6

103 ................................ 445 39.3528 10 15 29 53 80

104 ................................ 22854 14.5510 6 8 12 18 26

105 ................................ 19821 10.9286 5 7 9 13 19

106 ................................ 96166 11.7202 6 8 10 14 19

107 ................................ 61255 8.8314 5 6 7 10 14

108 ................................ 6560 12.5834 4 7 10 15 23

110 ................................ 59173 10.7795 3 6 9 13 20

111 ................................ 5800 6.6512 3 5 6 8 10

112 ................................ 191511 4.6987 1 2 4 6 9

113 ................................ 45003 14.3320 4 6 10 17 28

114 ................................ 8788 9.4467 2 4 7 12 18

115 ................................ 10395 11.3715 4 6 9 14 20

116 ................................ 81298 5.4177 1 2 4 7 11

117 ................................ 4482 4.1142 1 1 2 5 8

118 ................................ 6687 3.1952 1 1 2 4 7

119 ................................ 1705 5.4985 1 1 3 7 13

120 ................................ 40465 9.1860 1 2 6 12 21

121 ................................ 158928 7.4120 2 4 6 9 13

122 ................................ 87089 5.0036 1 3 5 6 9

123 ................................ 46281 4.6510 1 1 2 6 11

124 ................................ 138564 4.8885 1 2 4 6 9

125 ................................ 59232 3.0694 1 1 2 4 6

126 ................................ 4619 13.9985 4 7 11 17 29

127 ................................ 670461 6.2113 2 3 5 8 12

128 ................................ 19612 6.7259 3 4 6 8 11

129 ................................ 4584 3.4271 1 1 1 4 9

130 ................................ 91826 6.6818 2 4 6 8 12

131 ................................ 25592 5.1808 1 3 5 7 8

132 ................................ 127274 3.5716 1 2 3 4 6

133 ................................ 5813 2.9696 1 1 2 4 5

134 ................................ 28493 3.9142 1 2 3 5 7

135 ................................ 7141 4.9779 1 2 4 6 9

136 ................................ 1014 3.2209 1 2 3 4 6

138 ................................ 195932 4.5466 1 2 3 6 8

139 ................................ 67345 2.9337 1 1 2 4 5

140 ................................ 175930 3.4831 1 2 3 4 6

141 ................................ 76111 4.4923 1 2 3 5 8

142 ................................ 35701 3.1999 1 2 2 4 6

143 ................................ 132318 2.6077 1 1 2 3 5

144 ................................ 66761 5.6816 1 2 4 7 11

145 ................................ 6735 3.2413 1 1 2 4 6

146 ................................ 8626 11.2570 6 7 9 13 18

147 ................................ 1624 7.3651 4 6 7 9 11

148 ................................ 140141 13.4097 6 8 11 16 24
27554 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY95 MEDPAR Update 12/95 Grouper V13.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

149 ................................ 15769 7.7194 4 6 7 9 11

150 ................................ 22516 11.6884 4 7 10 14 21

151 ................................ 4518 6.4748 2 4 6 8 11

152 ................................ 4469 9.0257 4 6 8 10 15

153 ................................ 1710 6.1655 3 4 6 8 9

154 ................................ 35661 14.9524 5 8 12 18 28

155 ................................ 4557 5.8824 2 3 5 8 10

156 ................................ 4 15.7500 4 4 10 22 27

157 ................................ 11419 5.7824 1 2 4 7 11

158 ................................ 5082 2.9124 1 1 2 4 6

159 ................................ 17132 5.3155 1 2 4 7 10

160 ................................ 9971 2.9553 1 1 2 4 5

161 ................................ 14786 4.3655 1 2 3 5 9

162 ................................ 7990 2.1914 1 1 2 3 4

163 ................................ 5 2.2000 1 1 1 3 5

164 ................................ 4995 9.2993 4 6 8 11 16

165 ................................ 1674 5.7575 3 4 5 7 9

166 ................................ 3283 5.7286 2 3 4 7 10

167 ................................ 2284 3.2439 1 2 3 4 6

168 ................................ 1739 4.8562 1 2 3 6 10

169 ................................ 1025 2.5473 1 1 2 3 5

170 ................................ 12463 12.4436 2 5 9 15 25

171 ................................ 1157 5.4105 1 2 4 7 11

172 ................................ 30820 8.1481 2 3 6 10 16

173 ................................ 2188 4.2870 1 2 3 5 9

174 ................................ 231782 5.5456 2 3 4 7 10

175 ................................ 23071 3.5073 1 2 3 4 6

176 ................................ 16011 6.1346 2 3 5 7 11

177 ................................ 11991 4.9873 2 3 4 6 9

178 ................................ 4174 3.6195 1 2 3 5 7

179 ................................ 11198 7.1657 2 4 6 9 14

180 ................................ 79145 6.0471 2 3 5 7 11

181 ................................ 22152 3.9606 1 2 3 5 7

182 ................................ 226099 4.9591 2 2 4 6 9

183 ................................ 72147 3.4552 1 2 3 4 6

184 ................................ 67 3.7463 1 2 2 4 6

185 ................................ 3804 5.1966 1 2 4 6 10

186 ................................ 1 2.0000 2 2 2 2 2

187 ................................ 832 4.2524 1 2 3 6 8

188 ................................ 61112 6.1262 2 3 5 8 12

189 ................................ 7787 3.6773 1 1 3 5 7

190 ................................ 62 4.8548 1 3 4 6 10

191 ................................ 10459 16.1606 5 8 12 20 32

192 ................................ 880 7.9625 2 4 7 9 14

193 ................................ 8477 13.8662 5 8 11 17 25

194 ................................ 805 8.4348 3 5 7 10 15

195 ................................ 9196 10.4533 4 6 9 12 18

196 ................................ 796 6.7651 3 4 6 8 11

197 ................................ 28016 9.1380 4 5 7 11 16

198 ................................ 7906 4.9586 2 3 4 6 8

199 ................................ 2208 11.1005 3 5 9 14 22

200 ................................ 1525 11.8413 2 4 8 14 25

201 ................................ 1466 16.5750 4 7 13 21 34

202 ................................ 25094 7.6794 2 3 6 9 15

203 ................................ 28743 7.6566 2 3 6 10 15

204 ................................ 49035 6.6942 2 3 5 8 13

205 ................................ 21512 7.2152 2 3 5 9 14

206 ................................ 1692 4.7305 1 2 4 6 10

207 ................................ 35330 5.7193 2 3 4 7 11

208 ................................ 10251 3.4474 1 2 3 4 6

209 ................................ 328015 6.6569 3 4 6 7 10

210 ................................ 131592 8.5557 4 5 7 10 14

211 ................................ 25325 6.2610 3 4 6 7 10

212 ................................ 9 5.0000 2 3 4 5 8

213 ................................ 6788 9.6117 3 4 7 12 19

214 ................................ 51282 6.4551 2 3 5 8 12

215 ................................ 41115 3.6816 1 2 3 5 7

216 ................................ 6435 11.0449 2 5 8 14 22

217 ................................ 19341 15.2991 3 6 10 18 31

218 ................................ 21844 6.2064 2 3 5 7 11
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27555

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY95 MEDPAR Update 12/95 Grouper V13.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

219 ................................ 17973 3.7492 1 2 3 5 6

220 ................................ 2 5.5000 5 5 6 6 6

221 ................................ 4962 8.1475 2 4 6 10 16

222 ................................ 3560 4.0573 1 2 3 5 8

223 ................................ 18306 2.8650 1 1 2 3 5

224 ................................ 7946 2.2699 1 1 2 3 4

225 ................................ 6199 5.0045 1 2 3 6 11

226 ................................ 5349 6.7080 1 2 4 8 14

227 ................................ 4604 2.9622 1 1 2 4 6

228 ................................ 3014 3.5551 1 1 2 4 7

229 ................................ 1345 2.4007 1 1 2 3 5

230 ................................ 2455 5.1548 1 2 3 6 11

231 ................................ 10331 5.0624 1 2 3 6 11

232 ................................ 576 4.5017 1 1 2 5 10

233 ................................ 4538 8.9595 2 4 7 11 18

234 ................................ 2220 4.1730 1 2 3 5 8

235 ................................ 5543 6.7231 1 3 4 7 13

236 ................................ 37803 6.2862 2 3 5 7 12

237 ................................ 1510 4.4139 1 2 3 5 8

238 ................................ 7538 10.0649 3 5 7 12 19

239 ................................ 59581 7.6027 2 4 6 9 14

240 ................................ 12047 7.4987 2 3 5 9 15

241 ................................ 3019 4.6277 1 2 4 6 9

242 ................................ 2528 7.6606 2 4 6 9 15

243 ................................ 79979 5.6107 2 3 4 7 10

244 ................................ 11456 5.8092 2 3 4 7 11

245 ................................ 4259 4.2158 1 2 3 5 8

246 ................................ 1312 4.5899 1 2 4 6 9

247 ................................ 10591 3.9716 1 2 3 5 8

248 ................................ 6767 5.2815 1 2 4 6 10

249 ................................ 10077 4.2995 1 2 3 5 9

250 ................................ 3178 4.9091 1 2 3 6 9

251 ................................ 2090 3.2933 1 1 3 4 6

252 ................................ 1 1.0000 1 1 1 1 1

253 ................................ 17469 5.8164 2 3 4 7 11

254 ................................ 9208 3.8588 1 2 3 5 7

255 ................................ 1 2.0000 2 2 2 2 2

256 ................................ 4600 5.7178 1 2 4 7 11

257 ................................ 23640 3.4239 1 2 3 4 6

258 ................................ 18784 2.4905 1 2 2 3 4

259 ................................ 4010 3.5077 1 1 2 3 7

260 ................................ 4868 1.8683 1 1 1 2 3

261 ................................ 2334 2.3500 1 1 2 3 4

262 ................................ 712 3.9284 1 1 2 5 8

263 ................................ 29088 13.8669 4 6 10 16 28

264 ................................ 3559 8.3442 2 4 6 10 17

265 ................................ 4274 7.6467 1 2 5 9 16

266 ................................ 2712 3.6855 1 1 3 5 7

267 ................................ 222 4.0811 1 1 3 5 9

268 ................................ 891 4.0000 1 1 2 4 9

269 ................................ 10173 9.1218 2 3 7 12 18

270 ................................ 3456 3.3958 1 1 2 4 8

271 ................................ 21515 8.4984 3 4 7 10 15

272 ................................ 5863 7.4481 2 3 6 9 14

273 ................................ 1426 5.5035 2 2 4 7 11

274 ................................ 2526 7.7458 2 3 5 9 15

275 ................................ 250 3.5040 1 1 2 4 8

276 ................................ 889 5.0472 1 2 4 6 9

277 ................................ 79054 6.7240 3 4 5 8 12

278 ................................ 26008 5.1420 2 3 4 6 9

279 ................................ 5 4.8000 2 2 3 4 12

280 ................................ 13098 5.1142 1 2 4 6 9

281 ................................ 5890 3.6448 1 2 3 4 7

283 ................................ 5233 5.4888 2 2 4 7 10

284 ................................ 1755 3.8632 1 2 3 5 7

285 ................................ 4886 13.5014 3 6 10 16 26

286 ................................ 1918 8.7195 3 4 6 9 16

287 ................................ 6284 13.3908 3 6 9 16 26

288 ................................ 957 7.0449 2 4 5 7 11

289 ................................ 4992 3.9732 1 2 2 4 8
27556 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY95 MEDPAR Update 12/95 Grouper V13.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

290 ................................ 8514 2.8404 1 1 2 3 5

291 ................................ 86 1.7558 1 1 1 2 3

292 ................................ 5046 12.6958 2 5 9 16 25

293 ................................ 294 6.4456 1 3 5 8 14

294 ................................ 86024 5.6681 2 3 4 7 10

295 ................................ 3712 4.2826 1 2 3 5 8

296 ................................ 218940 6.3561 2 3 5 8 12

297 ................................ 31455 4.2781 1 2 3 5 8

298 ................................ 95 3.0211 1 1 2 4 5

299 ................................ 868 5.3652 1 2 4 7 10

300 ................................ 14115 7.3032 2 3 6 9 14

301 ................................ 2146 4.3877 1 2 3 6 9

302 ................................ 7567 12.3190 6 7 9 14 21

303 ................................ 18462 10.1938 4 6 8 12 18

304 ................................ 12867 10.2970 3 5 7 13 21

305 ................................ 2526 4.9097 1 3 4 6 9

306 ................................ 11305 6.2204 2 2 4 8 13

307 ................................ 2596 2.9819 1 2 2 3 5

308 ................................ 9137 7.0113 1 2 5 9 15

309 ................................ 3371 3.0009 1 1 2 4 6

310 ................................ 28549 4.6077 1 2 3 6 9

311 ................................ 9697 2.1734 1 1 2 3 4

312 ................................ 1995 4.7895 1 2 3 6 10

313 ................................ 745 2.2644 1 1 2 3 5

314 ................................ 1 5.0000 5 5 5 5 5

315 ................................ 27722 9.2695 1 2 6 12 20

316 ................................ 69941 7.4958 2 3 6 9 15

317 ................................ 779 2.8434 1 1 2 3 6

318 ................................ 5981 7.1195 2 3 5 9 14

319 ................................ 506 3.2174 1 1 2 4 7

320 ................................ 169078 6.4297 2 3 5 8 11

321 ................................ 25512 4.7020 2 3 4 6 8

322 ................................ 81 4.3580 2 2 4 6 8

323 ................................ 17690 3.5573 1 2 3 4 7

324 ................................ 8755 2.0870 1 1 2 3 4

325 ................................ 7381 4.5898 1 2 3 5 9

326 ................................ 2186 3.4492 1 1 2 4 6

327 ................................ 8 3.1250 1 2 2 2 4

328 ................................ 817 4.2742 1 2 3 5 9

329 ................................ 109 2.7523 1 1 2 3 5

330 ................................ 1 1.0000 1 1 1 1 1

331 ................................ 38181 6.1753 2 3 5 8 12

332 ................................ 4687 3.8835 1 2 3 5 8

333 ................................ 357 5.8319 1 3 4 7 13

334 ................................ 19011 6.0503 3 4 5 7 9

335 ................................ 9821 4.5786 2 3 4 6 7

336 ................................ 60748 4.1251 1 2 3 5 8

337 ................................ 38538 2.6717 1 2 2 3 4

338 ................................ 4813 5.2703 1 2 3 6 11

339 ................................ 2302 4.9392 1 2 3 6 10

340 ................................ 2 3.0000 1 1 5 5 5

341 ................................ 6427 3.2367 1 1 2 4 6

342 ................................ 224 4.0089 1 1 2 5 8

344 ................................ 3820 3.4652 1 1 2 4 7

345 ................................ 1355 3.9734 1 2 3 4 9

346 ................................ 5343 6.7477 1 3 5 8 14

347 ................................ 418 3.3349 1 1 2 4 7

348 ................................ 3021 4.8875 1 2 4 6 9

349 ................................ 684 2.9956 1 1 2 4 6

350 ................................ 6884 4.7451 2 3 4 6 8

352 ................................ 576 3.9392 1 2 3 5 8

353 ................................ 2621 8.3564 3 5 6 10 15

354 ................................ 9693 6.3330 3 4 5 7 11

355 ................................ 5607 3.8639 2 3 4 4 6

356 ................................ 28647 3.0247 1 2 3 4 5

357 ................................ 6526 9.8462 4 5 8 12 18

358 ................................ 26797 4.7425 2 3 4 5 8

359 ................................ 27392 3.2715 2 3 3 4 5

360 ................................ 16717 3.5393 1 2 3 4 6

361 ................................ 618 3.4644 1 1 2 4 7
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27557

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY95 MEDPAR Update 12/95 Grouper V13.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

363 ................................ 4355 3.4953 1 2 2 3 6

364 ................................ 1778 3.6310 1 1 2 5 8

365 ................................ 2396 8.1123 2 3 5 10 18

366 ................................ 4470 7.6707 2 3 5 10 16

367 ................................ 544 3.3107 1 1 2 4 7

368 ................................ 2285 6.9190 2 3 5 9 13

369 ................................ 2409 3.7410 1 1 3 5 7

370 ................................ 1083 5.5568 3 3 4 5 9

371 ................................ 950 3.5874 2 3 3 4 5

372 ................................ 809 3.3498 1 2 2 3 6

373 ................................ 3637 1.9249 1 1 2 2 3

374 ................................ 116 2.3621 1 2 2 2 3

375 ................................ 5 2.2000 1 1 2 3 4

376 ................................ 151 3.4834 1 1 2 4 8

377 ................................ 26 3.2308 1 1 1 3 8

378 ................................ 163 2.9755 1 2 3 3 5

379 ................................ 309 2.9256 1 1 2 3 5

380 ................................ 71 2.3239 1 1 2 3 4

381 ................................ 194 2.2835 1 1 1 2 5

382 ................................ 47 1.6596 1 1 1 1 3

383 ................................ 1455 4.0460 1 2 3 5 8

384 ................................ 123 3.3496 1 1 1 3 7

385 ................................ 3 17.0000 1 1 1 49 49

389 ................................ 24 10.6667 3 4 8 10 18

390 ................................ 10 5.0000 1 2 3 6 9

392 ................................ 2467 11.6700 4 6 8 15 24

394 ................................ 1642 7.8831 1 2 5 9 16

395 ................................ 65671 5.3672 1 2 4 7 10

396 ................................ 18 3.9444 1 1 3 7 8

397 ................................ 15421 6.0683 2 3 4 7 12

398 ................................ 16602 6.5798 2 3 5 8 12

399 ................................ 1424 4.4347 1 2 4 6 8

400 ................................ 7470 10.3424 2 4 7 13 23

401 ................................ 6368 12.3990 2 5 9 16 25

402 ................................ 1542 4.6984 1 1 3 6 10

403 ................................ 34812 9.2838 2 4 7 12 19

404 ................................ 3946 5.0867 1 2 4 7 10

406 ................................ 3264 11.1468 3 5 8 14 23

407 ................................ 723 4.9267 1 2 4 6 9

408 ................................ 2949 8.2035 1 2 5 10 18

409 ................................ 5649 6.6516 2 3 4 6 14

410 ................................ 85873 3.3544 1 2 3 4 5

411 ................................ 50 2.5600 1 1 2 3 7

412 ................................ 35 3.0857 1 1 2 4 8

413 ................................ 8421 8.2956 2 3 6 10 17

414 ................................ 797 5.2070 1 2 4 7 11

415 ................................ 38804 15.6974 4 7 12 19 31

416 ................................ 192133 8.2122 2 4 7 10 15

417 ................................ 45 4.6222 1 2 4 7 10

418 ................................ 18663 6.7433 2 3 5 8 13

419 ................................ 15677 5.6580 2 3 4 7 10

420 ................................ 2871 4.3006 2 2 4 5 8

421 ................................ 11386 4.6473 2 2 4 6 8

422 ................................ 89 3.6854 1 2 3 4 7

423 ................................ 9118 8.6534 2 4 6 10 18

424 ................................ 1990 17.7397 3 6 12 20 34

425 ................................ 15247 4.8955 1 2 3 6 10

426 ................................ 4721 5.4938 1 2 4 7 11

427 ................................ 1773 5.2775 1 2 4 7 11

428 ................................ 904 8.4303 1 3 5 10 18

429 ................................ 38861 8.9079 2 3 6 10 17

430 ................................ 53430 9.7495 2 4 7 12 19

431 ................................ 190 7.4632 1 3 5 9 14

432 ................................ 430 6.3395 1 2 4 6 11

433 ................................ 7843 3.4051 1 1 2 4 7

434 ................................ 20810 5.8148 2 3 4 7 11

435 ................................ 15477 4.8166 1 3 4 6 8

436 ................................ 2915 14.5413 4 8 14 21 28

437 ................................ 14205 10.8943 4 6 10 14 20

439 ................................ 867 8.9262 2 3 6 11 18
27558 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 7A.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY95 MEDPAR Update 12/95 Grouper V13.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

440 ................................ 4751 9.7838 2 3 6 12 21

441 ................................ 611 4.4386 1 1 2 4 7

442 ................................ 13818 8.7372 1 3 6 11 18

443 ................................ 3299 3.5335 1 1 2 5 7

444 ................................ 3319 5.3203 1 3 4 6 10

445 ................................ 1321 3.7858 1 2 3 5 7

446 ................................ 1 1.0000 1 1 1 1 1

447 ................................ 3816 2.7953 1 1 2 3 5

448 ................................ 84 1.0000 1 1 1 1 1

449 ................................ 28775 4.4101 1 2 3 5 9

450 ................................ 6807 2.3364 1 1 2 3 5

451 ................................ 7 6.1429 2 3 4 5 7

452 ................................ 19382 5.4066 1 2 4 6 11

453 ................................ 3636 3.1876 1 1 2 4 6

454 ................................ 5132 5.1046 1 2 3 6 10

455 ................................ 1092 2.8333 1 1 2 3 5

456 ................................ 194 8.3711 1 1 4 9 21

457 ................................ 127 4.7953 1 1 2 5 10

458 ................................ 1550 16.9387 4 7 13 22 35

459 ................................ 533 10.3471 2 4 7 13 22

460 ................................ 2303 6.6309 1 3 5 8 13

461 ................................ 3040 4.8862 1 1 2 5 12

462 ................................ 9360 13.7955 5 6 12 18 26

463 ................................ 11987 5.1410 1 2 4 6 10

464 ................................ 3079 3.7347 1 2 3 5 7

465 ................................ 197 3.9086 1 1 2 4 7

466 ................................ 1838 4.6366 1 1 2 4 10

467 ................................ 1722 4.1057 1 1 2 4 8

468 ................................ 58649 15.1829 3 7 12 19 30

471 ................................ 9111 8.0289 4 5 6 9 13

472 ................................ 150 30.6667 2 9 28 41 62

473 ................................ 8217 14.3113 2 4 8 21 35

475 ................................ 89514 12.1394 2 5 10 16 24

476 ................................ 6875 13.7876 3 7 11 17 25

477 ................................ 28128 8.8453 1 3 6 11 18

478 ................................ 117755 8.2916 1 3 6 10 17

479 ................................ 17758 4.5591 1 2 4 6 9

480 ................................ 359 29.7159 10 13 22 37 61

481 ................................ 119 35.0000 21 23 30 39 59

482 ................................ 6754 14.9011 5 8 11 17 28

483 ................................ 36200 45.7958 15 23 37 56 84

484 ................................ 327 15.3364 2 6 11 21 32

485 ................................ 3165 11.5893 4 6 9 13 21

486 ................................ 2045 13.3482 1 6 11 18 28

487 ................................ 3765 8.8770 1 3 7 11 17

488 ................................ 1593 17.5267 5 8 13 22 35

489 ................................ 17612 10.3989 2 4 7 13 22

490 ................................ 4999 6.5719 1 2 4 8 14

491 ................................ 9441 4.2777 2 3 3 5 7

492 ................................ 2029 17.3834 3 5 10 28 37

493 ................................ 52260 5.8809 1 2 5 8 11

494 ................................ 27127 2.4245 1 1 2 3 5

495 ................................ 107 23.7944 10 13 18 29 41

10571233

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY

[FY95 MEDPAR Update 12/95 Grouper V14.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

1 .................................... 32723 11.0372 3 4 8 14 23

2 .................................... 6165 11.5178 3 5 8 14 23

3 .................................... 1 10.0000 10 10 10 10 10

4 .................................... 5866 9.1202 2 3 6 11 20

5 .................................... 95896 4.4060 2 2 3 5 9

6 .................................... 444 3.3581 1 1 2 4 7

7 .................................... 10526 12.5752 3 5 8 14 25
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27559

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY95 MEDPAR Update 12/95 Grouper V14.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

8 .................................... 2248 4.1348 1 1 3 5 9

9 .................................... 1655 7.5287 2 3 5 9 16

10 .................................. 19194 7.9610 2 3 6 10 16

11 .................................. 2866 4.9215 1 2 4 6 10

12 .................................. 23355 7.5868 2 3 5 9 14

13 .................................. 5969 6.2406 2 4 5 7 11

14 .................................. 351205 7.4178 2 3 6 9 14

15 .................................. 138882 4.4367 1 2 3 5 8

16 .................................. 11877 6.5858 2 3 5 8 12

17 .................................. 3217 4.0258 1 2 3 5 7

18 .................................. 22783 6.3682 2 3 5 8 12

19 .................................. 7433 4.5271 1 2 4 6 8

20 .................................. 5990 11.2129 3 5 9 15 22

21 .................................. 1114 7.8905 2 3 6 10 16

22 .................................. 2585 4.8584 2 2 4 6 9

23 .................................. 5720 5.0336 1 2 4 6 10

24 .................................. 53620 5.8059 2 3 4 7 11

25 .................................. 21830 3.8592 1 2 3 5 7

26 .................................. 46 4.6087 1 2 3 6 10

27 .................................. 3475 6.2774 1 1 4 7 15

28 .................................. 11179 7.0945 1 3 5 9 14

29 .................................. 3684 4.0581 1 2 3 5 8

31 .................................. 3167 5.4436 1 2 4 6 10

32 .................................. 1723 3.1573 1 1 2 4 6

34 .................................. 16272 6.4700 2 3 5 8 12

35 .................................. 3648 4.2928 1 2 3 5 8

36 .................................. 9010 1.5970 1 1 1 2 3

37 .................................. 1878 4.0213 1 1 3 5 8

38 .................................. 234 2.5385 1 1 2 3 5

39 .................................. 3289 1.9663 1 1 1 2 4

40 .................................. 2779 3.3843 1 1 2 4 7

42 .................................. 7351 2.2049 1 1 1 2 5

43 .................................. 97 4.0928 1 2 3 5 8

44 .................................. 1614 5.7038 2 3 5 7 10

45 .................................. 2412 3.8163 1 2 3 5 7

46 .................................. 2952 5.4814 1 2 4 7 10

47 .................................. 1333 3.7802 1 2 3 5 7

49 .................................. 2139 5.6396 1 2 4 7 11

50 .................................. 3347 2.1138 1 1 2 2 3

51 .................................. 308 2.9870 1 1 1 3 7

52 .................................. 78 3.6282 1 1 2 3 8

53 .................................. 3340 3.5548 1 1 2 4 8

54 .................................. 1 1.0000 1 1 1 1 1

55 .................................. 1924 2.9569 1 1 2 3 6

56 .................................. 704 2.7514 1 1 2 3 6

57 .................................. 637 4.0973 1 1 3 5 8

59 .................................. 88 3.7045 1 1 2 4 7

60 .................................. 3 1.0000 1 1 1 1 1

61 .................................. 217 5.2535 1 1 2 7 14

62 .................................. 1 2.0000 2 2 2 2 2

63 .................................. 3996 4.6652 1 2 3 5 10

64 .................................. 3351 7.5067 1 2 5 9 16

65 .................................. 29525 3.4147 1 2 3 4 6

66 .................................. 6479 3.5658 1 2 3 4 6

67 .................................. 510 4.2039 2 2 3 5 8

68 .................................. 9443 4.7605 2 3 4 6 9

69 .................................. 3062 3.7606 1 2 3 5 7

70 .................................. 30 3.0667 1 2 3 3 5

71 .................................. 90 4.1556 1 2 3 5 8

72 .................................. 561 4.3529 1 2 3 5 9

73 .................................. 6017 4.9493 1 2 4 6 9

75 .................................. 39401 11.1088 4 6 8 14 21

76 .................................. 38785 12.4555 3 6 10 15 24

77 .................................. 2331 5.5268 1 2 4 8 12

78 .................................. 28979 8.2306 4 5 7 10 13

79 .................................. 207606 9.2488 3 5 7 11 17

80 .................................. 8932 6.6160 2 4 5 8 12

81 .................................. 9 7.2222 1 2 6 11 12

82 .................................. 68573 7.8881 2 3 6 10 16

83 .................................. 6976 6.3817 2 3 5 8 12
27560 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY95 MEDPAR Update 12/95 Grouper V14.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

84 .................................. 1430 3.7217 1 2 3 5 7

85 .................................. 18398 7.3317 2 3 6 9 14

86 .................................. 1372 4.5117 1 2 4 6 9

87 .................................. 58612 6.7959 1 3 6 9 13

88 .................................. 345365 6.0658 2 3 5 7 11

89 .................................. 415072 7.0754 3 4 6 9 12

90 .................................. 40306 5.1392 2 3 4 6 9

91 .................................. 50 4.5800 2 2 3 6 8

92 .................................. 11849 7.2524 2 4 6 9 13

93 .................................. 1262 4.9374 1 3 4 6 9

94 .................................. 12531 7.0527 2 3 5 9 14

95 .................................. 1365 4.1341 1 2 3 5 8

96 .................................. 60887 5.5101 2 3 5 7 10

97 .................................. 25835 4.2614 2 2 4 5 7

98 .................................. 19 4.4737 1 1 3 6 10

99 .................................. 25241 3.4914 1 2 3 4 7

100 ................................ 10191 2.4244 1 1 2 3 4

101 ................................ 19810 5.1725 1 2 4 7 10

102 ................................ 4399 3.1298 1 1 2 4 6

103 ................................ 445 39.3528 10 15 29 53 80

104 ................................ 22854 14.5510 6 8 12 18 26

105 ................................ 19821 10.9286 5 7 9 13 19

106 ................................ 96166 11.7202 6 8 10 14 19

107 ................................ 61255 8.8314 5 6 7 10 14

108 ................................ 6560 12.5834 4 7 10 15 23

110 ................................ 59173 10.7795 3 6 9 13 20

111 ................................ 5800 6.6512 3 5 6 8 10

112 ................................ 191511 4.6987 1 2 4 6 9

113 ................................ 45003 14.3320 4 6 10 17 28

114 ................................ 8788 9.4467 2 4 7 12 18

115 ................................ 10395 11.3715 4 6 9 14 20

116 ................................ 81298 5.4177 1 2 4 7 11

117 ................................ 4482 4.1142 1 1 2 5 8

118 ................................ 6687 3.1952 1 1 2 4 7

119 ................................ 1705 5.4985 1 1 3 7 13

120 ................................ 40465 9.1860 1 2 6 12 21

121 ................................ 158928 7.4120 2 4 6 9 13

122 ................................ 87089 5.0036 1 3 5 6 9

123 ................................ 46281 4.6510 1 1 2 6 11

124 ................................ 138564 4.8885 1 2 4 6 9

125 ................................ 59232 3.0694 1 1 2 4 6

126 ................................ 4619 13.9985 4 7 11 17 29

127 ................................ 670461 6.2113 2 3 5 8 12

128 ................................ 19612 6.7259 3 4 6 8 11

129 ................................ 4584 3.4271 1 1 1 4 9

130 ................................ 91826 6.6818 2 4 6 8 12

131 ................................ 25592 5.1808 1 3 5 7 8

132 ................................ 127274 3.5716 1 2 3 4 6

133 ................................ 5813 2.9696 1 1 2 4 5

134 ................................ 28493 3.9142 1 2 3 5 7

135 ................................ 7141 4.9779 1 2 4 6 9

136 ................................ 1014 3.2209 1 2 3 4 6

138 ................................ 195932 4.5466 1 2 3 6 8

139 ................................ 67345 2.9337 1 1 2 4 5

140 ................................ 175930 3.4831 1 2 3 4 6

141 ................................ 76111 4.4923 1 2 3 5 8

142 ................................ 35701 3.1999 1 2 2 4 6

143 ................................ 132318 2.6077 1 1 2 3 5

144 ................................ 66761 5.6816 1 2 4 7 11

145 ................................ 6735 3.2413 1 1 2 4 6

146 ................................ 8626 11.2570 6 7 9 13 18

147 ................................ 1624 7.3651 4 6 7 9 11

148 ................................ 140141 13.4097 6 8 11 16 24

149 ................................ 15769 7.7194 4 6 7 9 11

150 ................................ 22516 11.6884 4 7 10 14 21

151 ................................ 4518 6.4748 2 4 6 8 11

152 ................................ 4469 9.0257 4 6 8 10 15

153 ................................ 1710 6.1655 3 4 6 8 9

154 ................................ 35661 14.9524 5 8 12 18 28

155 ................................ 4557 5.8824 2 3 5 8 10
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27561

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY95 MEDPAR Update 12/95 Grouper V14.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

156 ................................ 4 15.7500 4 4 10 22 27

157 ................................ 11419 5.7824 1 2 4 7 11

158 ................................ 5082 2.9124 1 1 2 4 6

159 ................................ 17132 5.3155 1 2 4 7 10

160 ................................ 9971 2.9553 1 1 2 4 5

161 ................................ 14786 4.3655 1 2 3 5 9

162 ................................ 7990 2.1914 1 1 2 3 4

163 ................................ 5 2.2000 1 1 1 3 5

164 ................................ 4995 9.2993 4 6 8 11 16

165 ................................ 1674 5.7575 3 4 5 7 9

166 ................................ 3283 5.7286 2 3 4 7 10

167 ................................ 2284 3.2439 1 2 3 4 6

168 ................................ 1739 4.8562 1 2 3 6 10

169 ................................ 1025 2.5473 1 1 2 3 5

170 ................................ 12463 12.4436 2 5 9 15 25

171 ................................ 1157 5.4105 1 2 4 7 11

172 ................................ 30820 8.1481 2 3 6 10 16

173 ................................ 2188 4.2870 1 2 3 5 9

174 ................................ 231782 5.5456 2 3 4 7 10

175 ................................ 23071 3.5073 1 2 3 4 6

176 ................................ 16011 6.1346 2 3 5 7 11

177 ................................ 11991 4.9873 2 3 4 6 9

178 ................................ 4174 3.6195 1 2 3 5 7

179 ................................ 11198 7.1657 2 4 6 9 14

180 ................................ 79145 6.0471 2 3 5 7 11

181 ................................ 22152 3.9606 1 2 3 5 7

182 ................................ 226099 4.9591 2 2 4 6 9

183 ................................ 72147 3.4552 1 2 3 4 6

184 ................................ 67 3.7463 1 2 2 4 6

185 ................................ 3804 5.1966 1 2 4 6 10

186 ................................ 1 2.0000 2 2 2 2 2

187 ................................ 832 4.2524 1 2 3 6 8

188 ................................ 61112 6.1262 2 3 5 8 12

189 ................................ 7787 3.6773 1 1 3 5 7

190 ................................ 62 4.8548 1 3 4 6 10

191 ................................ 10459 16.1606 5 8 12 20 32

192 ................................ 880 7.9625 2 4 7 9 14

193 ................................ 8477 13.8662 5 8 11 17 25

194 ................................ 805 8.4348 3 5 7 10 15

195 ................................ 9196 10.4533 4 6 9 12 18

196 ................................ 796 6.7651 3 4 6 8 11

197 ................................ 28016 9.1380 4 5 7 11 16

198 ................................ 7906 4.9586 2 3 4 6 8

199 ................................ 2208 11.1005 3 5 9 14 22

200 ................................ 1525 11.8413 2 4 8 14 25

201 ................................ 1466 16.5750 4 7 13 21 34

202 ................................ 25094 7.6794 2 3 6 9 15

203 ................................ 28743 7.6566 2 3 6 10 15

204 ................................ 49035 6.6942 2 3 5 8 13

205 ................................ 21512 7.2152 2 3 5 9 14

206 ................................ 1692 4.7305 1 2 4 6 10

207 ................................ 35330 5.7193 2 3 4 7 11

208 ................................ 10251 3.4474 1 2 3 4 6

209 ................................ 328015 6.6569 3 4 6 7 10

210 ................................ 131592 8.5557 4 5 7 10 14

211 ................................ 25325 6.2610 3 4 6 7 10

212 ................................ 9 5.0000 2 3 4 5 8

213 ................................ 6789 9.6170 3 4 7 12 19

214 ................................ 51282 6.4551 2 3 5 8 12

215 ................................ 41115 3.6816 1 2 3 5 7

216 ................................ 6435 11.0449 2 5 8 14 22

217 ................................ 19341 15.2991 3 6 10 18 31

218 ................................ 21844 6.2064 2 3 5 7 11

219 ................................ 17973 3.7492 1 2 3 5 6

220 ................................ 2 5.5000 5 5 6 6 6

221 ................................ 4962 8.1475 2 4 6 10 16

222 ................................ 3560 4.0573 1 2 3 5 8

223 ................................ 18306 2.8650 1 1 2 3 5

224 ................................ 7946 2.2699 1 1 2 3 4

225 ................................ 6199 5.0045 1 2 3 6 11
27562 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY95 MEDPAR Update 12/95 Grouper V14.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

226 ................................ 5349 6.7080 1 2 4 8 14

227 ................................ 4604 2.9622 1 1 2 4 6

228 ................................ 3014 3.5551 1 1 2 4 7

229 ................................ 1345 2.4007 1 1 2 3 5

230 ................................ 2455 5.1548 1 2 3 6 11

231 ................................ 10331 5.0624 1 2 3 6 11

232 ................................ 576 4.5017 1 1 2 5 10

233 ................................ 4538 8.9595 2 4 7 11 18

234 ................................ 2220 4.1730 1 2 3 5 8

235 ................................ 5543 6.7231 1 3 4 7 13

236 ................................ 37803 6.2862 2 3 5 7 12

237 ................................ 1510 4.4139 1 2 3 5 8

238 ................................ 7538 10.0649 3 5 7 12 19

239 ................................ 59580 7.6024 2 4 6 9 14

240 ................................ 12047 7.4987 2 3 5 9 15

241 ................................ 3019 4.6277 1 2 4 6 9

242 ................................ 2528 7.6606 2 4 6 9 15

243 ................................ 79979 5.6107 2 3 4 7 10

244 ................................ 11456 5.8092 2 3 4 7 11

245 ................................ 4259 4.2158 1 2 3 5 8

246 ................................ 1312 4.5899 1 2 4 6 9

247 ................................ 10591 3.9716 1 2 3 5 8

248 ................................ 6767 5.2815 1 2 4 6 10

249 ................................ 10077 4.2995 1 2 3 5 9

250 ................................ 3178 4.9091 1 2 3 6 9

251 ................................ 2090 3.2933 1 1 3 4 6

252 ................................ 1 1.0000 1 1 1 1 1

253 ................................ 17469 5.8164 2 3 4 7 11

254 ................................ 9208 3.8588 1 2 3 5 7

255 ................................ 1 2.0000 2 2 2 2 2

256 ................................ 4600 5.7178 1 2 4 7 11

257 ................................ 23640 3.4239 1 2 3 4 6

258 ................................ 18784 2.4905 1 2 2 3 4

259 ................................ 4010 3.5077 1 1 2 3 7

260 ................................ 4868 1.8683 1 1 1 2 3

261 ................................ 2334 2.3500 1 1 2 3 4

262 ................................ 712 3.9284 1 1 2 5 8

263 ................................ 29088 13.8669 4 6 10 16 28

264 ................................ 3559 8.3442 2 4 6 10 17

265 ................................ 4274 7.6467 1 2 5 9 16

266 ................................ 2712 3.6855 1 1 3 5 7

267 ................................ 222 4.0811 1 1 3 5 9

268 ................................ 891 4.0000 1 1 2 4 9

269 ................................ 10174 9.1235 2 3 7 12 18

270 ................................ 3456 3.3958 1 1 2 4 8

271 ................................ 21515 8.4984 3 4 7 10 15

272 ................................ 5863 7.4481 2 3 6 9 14

273 ................................ 1426 5.5035 2 2 4 7 11

274 ................................ 2526 7.7458 2 3 5 9 15

275 ................................ 250 3.5040 1 1 2 4 8

276 ................................ 889 5.0472 1 2 4 6 9

277 ................................ 79054 6.7240 3 4 5 8 12

278 ................................ 26008 5.1420 2 3 4 6 9

279 ................................ 5 4.8000 2 2 3 4 12

280 ................................ 13098 5.1142 1 2 4 6 9

281 ................................ 5890 3.6448 1 2 3 4 7

283 ................................ 5233 5.4888 2 2 4 7 10

284 ................................ 1755 3.8632 1 2 3 5 7

285 ................................ 4886 13.5014 3 6 10 16 26

286 ................................ 1918 8.7195 3 4 6 9 16

287 ................................ 6284 13.3908 3 6 9 16 26

288 ................................ 957 7.0449 2 4 5 7 11

289 ................................ 4992 3.9732 1 2 2 4 8

290 ................................ 8514 2.8404 1 1 2 3 5

291 ................................ 86 1.7558 1 1 1 2 3

292 ................................ 5046 12.6958 2 5 9 16 25

293 ................................ 294 6.4456 1 3 5 8 14

294 ................................ 86024 5.6681 2 3 4 7 10

295 ................................ 3712 4.2826 1 2 3 5 8

296 ................................ 218940 6.3561 2 3 5 8 12
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27563

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY95 MEDPAR Update 12/95 Grouper V14.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

297 ................................ 31455 4.2781 1 2 3 5 8

298 ................................ 95 3.0211 1 1 2 4 5

299 ................................ 868 5.3652 1 2 4 7 10

300 ................................ 14115 7.3032 2 3 6 9 14

301 ................................ 2146 4.3877 1 2 3 6 9

302 ................................ 7567 12.3190 6 7 9 14 21

303 ................................ 18462 10.1938 4 6 8 12 18

304 ................................ 12867 10.2970 3 5 7 13 21

305 ................................ 2526 4.9097 1 3 4 6 9

306 ................................ 11305 6.2204 2 2 4 8 13

307 ................................ 2596 2.9819 1 2 2 3 5

308 ................................ 9137 7.0113 1 2 5 9 15

309 ................................ 3371 3.0009 1 1 2 4 6

310 ................................ 28549 4.6077 1 2 3 6 9

311 ................................ 9697 2.1734 1 1 2 3 4

312 ................................ 1995 4.7895 1 2 3 6 10

313 ................................ 745 2.2644 1 1 2 3 5

314 ................................ 1 5.0000 5 5 5 5 5

315 ................................ 27722 9.2695 1 2 6 12 20

316 ................................ 69941 7.4958 2 3 6 9 15

317 ................................ 779 2.8434 1 1 2 3 6

318 ................................ 5981 7.1195 2 3 5 9 14

319 ................................ 506 3.2174 1 1 2 4 7

320 ................................ 169078 6.4297 2 3 5 8 11

321 ................................ 25512 4.7020 2 3 4 6 8

322 ................................ 81 4.3580 2 2 4 6 8

323 ................................ 17690 3.5573 1 2 3 4 7

324 ................................ 8755 2.0870 1 1 2 3 4

325 ................................ 7381 4.5898 1 2 3 5 9

326 ................................ 2186 3.4492 1 1 2 4 6

327 ................................ 8 3.1250 1 2 2 2 4

328 ................................ 817 4.2742 1 2 3 5 9

329 ................................ 109 2.7523 1 1 2 3 5

330 ................................ 1 1.0000 1 1 1 1 1

331 ................................ 38181 6.1753 2 3 5 8 12

332 ................................ 4687 3.8835 1 2 3 5 8

333 ................................ 357 5.8319 1 3 4 7 13

334 ................................ 19011 6.0503 3 4 5 7 9

335 ................................ 9821 4.5786 2 3 4 6 7

336 ................................ 60748 4.1251 1 2 3 5 8

337 ................................ 38538 2.6717 1 2 2 3 4

338 ................................ 4813 5.2703 1 2 3 6 11

339 ................................ 2302 4.9392 1 2 3 6 10

340 ................................ 2 3.0000 1 1 5 5 5

341 ................................ 6427 3.2367 1 1 2 4 6

342 ................................ 224 4.0089 1 1 2 5 8

344 ................................ 3820 3.4652 1 1 2 4 7

345 ................................ 1355 3.9734 1 2 3 4 9

346 ................................ 5344 6.7500 1 3 5 8 14

347 ................................ 418 3.3349 1 1 2 4 7

348 ................................ 3021 4.8875 1 2 4 6 9

349 ................................ 684 2.9956 1 1 2 4 6

350 ................................ 6884 4.7451 2 3 4 6 8

352 ................................ 576 3.9392 1 2 3 5 8

353 ................................ 2621 8.3564 3 5 6 10 15

354 ................................ 9693 6.3330 3 4 5 7 11

355 ................................ 5607 3.8639 2 3 4 4 6

356 ................................ 28647 3.0247 1 2 3 4 5

357 ................................ 6526 9.8462 4 5 8 12 18

358 ................................ 26797 4.7425 2 3 4 5 8

359 ................................ 27392 3.2715 2 3 3 4 5

360 ................................ 16717 3.5393 1 2 3 4 6

361 ................................ 618 3.4644 1 1 2 4 7

363 ................................ 4355 3.4953 1 2 2 3 6

364 ................................ 1778 3.6310 1 1 2 5 8

365 ................................ 2396 8.1123 2 3 5 10 18

366 ................................ 4471 7.6741 2 3 5 10 16

367 ................................ 545 3.3266 1 1 2 4 7

368 ................................ 2285 6.9190 2 3 5 9 13

369 ................................ 2409 3.7410 1 1 3 5 7
27564 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY95 MEDPAR Update 12/95 Grouper V14.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

370 ................................ 1083 5.5568 3 3 4 5 9

371 ................................ 950 3.5874 2 3 3 4 5

372 ................................ 809 3.3498 1 2 2 3 6

373 ................................ 3637 1.9249 1 1 2 2 3

374 ................................ 116 2.3621 1 2 2 2 3

375 ................................ 5 2.2000 1 1 2 3 4

376 ................................ 151 3.4834 1 1 2 4 8

377 ................................ 26 3.2308 1 1 1 3 8

378 ................................ 163 2.9755 1 2 3 3 5

379 ................................ 309 2.9256 1 1 2 3 5

380 ................................ 71 2.3239 1 1 2 3 4

381 ................................ 194 2.2835 1 1 1 2 5

382 ................................ 47 1.6596 1 1 1 1 3

383 ................................ 1455 4.0460 1 2 3 5 8

384 ................................ 123 3.3496 1 1 1 3 7

385 ................................ 3 17.0000 1 1 1 49 49

389 ................................ 24 10.6667 3 4 8 10 18

390 ................................ 10 5.0000 1 2 3 6 9

392 ................................ 2467 11.6700 4 6 8 15 24

394 ................................ 1642 7.8831 1 2 5 9 16

395 ................................ 65671 5.3672 1 2 4 7 10

396 ................................ 18 3.9444 1 1 3 7 8

397 ................................ 15421 6.0683 2 3 4 7 12

398 ................................ 16601 6.5794 2 3 5 8 12

399 ................................ 1424 4.4347 1 2 4 6 8

400 ................................ 7468 10.3293 2 4 7 13 23

401 ................................ 6365 12.3829 2 5 9 16 25

402 ................................ 1542 4.6984 1 1 3 6 10

403 ................................ 34765 9.2628 2 4 7 12 19

404 ................................ 3944 5.0822 1 2 4 7 10

406 ................................ 3264 11.1468 3 5 8 14 23

407 ................................ 723 4.9267 1 2 4 6 9

408 ................................ 2949 8.2035 1 2 5 10 18

409 ................................ 5649 6.6516 2 3 4 6 14

410 ................................ 85871 3.3540 1 2 3 4 5

411 ................................ 50 2.5600 1 1 2 3 7

412 ................................ 35 3.0857 1 1 2 4 8

413 ................................ 8422 8.2992 2 3 6 10 17

414 ................................ 797 5.2070 1 2 4 7 11

415 ................................ 38804 15.6974 4 7 12 19 31

416 ................................ 192133 8.2122 2 4 7 10 15

417 ................................ 45 4.6222 1 2 4 7 10

418 ................................ 18663 6.7433 2 3 5 8 13

419 ................................ 15677 5.6580 2 3 4 7 10

420 ................................ 2871 4.3006 2 2 4 5 8

421 ................................ 11386 4.6473 2 2 4 6 8

422 ................................ 89 3.6854 1 2 3 4 7

423 ................................ 9118 8.6534 2 4 6 10 18

424 ................................ 1990 17.7397 3 6 12 20 34

425 ................................ 15247 4.8955 1 2 3 6 10

426 ................................ 4721 5.4938 1 2 4 7 11

427 ................................ 1773 5.2775 1 2 4 7 11

428 ................................ 904 8.4303 1 3 5 10 18

429 ................................ 38861 8.9079 2 3 6 10 17

430 ................................ 53430 9.7495 2 4 7 12 19

431 ................................ 190 7.4632 1 3 5 9 14

432 ................................ 430 6.3395 1 2 4 6 11

433 ................................ 7843 3.4051 1 1 2 4 7

434 ................................ 20810 5.8148 2 3 4 7 11

435 ................................ 15477 4.8166 1 3 4 6 8

436 ................................ 2915 14.5413 4 8 14 21 28

437 ................................ 14205 10.8943 4 6 10 14 20

439 ................................ 867 8.9262 2 3 6 11 18

440 ................................ 4751 9.7838 2 3 6 12 21

441 ................................ 611 4.4386 1 1 2 4 7

442 ................................ 13818 8.7372 1 3 6 11 18

443 ................................ 3299 3.5335 1 1 2 5 7

444 ................................ 3319 5.3203 1 3 4 6 10

445 ................................ 1321 3.7858 1 2 3 5 7

446 ................................ 1 1.0000 1 1 1 1 1
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27565

TABLE 7B.—MEDICARE PROSPECTIVE PAYMENT SYSTEM SELECTED PERCENTILE LENGTHS OF STAY—Continued

[FY95 MEDPAR Update 12/95 Grouper V14.0]

DRG Number

discharges

Arithmetic

mean LOS

10th

percentile

25th

percentile

50th

percentile

75th

percentile

90th

percentile

447 ................................ 3816 2.7953 1 1 2 3 5

448 ................................ 84 1.0000 1 1 1 1 1

449 ................................ 28775 4.4101 1 2 3 5 9

450 ................................ 6807 2.3364 1 1 2 3 5

451 ................................ 7 6.1429 2 3 4 5 7

452 ................................ 19382 5.4066 1 2 4 6 11

453 ................................ 3636 3.1876 1 1 2 4 6

454 ................................ 5132 5.1046 1 2 3 6 10

455 ................................ 1092 2.8333 1 1 2 3 5

456 ................................ 194 8.3711 1 1 4 9 21

457 ................................ 127 4.7953 1 1 2 5 10

458 ................................ 1550 16.9387 4 7 13 22 35

459 ................................ 533 10.3471 2 4 7 13 22

460 ................................ 2303 6.6309 1 3 5 8 13

461 ................................ 3040 4.8862 1 1 2 5 12

462 ................................ 9360 13.7955 5 6 12 18 26

463 ................................ 11987 5.1410 1 2 4 6 10

464 ................................ 3079 3.7347 1 2 3 5 7

465 ................................ 197 3.9086 1 1 2 4 7

466 ................................ 1838 4.6366 1 1 2 4 10

467 ................................ 1722 4.1057 1 1 2 4 8

468 ................................ 56350 15.2546 3 7 12 19 30

471 ................................ 9111 8.0289 4 5 6 9 13

472 ................................ 150 30.6667 2 9 28 41 62

473 ................................ 8211 14.3041 2 4 8 21 35

475 ................................ 89514 12.1394 2 5 10 16 24

476 ................................ 6875 13.7876 3 7 11 17 25

477 ................................ 30427 9.1915 1 3 7 12 19

478 ................................ 117755 8.2916 1 3 6 10 17

479 ................................ 17758 4.5591 1 2 4 6 9

480 ................................ 359 29.7159 10 13 22 37 61

481 ................................ 177 32.0678 19 22 28 35 52

482 ................................ 6754 14.9011 5 8 11 17 28

483 ................................ 36200 45.7958 15 23 37 56 84

484 ................................ 327 15.3364 2 6 11 21 32

485 ................................ 3165 11.5893 4 6 9 13 21

486 ................................ 2045 13.3482 1 6 11 18 28

487 ................................ 3765 8.8770 1 3 7 11 17

488 ................................ 1593 17.5267 5 8 13 22 35

489 ................................ 17612 10.3989 2 4 7 13 22

490 ................................ 4999 6.5719 1 2 4 8 14

491 ................................ 9441 4.2777 2 3 3 5 7

492 ................................ 2029 17.3834 3 5 10 28 37

493 ................................ 52260 5.8809 1 2 5 8 11

494 ................................ 27127 2.4245 1 1 2 3 5

495 ................................ 107 23.7944 10 13 18 29 41

10571233

TABLE 8A.—STATEWIDE AVERAGE OPERATING COST-TO-CHARGE RATIOS

FOR URBAN AND RURAL HOSPITALS

(CASE WEIGHTED) APRIL 1996

State Urban Rural

ALABAMA ......................... 0.421 0.476

ALASKA ............................ 0.505 0.795

ARIZONA .......................... 0.426 0.567

ARKANSAS ....................... 0.539 0.501

CALIFORNIA ..................... 0.408 0.544

COLORADO ...................... 0.509 0.595

CONNECTICUT ................ 0.553 0.551

DELAWARE ...................... 0.533 0.523

DISTRICT OF COLUMBIA 0.525 ............

FLORIDA ........................... 0.414 0.414

GEORGIA ......................... 0.527 0.532

HAWAII ............................. 0.484 0.567

TABLE 8A.—STATEWIDE AVERAGE OPERATING COST-TO-CHARGE RATIOS

FOR URBAN AND RURAL HOSPITALS

(CASE WEIGHTED) APRIL 1996—

Continued

State Urban Rural

IDAHO ............................... 0.563 0.639

ILLINOIS ........................... 0.490 0.588

INDIANA ............................ 0.565 0.628

IOWA ................................. 0.546 0.685

KANSAS ............................ 0.457 0.651

KENTUCKY ....................... 0.507 0.562

LOUISIANA ....................... 0.478 0.538

MAINE ............................... 0.589 0.590

MARYLAND ...................... 0.765 0.816

MASSACHUSETTS .......... 0.579 0.600

MICHIGAN ........................ 0.514 0.619

TABLE 8A.—STATEWIDE AVERAGE OPERATING COST-TO-CHARGE RATIOS

FOR URBAN AND RURAL HOSPITALS

(CASE WEIGHTED) APRIL 1996—

Continued

State Urban Rural

MINNESOTA ..................... 0.565 0.655

MISSISSIPPI ..................... 0.524 0.527

MISSOURI ........................ 0.460 0.532

MONTANA ........................ 0.513 0.622

NEBRASKA ....................... 0.526 0.696

NEVADA ........................... 0.322 0.550

NEW HAMPSHIRE ........... 0.597 0.615

NEW JERSEY ................... 0.479 ............

NEW MEXICO .................. 0.484 0.546

NEW YORK ...................... 0.595 0.684

NORTH CAROLINA .......... 0.546 0.501
27566 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE 8A.—STATEWIDE AVERAGE OPERATING COST-TO-CHARGE RATIOS

FOR URBAN AND RURAL HOSPITALS

(CASE WEIGHTED) APRIL 1996—

Continued

State Urban Rural

NORTH DAKOTA ............. 0.651 0.693

OHIO ................................. 0.567 0.606

OKLAHOMA ...................... 0.494 0.572

OREGON .......................... 0.573 0.649

PENNSYLVANIA ............... 0.437 0.585

PUERTO RICO ................. 0.495 0.642

RHODE ISLAND ............... 0.587 ............

SOUTH CAROLINA .......... 0.476 0.497

SOUTH DAKOTA .............. 0.571 0.629

TENNESSEE .................... 0.534 0.577

TEXAS .............................. 0.463 0.565

UTAH ................................ 0.578 0.665

VERMONT ........................ 0.638 0.596

VIRGINIA .......................... 0.499 0.538

WASHINGTON ................. 0.636 0.686

WEST VIRGINIA ............... 0.579 0.541

WISCONSIN ..................... 0.607 0.686

WYOMING ........................ 0.495 0.735

TABLE 8B.—STATEWIDE AVERAGE

CAPITAL COST-TO-CHARGE RATIOS

(CASE WEIGHTED) APRIL 1996

State Ratio

ALABAMA ......................................... 0.055

ALASKA ............................................ 0.077

ARIZONA .......................................... 0.051

ARKANSAS ...................................... 0.055

CALIFORNIA .................................... 0.040

COLORADO ..................................... 0.053

CONNECTICUT ................................ 0.037

DELAWARE ...................................... 0.054

DISTRICT OF COLUMBIA ............... 0.042

FLORIDA .......................................... 0.051

GEORGIA ......................................... 0.052

HAWAII ............................................. 0.051

IDAHO ............................................... 0.067

ILLINOIS ........................................... 0.045

INDIANA ........................................... 0.059

IOWA ................................................ 0.062

KANSAS ........................................... 0.055

KENTUCKY ...................................... 0.056

LOUISIANA ....................................... 0.069

MAINE ............................................... 0.045

MARYLAND ...................................... 0.013

MASSACHUSETTS .......................... 0.060

MICHIGAN ........................................ 0.053

MINNESOTA ..................................... 0.055

MISSISSIPPI ..................................... 0.056

MISSOURI ........................................ 0.053

MONTANA ........................................ 0.064

NEBRASKA ...................................... 0.058

NEVADA ........................................... 0.034

NEW HAMPSHIRE ........................... 0.065

NEW JERSEY .................................. 0.045

NEW MEXICO .................................. 0.055

NEW YORK ...................................... 0.059

NORTH CAROLINA .......................... 0.050

NORTH DAKOTA ............................. 0.074

OHIO ................................................. 0.056

OKLAHOMA ...................................... 0.058

OREGON .......................................... 0.051

PENNSYLVANIA .............................. 0.045

PUERTO RICO ................................. 0.078

RHODE ISLAND ............................... 0.039

TABLE 8B.—STATEWIDE AVERAGE

CAPITAL COST-TO-CHARGE RATIOS

(CASE WEIGHTED) APRIL 1996—

Continued

State Ratio

SOUTH CAROLINA .......................... 0.053

SOUTH DAKOTA ............................. 0.064

TENNESSEE .................................... 0.057

TEXAS .............................................. 0.055

UTAH ................................................ 0.055

VERMONT ........................................ 0.050

VIRGINIA .......................................... 0.058

WASHINGTON ................................. 0.063

WEST VIRGINIA ............................... 0.060

WISCONSIN ..................................... 0.048

WYOMING ........................................ 0.067

Appendix A—Regulatory Impact

Analysis

I. Introduction

We generally prepare a regulatory

flexibility analysis that is consistent

with the Regulatory Flexibility Act

(RFA)(5 U.S.C. 601 through 612), unless

the Secretary certifies that a proposed

rule would not have a significant

economic impact on a substantial

number of small entities. For purposes

of the RFA, we consider all hospitals to

be small entities.

Also, section 1102(b) of the Social

Security Act (the Act) requires the

Secretary to prepare a regulatory impact

analysis for any proposed rule that may

have a significant impact on the

operations of a substantial number of

small rural hospitals. Such an analysis

must conform to the provisions of

section 603 of the RFA. With the

exception of hospitals located in certain

New England counties, for purposes of

section 1102(b) of the Act, we define a

small rural hospital as a hospital with

fewer than 100 beds that is located

outside of a Metropolitan Statistical

Area (MSA) or New England County

Metropolitan Area (NECMA). Section

601(g) of the Social Security

Amendments of 1983 (Public Law 98-

21) designated hospitals in certain New

England counties as belonging to the

adjacent NECMA. Thus, for purposes of

the prospective payment system, we

classify these hospitals as urban

hospitals.

It is clear that the changes being

proposed in this document would affect

both a substantial number of small rural

hospitals as well as other classes of

hospitals, and the effects on some may

be significant. Therefore, the discussion

below, in combination with the rest of

this proposed rule, constitutes a

combined regulatory impact analysis

and regulatory flexibility analysis.

II. Objectives

The primary objective of the

prospective payment system is to create

incentives for hospitals to operate

efficiently and minimize unnecessary

costs while at the same time ensuring

that payments are sufficient to

adequately compensate hospitals for

their legitimate costs. In addition, we

share national goals of deficit reduction

and restraints on government spending

in general.

We believe the proposed changes

would further each of these goals while

maintaining the financial viability of the

hospital industry and ensuring access to

high quality health care for Medicare

beneficiaries. We expect that these

proposed changes would ensure that the

outcomes of this payment system are, in

general, reasonable and equitable while

avoiding or minimizing unintended

adverse consequences.

III. Limitations of Our Analysis

As has been the case in previously

published regulatory impact analyses,

the following quantitative analysis

presents the projected effects of our

proposed policy changes, as well as

statutory changes effective for FY 1997,

on various hospital groups. We estimate

the effects of individual policy changes

by estimating payments per case while

holding all other payment policies

constant. We use the best data available,

but we do not attempt to predict

behavioral responses to our policy

changes, and we do not make

adjustments for future changes in such

variables as admissions, lengths of stay,

or case mix. As we have done in

previous proposed rules, we are

soliciting comments and information

about the anticipated effects of these

changes on hospitals, and our

methodology for estimating them.

IV. Hospitals Included In and Excluded

From the Prospective Payment System

The prospective payment systems for

hospital inpatient operating and capitalrelated costs encompass nearly all

general, short-term, acute care hospitals

that participate in the Medicare

program. There were 46 Indian Health

Service hospitals in our data base,

which we excluded from the analysis

due to the special characteristics of the

prospective payment method for these

hospitals. Among other short-term,

acute care hospitals, only the 50 such

hospitals in Maryland remain excluded

from the prospective payment system

under the waiver at section 1814(b)(3) of

the Act. Thus, as of April 1996, we have

included 5,130 hospitals in our analysis.

This represents about 82 percent of all
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27567

Medicare-participating hospitals. The

majority of this impact analysis focuses

on this set of hospitals.

The remaining 18 percent are

specialty hospitals that are excluded

from the prospective payment system

and continue to be paid on the basis of

their reasonable costs (subject to a rateof-increase ceiling on their inpatient

operating costs per discharge). These

hospitals include psychiatric,

rehabilitation, long-term care,

children’s, and cancer hospitals. The

impacts of our proposed policy changes

on these hospitals are discussed below.

V. Impact on Excluded Hospitals and

Units

As of April 1996, there were 1,141

specialty hospitals excluded from the

prospective payment system and instead

paid on a reasonable cost basis subject

to the rate-of-increase ceiling under

§ 413.40. In addition, there were 2,258

psychiatric and rehabilitation units in

hospitals otherwise subject to the

prospective payment system. These

excluded units are also paid in

accordance with § 413.40.

In accordance with section

1886(b)(3)(B)(ii)(V) of the Act, the

update factor applicable to the rate-ofincrease limit for excluded hospitals

and units for FY 1997 would be 1.7

percent (excluded hospital market

basket minus 1.0 percentage points),

adjusted to account for the relationship

between the hospital’s allowable

operating cost per case and its target

amounts.

The impact on excluded hospitals and

units of the proposed update in the rateof-increase limit depends on the

cumulative cost increases experienced

by each excluded hospital and excluded

unit since its applicable base period. For

excluded hospitals and units that have

maintained their cost increases at a level

below the percentage increases in the

rate-of-increase limits since their base

period, the major effect will be on the

level of incentive payments these

hospitals and units receive. Conversely,

for excluded hospitals and units with

per-case cost increases above the

cumulative update in their rate-ofincrease limit, the major effect will be

the amount of excess costs that the

hospitals would have to absorb.

In this context, we note that, under

§ 413.40(d)(3), an excluded hospital or

unit whose costs exceed the rate-ofincrease limit is allowed to receive the

lower of its rate-of-increase ceiling plus

50 percent of reasonable costs in excess

of the ceiling, or 110 percent of its

ceiling. In addition, under the various

provisions set forth in § 413.40,

excluded hospitals and units can obtain

payment adjustments for significant,

justifiable, increases in operating costs

that exceed the limit. At the same time,

however, by generally limiting payment

increases, we continue to provide an

incentive for excluded hospitals and

units to restrain the growth in their

spending for patient services.

VI. Quantitative Impact Analysis of the

Proposed Policy Changes Under the

Prospective Payment System for

Operating Costs

A. Basis and Methodology of Estimates

In this proposed rule, we are

announcing policy changes and

payment rate updates for the

prospective payment systems for

operating and capital-related costs. We

have prepared separate analyses of the

proposed changes to each system,

beginning with changes to the operating

prospective payment system.

The data used in developing the

quantitative analyses presented below

are taken from the FY 1995 MedPAR file

and the most current provider-specific

file that is used for payment purposes.

Although the analyses of the changes to

the operating prospective payment

system do not incorporate cost data, the

most recently available hospital cost

report data were used to create some of

the variables by which hospitals are

categorized. Our analysis has several

qualifications. First, we do not make

adjustments for behavioral changes that

hospitals may adopt in response to these

proposed policy changes. Second, due

to the interdependent nature of the

prospective payment system, it is very

difficult to precisely quantify the impact

associated with each proposed change.

Third, we draw upon various sources

for the data used to categorize hospitals

in the tables. In some cases, particularly

the number of beds, there is a fair degree

of variation in the data from different

sources. We have attempted to construct

these variables with the best available

source overall. For individual hospitals,

however, some miscategorizations are

possible.

Using cases in the FY 1995 MedPAR

file, we simulated payments under the

operating prospective payment system

given various combinations of payment

parameters. Any short-term, acute care

hospitals not paid under the general

prospective payment systems (Indian

Health Service hospitals and hospitals

in Maryland) are excluded from the

simulations. Payments under the capital

prospective payment system, or

payments for costs other than inpatient

operating costs, are not analyzed here.

Estimated payment impacts of proposed

FY 1997 changes to the capital

prospective payment system are

discussed below in section VII of this

Appendix.

The proposed changes discussed

separately below are the following:

• The effects of the annual

reclassification of diagnoses and

procedures and the recalibration of the

diagnosis-related group (DRG) relative

weights required by section

1886(d)(4)(C) of the Act.

• The effects of changes in hospitals’

wage index values reflecting the wage

index update (FY 1993 data).

• The effects of geographic

reclassifications by the Medicare

Geographic Classification Review Board

(MGCRB) that will be effective in FY

1997.

• The effects of phasing out payments

for extraordinarily lengthy cases (day

outlier cases) with a corresponding

increase in payments for extraordinarily

costly cases (cost outliers), in

accordance with section

1886(d)(5)(A)(v) of the Act.

• The total change in payments based

on FY 1997 policies relative to

payments based on FY 1996 policies.

To illustrate the impacts of the FY

1997 proposed changes, our analysis

begins with an FY 1997 baseline

simulation model using: the FY 1996

GROUPER (version 13.0); the FY 1996

wage indexes; no MGCRB

reclassifications; and current outlier

policy (50 percent phase out of day

outlier payments). Outlier payments are

assumed to be 5.1 percent of total DRG

payments.

Each policy change is then added

incrementally to this baseline model,

finally arriving at an FY 1997 model

incorporating all of the proposed

changes. This allows us to isolate the

effects of each proposed change.

Our final comparison illustrates the

percent change in payments per case

from FY 1996 to FY 1997. Four factors

not displayed in the previous five

columns have significant impacts here.

First is the update to the standardized

amounts. In accordance with section

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

proposing to update the large urban and

the other areas average standardized

amounts for FY 1997 using the most

recently forecasted hospital market

basket increase for FY 1997 of 2.7

percent, minus 0.5 percentage points.

Thus, the update to the large urban and

other areas standardized amounts is 2.2

percent. Similarly, section

1886(b)(3)(C)(ii) of the Act provides that

the update factor applicable to the

hospital-specific rates for sole

community hospitals (SCHs) and

essential access community hospitals

(EACHs) (which are treated as SCHs for
27568 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

payment purposes) is also the market

basket increase minus 0.5 percent, or 2.2

percent.

A second significant factor impacting

changes in hospitals’ payments per case

from FY 1996 to FY 1997 is a change in

MGCRB reclassification status from one

year to the next. That is, hospitals

reclassified in FY 1996 that are no

longer reclassified in FY 1997 may have

a negative payment impact going from

FY 1996 to FY 1997; conversely,

hospitals not reclassified in FY 1996

that are reclassified in FY 1997 may

have a positive impact. In some cases

these impacts can be quite substantial,

so if a relatively small number of

hospitals in a particular category lose

their reclassification status, the

percentage increase in payments for the

category may be below the national

mean.

A third significant factor is that we

currently estimate that actual outlier

payments during FY 1996 will be 4.2

percent of actual total DRG payments.

When the FY 1996 final rule was

published, we projected FY 1996 outlier

payments would be 5.1 percent of total

DRG payments, and the standardized

amounts were reduced correspondingly.

The effects of the lower than expected

outlier payments during FY 1996 (as

discussed in the Addendum to this

proposed rule) are reflected in the

analyses below comparing our current

estimates of FY 1996 payments per case

to estimated FY 1997 payments per

case.

Finally, the regional floor provision

(section 1886(d)(1)(A)(iii)(II) of the Act)

expires effective with discharges

occurring on or after October 1, 1996.

Under this provision (applicable during

FY 1996), hospitals within any census

division having a regional standardized

amount greater than the national

standardized amount (large urban or

other, depending on which amount was

applicable) received a blend of 85

percent of the national amount and 15

percent of the regional amount.

Hospitals in census divisions where the

regional floor was applicable during FY

1996 will be negatively impacted by its

expiration when comparing FY 1996 to

FY 1997.

Table I demonstrates the results of our

analysis. The table categorizes hospitals

by various geographic and special

payment consideration groups to

illustrate the varying impacts on

different types of hospitals. The top row

of the table shows the overall impact on

the 5,130 hospitals included in the

analysis. This is 77 fewer hospitals than

were included in the impact analysis in

the FY 1996 final rule (60 FR 45924).

Data for 107 hospitals that were

included in last year’s analysis were not

available for analysis this year; however,

data were available this year for 30

hospitals for which data were not

available last year.

The next four rows of Table I contain

hospitals categorized according to their

geographic location (all urban, which is

further divided into large urban and

other urban, or rural). There are 2,878

hospitals located in urban areas (MSAs

or NECMAs) included in our analysis.

Among these, there are 1,597 hospitals

located in large urban areas

(populations over 1 million), and 1,281

hospitals in other urban areas

(populations of 1 million or fewer). In

addition, there are 2,252 hospitals in

rural areas. The next two groupings are

by bed size categories, shown separately

for urban and rural hospitals. The final

groupings by geographic location are by

census divisions, also shown separately

for urban and rural hospitals.

The second part of Table I shows

hospital groups based on hospitals’ FY

1997 payment classifications, including

any reclassifications under section

1886(d)(10) of the Act. For example, the

rows labeled urban, large urban, other

urban, and rural, show the numbers of

hospitals being paid based on these

categorizations (after consideration of

geographic reclassifications), are 2,978,

1,793, 1,185, and 2,152, respectively.

The next three groupings examine the

impacts of the proposed changes on

hospitals grouped by whether or not

they have residency programs (teaching

hospitals that receive an indirect

medical education (IME) adjustment),

receive disproportionate share (DSH)

payments, or some combination of these

two adjustments. There are 4,057

nonteaching hospitals in our analysis,

841 teaching hospitals with fewer than

100 residents, and 232 teaching

hospitals with 100 or more residents.

In the DSH categories, hospitals are

grouped according to their DSH

payment status, and whether they are

considered urban or rural after MGCRB

reclassifications. Hospitals in the rural

DSH categories, therefore, represent

hospitals that were not reclassified for

purposes of the standardized amount.

(They may, however, have been

reclassified for purposes of the wage

index.) The next category groups

hospitals considered urban after

geographic reclassification, in terms of

whether they receive the IME

adjustment, the DSH adjustment, both,

or neither.

The next four rows examine the

impacts of the proposed changes on

rural hospitals by special payment

groups (SCHs, rural referral centers

(RRCs), and EACHs), as well as rural

hospitals not receiving a special

payment designation. Rural hospitals

reclassified for FY 1997 for purposes of

the standardized amount are not

included here.

The RRCs (90), SCH/EACHs (641),

and SCH/EACH and RRCs (39) shown

here were not reclassified for purposes

of the standardized amount. There are

four EACHs included in our analysis

and five EACH/RRCs.

There are two RRCs and three SCHs

that will be reclassified for the

standardized amount in FY 1997 that,

therefore, are not included in these

rows. There are significantly fewer

reclassifications among these groups

than there were in FY 1996, owing to

the new criterion under

§ 412.230(a)(5)(ii) that a hospital may

not be reclassified for purposes of the

standardized amount if the area to

which the hospital seeks reclassification

does not have a higher standardized

amount than that currently received by

the hospital. (See the September 1, 1995

final rule (60 FR 45799).) Before this

change (effective with reclassifications

for FY 1997), some rural hospitals

reclassified to other urban areas in order

to qualify for urban DSH payments. For

other rural hospitals that already

qualified for DSH payments, the urban

designation enabled them to qualify for

a higher DSH adjustment than they

would receive as a rural hospital.

The next two groupings are based on

type of ownership and the hospital’s

Medicare utilization expressed as a

percent of total patient days. These data

are taken primarily from the FY 1994

Medicare cost report files, if available

(otherwise FY 1993 data are used). Data

needed to calculate Medicare utilization

percentages were unavailable for 131

hospitals. For the most part, these are

either new hospitals or hospitals filing

manual cost reports that are not yet

entered into the data base.

The next series of groupings concern

the geographic reclassification status of

hospitals. The first three groupings

display hospitals that were reclassified

by the MGCRB for either FY 1996 or FY

1997, or for both years, by urban/rural

status. The next rows illustrate the

overall number of FY 1997

reclassifications, as well as the numbers

of reclassified hospitals grouped by

urban and rural location. The final row

in Table I contains hospitals located in

rural counties but deemed to be urban

under section 1886(d)(8)(B) of the Act.
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27569

TABLE I.—IMPACT ANALYSIS OF CHANGES FOR FY 1997 OPERATING PROSPECTIVE PAYMENT SYSTEM

[Percent changes in payments per case]

Number of

hosps.1

DRG recalibration 2New wage

data 3

MGCRB reclassification 4Day outlier

policy

changes 5

All FY 97

changes 6

(0) (1) (2) (3) (4) (5)

(By Geographic Location)

All hospitals ....................................................................... 5,130 0.1 ¥0.1 0.0 0.0 3.1

Urban hospitals ................................................................. 2,878 0.1 0.0 ¥0.4 ¥0.1 3.2

Large urban ............................................................... 1,597 0.1 0.0 ¥0.5 ¥0.2 3.1

Other urban ................................................................ 1,281 0.1 ¥0.1 ¥0.2 0.1 3.3

Rural hospitals .................................................................. 2,252 0.0 ¥0.1 2.3 0.1 2.7

Bed size (urban):

0–99 beds .................................................................. 716 0.0 ¥0.3 ¥0.5 0.2 3.0

100–199 beds ............................................................ 938 0.0 ¥0.2 ¥0.4 0.1 2.9

200–299 beds ............................................................ 577 0.1 ¥0.1 ¥0.4 0.0 3.1

300–499 beds ............................................................ 479 0.1 0.0 ¥0.4 ¥0.1 3.4

500 or more beds ...................................................... 168 0.1 0.1 ¥0.2 ¥0.4 3.4

Bed size (rural):

0–49 beds .................................................................. 1,173 ¥0.1 0.0 0.0 0.1 2.8

50–99 beds ......................................................... 663 ¥0.1 ¥0.1 1.1 0.2 2.8

100–149 beds ..................................................... 241 0.0 ¥0.1 3.1 0.2 2.9

150–199 beds ..................................................... 99 0.0 ¥0.1 2.8 0.1 2.8

200 or more beds ............................................... 76 0.1 ¥0.2 4.9 0.1 2.2

Urban by census division:

New England ............................................................. 160 0.1 0.0 ¥0.1 ¥0.1 2.4

Middle Atlantic ........................................................... 434 0.1 0.6 ¥0.3 ¥1.1 3.5

South Atlantic ............................................................. 419 0.1 ¥0.2 ¥0.5 0.1 3.3

East North Central ..................................................... 483 0.1 0.3 ¥0.2 0.2 2.9

East South Central .................................................... 163 0.1 ¥0.3 ¥0.5 0.2 3.4

West North Central .................................................... 193 0.1 ¥0.4 ¥0.5 0.3 3.4

West South Central ................................................... 375 0.1 ¥0.4 ¥0.5 0.4 3.6

Mountain .................................................................... 125 0.2 ¥0.4 ¥0.4 0.3 3.3

Pacific ........................................................................ 478 0.1 ¥0.5 ¥0.4 0.2 2.9

Puerto Rico ................................................................ 48 ¥0.1 ¥0.7 ¥0.5 0.0 2.6

Rural by census division:

New England ............................................................. 53 0.1 ¥1.0 2.0 0.3 2.1

Middle Atlantic ........................................................... 85 0.1 ¥0.5 0.8 ¥0.2 1.9

South Atlantic ............................................................. 297 0.0 ¥0.5 3.1 0.1 2.6

East North Central ..................................................... 304 0.1 0.2 2.1 0.2 2.9

East South Central .................................................... 278 ¥0.1 0.2 2.5 0.2 2.2

West North Central .................................................... 525 0.0 ¥0.1 2.1 0.2 2.8

West South Central ................................................... 351 ¥0.1 0.2 3.1 0.2 3.2

Mountain .................................................................... 213 0.1 ¥0.2 0.8 0.1 3.0

Pacific ........................................................................ 141 0.1 0.5 2.4 0.2 4.0

Puerto Rico ................................................................ 5 ¥0.2 ¥2.1 2.7 ¥0.1 3.8

(by payment categories)

Urban hospitals ................................................................. 2,978 0.1 0.0 ¥0.3 ¥0.1 3.2

Large urban ............................................................... 1,793 0.1 0.0 ¥0.2 ¥0.2 3.2

Other urban ................................................................ 1,185 0.1 ¥0.1 ¥0.4 0.1 3.3

Rural hospitals .................................................................. 2,152 0.0 ¥0.1 1.9 0.1 2.6

Teaching status:

Non-teaching .............................................................. 4,057 0.0 ¥0.2 0.3 0.2 3.1

Less than 100 res. ..................................................... 841 0.1 0.0 ¥0.4 0.0 3.2

100+ residents ........................................................... 232 0.1 0.2 ¥0.1 ¥0.5 3.2

Disproportionate Share Hospitals (DSH)

Non-DSH .................................................................... 3,200 0.1 ¥0.2 0.2 0.1 3.2

Urban DSH:

100 beds or more ............................................... 1,410 0.0 0.0 ¥0.3 ¥0.2 3.2

Fewer than 100 beds ......................................... 111 ¥0.3 ¥0.4 ¥0.5 0.3 2.5

Rural DSH:

Sole community (SCH) ....................................... 146 ¥0.1 ¥0.1 0.2 0.0 3.3

Referral centers (RRC) ....................................... 25 0.0 ¥0.1 3.9 ¥0.1 3.7

Over 65 ...................................................................... 1,353 0.0 ¥0.1 0.1 0.1 3.1

Unknown .................................................................... 131 ¥0.1 0.9 ¥0.4 ¥1.4 3.1

Hospitals Reclassified by the Medicare Geographic Review Board

Reclassification status during FY96 and FY97

Reclassified during both FY96 and FY97 ................. 381 0.1 0.1 5.9 0.0 3.1
27570 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE I.—IMPACT ANALYSIS OF CHANGES FOR FY 1997 OPERATING PROSPECTIVE PAYMENT SYSTEM—Continued

[Percent changes in payments per case]

Number of

hosps.1

DRG recalibration 2New wage

data 3

MGCRB reclassification 4Day outlier

policy

changes 5

All FY 97

changes 6

(0) (1) (2) (3) (4) (5)

Urban .................................................................. 133 0.1 0.3 3.6 ¥0.2 3.4

Rural ................................................................... 248 0.0 ¥0.2 9.1 0.1 2.8

Reclassified during FY97 only ................................... 103 0.1 0.3 3.5 ¥0.4 8.6

Urban .................................................................. 34 0.2 0.4 2.4 ¥0.5 8.0

Rural ................................................................... 69 0.0 ¥0.2 7.1 0.1 10.5

Reclassified during FY96 only 251 0.1 ¥0.6 ¥1.3 0.1 ¥0.5

Urban .................................................................. 88 0.1 ¥0.9 ¥2.0 0.0 0.8

Rural ................................................................... 163 0.0 ¥0.2 ¥0.4 0.2 ¥2.1

FY 97 Reclassifications:

All reclassified hosp. .................................................. 484 0.1 0.1 5.3 ¥0.1 4.3

Stand. amount only ............................................ 120 0.1 0.0 1.7 0.1 3.1

Wage index only ................................................. 274 0.1 ¥0.3 8.1 ¥0.1 3.9

Both .................................................................... 90 0.1 0.8 4.4 ¥0.2 5.9

Nonreclassified ................................................... 4,619 0.1 ¥0.1 ¥0.6 0.0 3.0

All urban reclass. ....................................................... 167 0.1 0.3 3.3 ¥0.3 4.6

Stand. amount only ............................................ 63 0.1 0.1 0.9 0.0 3.3

Wage index only ................................................. 30 0.2 ¥0.6 6.7 ¥0.6 4.5

Both .................................................................... 74 0.1 0.9 3.1 ¥0.2 5.6

Nonreclassified ................................................... 2,711 0.1 ¥0.1 ¥0.6 ¥0.1 3.1

All rural reclass. ......................................................... 317 0.0 ¥0.2 8.8 0.1 3.8

Stand. amount only ............................................ 57 0.0 ¥0.3 4.6 0.3 2.7

Wage index only ................................................. 244 0.0 ¥0.1 8.8 0.1 3.6

Both .................................................................... 16 0.1 ¥0.4 18.8 0.2 9.1

Nonreclassified ................................................... 1,908 0.0 ¥0.1 ¥0.4 0.1 2.2

Other reclassifed:

Hospitals (section 1886(d)(8)(B)) .............................. 27 0.1 ¥0.1 0.8 0.2 3.1

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 1995, and hospital cost report data are from reporting periods beginning in FY 1993 and FY 1994. 2This column displays the payment impacts of the recalibration of the DRG weights, based on FY 1995 MedPAR data and the DRG classification changes, in accordance with section 1886(d)(4)(C) of the Act. 3This column shows the payment effects of updating the data used to calculate the wage index with data from the FY 1993 cost reports. The

percentage changes displayed here reflect the impacts of the wage and recalibration budget neutrality factor (0.998509). 4Shown here are the combined effects of geographic reclassification by the Medicare Geographic Classification Review Board (MGCRB). The

effects shown here demonstrate the FY 1997 payment impacts of going from no reclassifications to the reclassifications scheduled to be in effect

for FY 1997. Reclassification for prior years has no bearing on the payment impacts shown here. 5This column illustrates the payment impacts of changes in outlier payments, in accordance with section 1886(d)(5) of the Act.

6This column shows changes in payments from FY 1996 to FY 1997. It incorporates all of the changes displayed in columns 1 through 5. It

also displays the impacts of the updates to the FY 1997 standardized amounts, changes in hospitals’ reclassification status in FY 1997 compared to FY 1996, the expiration of the regional floor provision at section 1886(d)(1)(A)(iii)(II) of the Act, and the difference in outlier payments

from FY 1996 to FY 1997. The sum of the first five columns plus these effects may be different from the percentage changes shown here due to

changes in hospitals’ geographic reclassification status from FY 1996 to FY 1997, rounding errors and interactive effects.

B. The Impact of the Proposed Changes

to the DRG Classifications and Relative

Weights (Column 1)

In column 1 of Table I, we present the

combined effects of the DRG

reclassifications and recalibration, as

discussed in section II of the preamble

to this proposed rule. Section

1886(d)(4)(C)(i) of the Act requires us

each year to make appropriate

classification changes and to recalibrate

the DRG weights in order to reflect

changes in treatment patterns,

technology, and any other factors that

may change the relative use of hospital

resources.

The impact of reclassifications and

recalibration on aggregate payments is

required by section 1886(d)(4)(C)(iii) of

the Act to be budget neutral. In

addition, section 1886(d)(3)(E) specifies

that any updates or adjustments to the

wage index are budget neutral. As

pointed out in the Addendum to this

proposed rule, we compared aggregate

payments using the FY 1996 DRG

relative weights and the wage index

effective October 1, 1995 to aggregate

payments using the proposed FY 1997

DRG relative weights and wage index.

Based on this comparison, we computed

a wage and recalibration budget

neutrality factor of 0.998509. In Table I,

the combined overall impacts of the

effects of both the DRG reclassifications

and recalibration and the updated wage

index (the All Hospitals row of columns

1 and 2) demonstrate that the net effect

of these changes are budget neutral.

That is, the 0.1 percent increase for all

hospitals due to the DRG changes is

negated by the 0.1 percent decrease for

all hospitals with the new wage data.

Consistent with the minor changes we

are proposing for the FY 1997

GROUPER, the redistributional impacts

across hospital groups are very small (an

increase of 0.1 for large and other urban

hospitals). Among other hospital

categories, the net effects are slightly

negative changes for small (up to 99

beds) rural hospitals and slightly

positive changes for larger (over 200

beds) rural and urban hospitals.

The largest single effect on any of the

hospital categories examined is a 0.3

percent decrease in payments for

smaller (100 or fewer beds) urban and

rural hospitals that receive DSH

payments. We note that the only other

hospital category to experience a
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27571

decrease of more than 0.1 percent is

rural hospitals in Puerto Rico.

We attribute these negative changes to

the increasing gap between the relative

weights for medical, diagnostic, and less

complicated surgical DRGs and the

weights for the more complicated

surgical DRGs. Since the cases

associated with the former DRGs tend to

be treated more often in smaller

hospitals with fewer resources available,

lowering the relative weights associated

with those cases would

disproportionately affect these

hospitals. In general, small hospitals

that serve a disproportionate share of

low-income patients and hospitals in

rural Puerto Rico fit this definition. We

note, however, that these negative

impacts are relatively minor and do not

result solely from the limited DRG

revisions we are proposing for FY 1997.

C. The Impact of Updating the Wage

Data (Column 2)

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

requires that, beginning October 1, 1993,

we annually update the wage data used

to calculate the wage index. In

accordance with this requirement, the

proposed wage index for FY 1997 is

based on data submitted for hospital

cost reporting periods beginning on or

after October 1, 1992 and before October

1, 1993. As with the previous column,

the impact of the new data on hospital

payments is isolated by holding the

other payment parameters constant in

the two simulations. That is, column 2

shows the percentage changes in

payments when going from a model

using the FY 1996 wage index before

geographic reclassifications based on FY

1992 wage data to a model using the FY

1997 prereclassification wage index

based on FY 1993 wage data.

As noted above, to comply with the

requirements that the DRG and wage

index changes be implemented in a

budget neutral manner, we compute a

budget neutrality adjustment factor to

apply to the standardized amounts. The

0.1 percent decrease for all hospitals in

this column reflects the wage and

recalibration budget neutrality factor of

0.998509. This decrease, combined with

the 0.1 percent increase for all hospitals

in column 1, demonstrates that the net

effect on aggregate payments of the

proposed DRG and wage index changes

are budget neutral.

The results indicate that the new

wage data do not have a significant

overall impact on hospital payments. (It

should be noted that the percentage

changes attributed here to the new wage

data are generally reduced by 0.2

percentage points due to the budget

neutrality factor.) Thus, hospitals with

significant changes in their wage

indexes are not concentrated within any

particular hospital group. Some of the

largest changes are found among both

urban and rural hospitals grouped by

census division. In almost all cases,

payments change by less than 1 percent.

Our review of the wage data (as

described below) indicates that these

changes were attributable to improved

reporting, as well as relative changes in

labor costs.

In the 50 States and the District of

Columbia, among the urban hospitals,

the largest increase (0.6 percent) is in

the Middle Atlantic census division.

Significantly, New York City’s wage

index rises by over 1.6 percent (this also

contributes to the 0.2 percent increase

among major teaching hospitals and the

0.9 percent increase in the Unknown

category under the Medicare Utilization

rows). Last year, the Middle Atlantic

experienced one of the largest decreases

(0.6 percent), which contributed to the

0.4 percent decline among major

teaching hospitals—New York City’s

wage index fell by nearly 2.0 percent in

FY 1996 (60 FR 45929). The largest

decrease among urban hospitals occurs

in the Pacific census division, with a

decline of 0.5 percent.

Among the rural hospitals, the largest

increase (0.5 percent) is in the Pacific

census division; the largest decrease (1.0

percent) is in the New England census

division. This decrease is primarily due

to a 2.5 percent decrease in the wage

index for rural Connecticut hospitals

and a 2.4 percent decrease in the wage

index for rural New Hampshire

hospitals. The Pacific rural hospitals

also experienced one of the greatest

increases (0.6 percent) among rural

hospitals last year.

In Puerto Rico, payments decline by

2.1 percent for the five rural hospitals

and by 0.7 percent for the urban

hospitals. The average hourly wages

reported in FY 1993 by two rural Puerto

Rico hospitals fell from those reported

in FY 1992 by 22.4 percent and 18.1

percent, leading to the 2.1 percent

overall decline. Of the six urban areas

in Puerto Rico, two experience increases

in wage index values while four

experience decreases. Among these four,

three experience a decline of more than

5 percent. These MSAs have relatively

few hospitals (two, five, and seven

hospitals). The decreases appear to be

the result of one or two hospitals in

each area with a decrease of more than

5 percent in average hourly wages.

The proposed FY 1997 wage index

represents the fourth annual update to

the wage data, and will continue to

include salaries, fringe benefits, home

office salaries, and certain contract labor

costs. In the past, updates to the wage

data have resulted in significant

payment shifts among hospitals. Since

the wage index is now updated

annually, we expect these payment

fluctuations will decrease.

This expectation is borne out by

comparing the proposed FY 1997 wage

index (after reclassifications under

sections 1886(d)(8)(B) and 1886(d)(10)

of the Act) to the FY 1996 wage index.

The following chart compares the shifts

in wage index values (after

reclassifications) for labor markets for

FY 1997 with those from FY 1996. The

majority of labor market areas (339)

experience less than a 5 percent change.

Only 25 labor market areas experience

a change between 5 and 10 percent; 13

of those experience increases. Still

fewer labor markets experience a change

of more than 10 percent; two experience

increases and two experience decreases.

For FY 1996, by comparison, 10 labor

market areas experienced an increase in

their wage index value of more than 10

percent. We reviewed the data for any

area that experienced a wage index

change of 10 percent or more to

determine the reason for the fluctuation.

Percentage change in area

wage index values

Number of

labor market

areas

FY

1997

FY

1996

Increase more than 10

percent ........................... 2 10

Increase between 5 and

10 percent, (inclusive) ... 13 21

Increase/decrease below 5

percent ........................... 339 331

Decrease between 5 and

10 percent, (inclusive) ... 12 6

Decrease more than 10

percent ........................... 2 0

Under the proposed FY 1997 wage

index, 96.2 percent of urban hospitals

and 92.7 percent of rural hospitals

would experience a change in their

wage index of less than 5 percent.

Approximately 5.9 percent (3.1 percent

of urban hospitals and 2.8 percent of

rural hospitals) would experience a

change of between 5 and 10 percent,

and 5.3 percent (0.8 percent of urban

hospitals and 4.5 percent of rural

hospitals) would experience a change of

more than 10 percent. The following

chart shows the projected impact for

urban and rural hospitals.
27572 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

Percentage change in area

wage index values

Percent of hospitals (by

Urban/Rural)

Urban Rural

Increase more than 10

percent ........................... 0.4 2.5

Increase between 5 and

10 percent (inclusive) .... 1.5 0.9

Increase or decrease less

than 5 percent ............... 96.2 2.7

Decrease between 5 and

10 percent (inclusive) .... 1.6 1.9

Decrease more than 10

percent ........................... 0.4 2.0

ANote: The sum of the columns may not

total to 100 due to rounding.

D. The Impact of MGCRB

Reclassifications (Column 3)

Our impact analysis to this point has

assumed hospitals are paid on the basis

of their actual geographic location (with

the exception of ongoing policies that

provide that certain hospitals receive

payments on bases other than where

they are geographically located, such as

RRCs and hospitals in rural counties

that are deemed urban under section

1886(d)(8)(B) of the Act). The changes in

column 3 reflect the per case payment

impact of moving from this baseline to

a simulation incorporating the MGCRB

decisions for FY 1997. As noted below,

these decisions affect hospitals’

standardized amount and wage index

area assignments. In addition, rural

hospitals reclassified for purposes of the

standardized amount also qualify to be

treated as urban for purposes of the DSH

adjustment.

By March 30 of each year, the MGCRB

makes reclassification determinations

that will be effective for the next fiscal

year, which begins on October 1. The

MGCRB may reclassify a hospital for the

purpose of using the other area’s

standardized amount, wage index value,

or both. (RRCs and SCHs are exempt

from the proximity requirement.)

Effective FY 1997, rural hospitals can no

longer be reclassified to an other urban

area for purposes of the standardized

amount under section 1886(d)(10) of the

Act.

The proposed FY 1997 wage index

values incorporate all of the MGCRB’s

reclassification decisions for FY 1997.

The wage index values also reflect any

decisions made by the HCFA

Administrator through the appeals and

review process for MGCRB decisions as

of March 29, 1996. Additional changes

that result from the Administrator’s

review of MGCRB decisions or a request

by a hospital to withdraw its application

will be reflected in the final rule for FY

1997.

The overall effect of geographic

reclassification is required to be budget

neutral by section 1886(d)(8)(D) of the

Act. Therefore, we applied an

adjustment of 0.994059 to ensure that

the effects of reclassification are budget

neutral. (See section II.A.4 of the

Addendum to this proposed rule).

As a group, rural hospitals benefit

from geographic reclassification. Their

payments rise 2.3 percent, while

payments to urban hospitals decline 0.4

percent. Large urban hospitals lose 0.5

percent because, as a group, they have

the smallest percentage of hospitals that

are reclassified (fewer than 3 percent of

large urban hospitals are reclassified).

There are enough hospitals in other

urban areas that are reclassified to limit

the decrease in payments to urban

hospitals stemming from the budget

neutrality offset to 0.2 percent. Among

urban hospital groups generally (that is,

bed size, census division, and special

payment status), payments fall between

0.2 and 0.5 percent.

A positive impact is evident among

all rural hospital groups except rural

hospitals with up to 49 beds, which

experience a 0.0 percent impact. The

smallest effect among all rural census

divisions is 0.8 percent for the Middle

Atlantic and Mountain divisions. These

divisions have relatively fewer MGCRB

reclassifications. Among urban census

divisions, New England displays the

smallest negative impact, 0.1 percent.

Among rural hospitals designated as

RRCs, 50 hospitals are reclassified for

purposes of the wage index only and

experience a 9.5 percent increase in

payments overall. This positive impact

on RRCs is also reflected in the category

of rural hospitals with 200 or more beds,

which have a 4.9 percent increase in

payments.

Rural hospitals reclassified for FY

1996 and FY 1997 experience a 9.1

percent increase in payments, the

greatest of any group in the category.

This may be due to the fact that these

hospitals have the most to gain from

reclassification and have been

reclassified for a period of years. Rural

hospitals reclassified for FY 1997 only

experience a 7.1 percent increase in

payments while rural hospitals

reclassified for FY 1996 only experience

a 0.4 decrease in payments. This is due

to the budget neutrality adjustment,

since the changes in this column reflect

FY 1997 payments relative to no

reclassifications, rather than to FY 1996

reclassifications. Urban hospitals

reclassified for FY 1996 but not FY 1997

experience a 2.0 percent decline in

payments overall. This appears to be

due to the combined impacts of the

budget neutrality adjustment and a

number of hospitals in this category that

experience a 6 percent drop in their

wage index after reclassification. Urban

hospitals reclassified for FY 1997 but

not for FY 1996 experience a 2.4 percent

increase in payments.

The FY 1997 Reclassification rows of

Table I show the changes in payments

per case for all FY 1997 reclassified and

nonreclassified hospitals in urban and

rural locations for each of the three

reclassification categories (standardized

amount only, wage index only, or both).

The table illustrates that the largest

impact for reclassified rural hospitals is

for those hospitals reclassified for both

the standardized amount and the wage

index. These hospitals receive an 18.8

percent increase in payments. The

number of hospitals in this category has

declined from 42 in FY 1996 to 16 in FY

1997. In addition, rural hospitals

reclassified for the wage index receive

an 8.8 percent payment increase. The

overall impact on reclassified hospitals

is to increase their payments per case by

an average of 5.3 percent for FY 1997.

Among the 27 rural hospitals deemed

to be urban under section 1886(d)(8)(B)

of the Act, payments increase 0.8

percent due to MGCRB reclassification.

This is because, although these

hospitals are treated as being attached to

an urban area in our baseline (their

redesignation is ongoing, rather than

annual like the MGCRB

reclassifications), they are eligible for

MGCRB reclassification. For FY 1997,

one hospital in this category reclassified

to a large urban area, resulting in a net

increase due to reclassifications of 0.8

percent.

The reclassification of hospitals

primarily affects payment to

nonreclassified hospitals through

changes in the wage index and the

geographic reclassification budget

neutrality adjustment required by

section 1886(d)(8)(D) of the Act. Among

hospitals that are not reclassified, the

overall impact of hospital

reclassifications is an average decrease

in payments per case of about 0.6

percent, which corresponds closely with

the geographic reclassification budget

neutrality factor. Rural nonreclassified

hospitals decrease slightly less,

experiencing a 0.4 percent decrease.

This occurs because the wage index

values in some rural areas increase after

reclassified hospitals are excluded from

the calculation of those index values.

The number of reclassifications for

purposes of the standardized amount, or

for both the standardized amount and

the wage index, has declined from 358

in FY 1996 to 210 in FY 1997. This is

not surprising because of the

elimination of standardized amount
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27573

reclassifications from rural to other

urban areas for individual hospitals.

Individual rural hospitals can continue

to reclassify to large urban areas for

purposes of the standardized amount.

The number of wage index only

reclassifications increased slightly from

260 in FY 1996 to 274 in FY 1997.

The foregoing analysis was based on

MGCRB and HCFA Administrator

decisions made by March 29 of this

year. As previously noted, there may be

changes to some MGCRB decisions

through the appeals, review, and

applicant withdrawal process. The

outcome of these cases will be reflected

in the analysis presented in the final

rule.

E. Outlier Changes (Column 4)

Medicare provides extra payment in

addition to the basic DRG payment

amount for extremely costly or

extraordinarily lengthy cases (cost

outliers and day outliers, respectively).

Section 1886(d)(5)(A)(v) of the Act

requires the Secretary to phase out

payment for day outliers from FY 1994

day outlier levels in 25 percent

increments beginning in FY 1995. Day

outliers in FY 1997 should account for

approximately 8 percent of total outlier

payments (25 percent of FY 1994

levels). This reduction in day outlier

payments will be offset by an increase

in cost outlier payments.

As discussed in the Addendum, for

FY 1997, we are proposing a day outlier

threshold equal to the geometric mean

length of stay for each DRG plus the

lesser of 24 days or 3.0 standard

deviations. The proposed marginal cost

factor for day outliers is 35 percent. For

FY 1997, we are proposing that a case

would receive cost outlier payments if

its costs exceed the DRG amount plus

$11,050. We are also proposing to

maintain the marginal cost factor for

cost outliers at 80 percent.

The payment impacts of these

changes are minimal. Hospital

categories negatively affected by

phasing out day outliers are consistent

with the categories negatively affected

in previous years: urban New England

(0.1 percent decline); urban and rural

Middle Atlantic census divisions (1.1

percent and 0.2 percent declines,

respectively); urban hospitals with 500

or more beds (0.4 percent decline);

teaching hospitals with 100 or more

residents (0.5 percent decline); and

hospitals for which data were

unavailable to calculate Medicare

utilization rates (1.4 percent decline).

As noted in the wage index discussion

previously, this last category contains a

number of New York City hospitals.

Because the changes to outlier policy

result in a shift in payments from cases

paid as day outliers to cases paid as cost

outliers, this indicates that these

categories have higher percentages of

day outliers. The largest positive impact

is among urban hospitals in the West

South Central census division (0.4

percent increase).

F. All Changes (Column 5)

Column 5 compares our estimate of

payments per case incorporating all of

our proposed changes for FY 1997 to

our estimate of payments per case in FY

1996. It also includes the effects of the

2.2 percent update to the standardized

amounts and the hospital-specific rates

for SCHs and EACHs, and the 0.9

percentage point difference between the

percentage of projected outlier

payments in FY 1997 (5.1 percent) and

the current estimate of the percentage of

actual outlier payments in FY 1996 (4.2

percent), as described in the

introduction to this Appendix and the

Addendum.

We also note that column 5 includes

the impacts of FY 1997 MGCRB

reclassifications compared to the

payment impacts of FY 1996

reclassifications. Therefore, when

comparing FY 1997 payments to FY

1996, the percent changes due to FY

1997 reclassifications shown in column

3 need to be offset by the effects of

reclassification on hospitals’ FY 1996

payments (column 4 of Table 1,

September 1, 1995 final rule; 60 FR

45926). That is, column 3 of Table 1

shows the impacts of going from no

MGCRB reclassifications to the FY 1997

reclassifications. When comparing FY

1996 and FY 1997 payments, hospitals

similarly reclassified during FY 1996

would not experience the full extent of

the change shown in column 3. For

example, the impact of MGCRB

reclassifications on rural hospitals’ FY

1996 payments was approximately a 2.3

percent increase, equal to the 2.3

percent increase for FY 1997. Therefore,

the net increase in FY 1997 payments

due to reclassification for rural hospitals

is 0 percent.

In addition, eliminating the regional

floor provision effective for discharges

occurring on or after October 1, 1996,

results in approximately a 0.2 percent

lower average payment in FY 1997 than

would occur otherwise. Of course, this

effect is attributable to particular census

divisions, as discussed below.

Finally, the FY 1996 standardized

amounts were adjusted by a budget

neutrality factor of 0.997575, in

accordance with section 1886(d)(5)(I) of

the Act, so that the change to the

transfer payment methodology we

implemented last year (doubling the per

diem payment for the first day of a

transfer) would not affect aggregate

payments. As we indicated in last year’s

final rule (60 FR 45854), this adjustment

was applied on a one-time basis to the

FY 1996 standardized amounts. After

FY 1996, there will be no need for a

further budget neutrality adjustment

unless or until we make further changes

to the transfer payment methodology.

As a result, the FY 1997 standardized

amounts are relatively higher (0.2

percent).

A single geographic reclassification

budget neutrality factor of 0.994059 was

applied to the proposed FY 1997

standardized amounts, compared to the

FY 1996 factor of 0.994011. The budget

neutrality adjustment factor for the

updated wage index and the DRG

recalibration is 0.998509, compared to

the FY 1996 factor of 0.999306.

Although the net effect of these changes

is small, they are reflected in the

payment differences shown in this

column.

There may also be interactive effects

among the various factors comprising

the payment system that we are not able

to isolate. For these reasons, the values

in column 5 may not equal the sum of

the previous columns plus the other

impacts that we are able to identify.

The overall payment increase from FY

1997 to FY 1996 for all hospitals is a 3.1

percent increase. This reflects the 0.0

percent net change in total payments

due to the proposed changes for FY

1997 shown in columns 1 through 4, the

2.2 percent update for FY 1997, and the

0.9 percent higher outlier payments in

FY 1997 compared to FY 1996, as

discussed above.

Hospitals in urban areas experience a

3.2 percent rise in payments per case

over FY 1996. Similar to all hospitals

nationally, this is primarily due to the

factors discussed above: the 2.2 percent

update; a 0.9 percent higher level of

outlier payments estimated for FY 1997;

and the offsetting effects of eliminating

the regional floor and the FY 1996

transfer budget neutrality factor. Urban

hospitals benefit 0.1 percent from DRG

recalibration, while losing 0.1 percent

due to the phase out of the day outlier

policy. Their 0.4 negative impact in FY

1997 due to reclassification is offset by

a similar impact from FY 1996

reclassifications.

Hospitals in large and other urban

areas experience 3.1 percent and 3.3

percent increases, respectively. The

lower increase for hospitals in large

urban areas appears to be attributable

primarily to the 0.2 percent negative

impact of the continuing phase out of

day outliers.
27574 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

Hospitals in rural areas experience a

2.7 percent increase. Their FY 1997

payments are estimated to be 0.6

percent higher than for FY 1996 due to

higher outlier payments. Like urban

hospitals, the impact of geographic

reclassification in FY 1997 is offset by

an identical 2.3 percent increase in FY

1996.

Among urban bed size groups,

column 5 shows changes in payments

are higher for the largest urban hospitals

compared to smaller urban hospitals.

The relatively smaller increases for the

smaller urban hospitals appear to be due

to the negative impacts of the new wage

data, as shown in column 2. Among

rural bed size groups, the impacts range

from 2.8 percent to 2.9 percent, with the

exception of rural hospitals with 200 or

more beds. Payments per case for this

group of hospitals is estimated to

increase 2.2 percent during FY 1997.

This below average rate of increase

appears to be attributable primarily to a

smaller, though still significant, impact

of MGCRB reclassifications during FY

1997 compared to FY 1996. In column

3 the FY 1997 impact of reclassification

is shown to be 4.9 percent. For FY 1996,

however, this impact was 5.4 percent.

Thus, the rate of increase is 0.5 percent

less for FY 1997 due to a smaller

reclassification impact.

As discussed previously, effective for

discharges on or after October 1, 1996,

the regional floor, which benefitted

certain census divisions, expires. The

regional floor provided that, in those

census divisions where the regional

standardized amount exceeded the

national standardized amount, hospitals

would be paid a blend of 85 percent of

the national amount and 15 percent of

the regional amount. The census

divisions affected by the regional floor

during FY 1996 are New England and

East North Central. In New England, the

impacts of eliminating the regional floor

are a 0.7 percent decrease for urban

hospitals and a 0.6 percent decrease

among rural hospitals. In the East North

Central region, the impacts are a 1.0

percent reduction for urban hospitals,

and a 0.7 percent reduction for rural

hospitals. The negative impacts of

losing the regional floor for urban

hospitals in the East North Central

region are largely offset by higher

estimated outlier payments in FY 1997

compared to FY 1996, the 0.3 percent

higher payments due to the FY 1993

wage data (column 2), and the 0.2

percent increase due to the phase-out of

day outliers (column 4). On the other

hand, urban New England hospitals’

higher outlier payments in FY 1997 are

offset entirely by the negative impacts of

the expiration of the regional floor.

Rural New England hospitals also see a

1.0 percent decrease in payments

stemming from the FY 1993 wage data.

Other census divisions below the

average payment increase are urban

Pacific, urban Puerto Rico, rural Middle

Atlantic, rural South Atlantic, rural East

South Central, and rural Mountain.

With the exception of the rural Middle

Atlantic and rural East South Central,

the below average overall payment

impacts of these census divisions are

related to negative impacts of

introducing the FY 1993 wage data. In

the rural Middle Atlantic, the negative

impact of the new wage data is

combined with a smaller impact

stemming from MGCRB reclassifications

in FY 1997 (0.8 percent compared to 1.5

percent in FY 1996). A smaller FY 1997

reclassification impact (2.5 percent

compared with 3.7 percent in FY 1996)

is also the reason for the small (2.2

percent) rate of increase in the rural East

South Central census division.

Conversely, the urban Middle

Atlantic, urban West South Central,

rural Pacific, and rural Puerto Rico

census divisions all have overall rates of

increase at least 0.4 percent above the

national average. The urban West South

Central gains from the continued phaseout of day outliers, as well as higher

estimated FY 1997 outlier payments

compared to FY 1996. As noted

previously, the urban Middle Atlantic

benefits significantly from the updated

wage index data. These hospitals also

have higher estimated FY 1997 outlier

payments, which offset their 1.1 percent

decrease due to the phase-out of day

outliers. Rural Pacific hospitals benefit

from geographic reclassification in FY

1997, with 12 hospitals being

reclassified that were not reclassified in

FY 1996.

The only hospital groups with

negative payment impacts from FY 1996

to FY 1997 are hospitals that were

reclassified for FY 1996 and are not

reclassified for FY 1997. Overall, these

hospitals lose 0.5 percent. The urban

hospitals in this category actually

experience slight payment increases

over FY 1996 (0.8 percent), while the

rural hospitals lose 2.1 percent. On the

other hand, hospitals reclassified for FY

1997 that were not reclassified for FY

1996 would experience the greatest

payment increases: 10.5 percent for 69

rural hospitals in this category and 8.0

percent for 34 urban hospitals.

Reclassification appears to be a

significant factor influencing the

payment increases for a number of rural

hospital groups with above average

overall payment increases in column 5.

For example, among hospital groups

identified in the discussion of the

impacts of MGCRB reclassifications for

FY 1997 (column 3), almost all have

overall increases of 3.6 percent or

greater. This outcome highlights the

redistributive effects of reclassification

decisions upon hospital payments. This

impact is illustrated even more clearly

when one examines the rows

categorizing hospitals by their

reclassification status for FY 1997. All

nonreclassified hospitals have an

average payment increase of 3.0 percent.

The average payment increase for all

reclassified hospitals is 4.3 percent.

Among SCH/EACHs, the payment

increase is 2.7 percent. The primary

reason for this below average increase is

that there is minimal impact upon these

hospitals from the higher estimated FY

1997 outlier payments. Because these

hospital groups receive their hospitalspecific rate if it exceeds the applicable

Federal amount (including outliers),

there is less of an impact due to changes

in outlier payment levels, which are not

applied to the hospital-specific rate. In

addition, nonspecial status rural

hospitals experience only a 2.1 percent

increase. This is largely attributable to a

much smaller reclassification impact for

FY 1997 among these hospitals.
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27575

TABLE II.—IMPACT ANALYSIS OF CHANGES FOR FY 1997 OPERATING PROSPECTIVE PAYMENT SYSTEM

[Payments per case]

Number of

hospitals

Average FY

1996 payment

percase

Average FY

1997 payment

percase

All changes

(1) (2) 1 (3) 1 (4)

(By Geographic Location)

All hospitals ...................................................................................................................... 5,130 6,470 6,673 3.1

Urban hospitals ................................................................................................................. 2,878 7,004 7,229 3.2

Large urban areas ............................................................................................................ 1,597 7,524 7,761 3.1

Other urban areas ............................................................................................................ 1,281 6,317 6,524 3.3

Rural areas ....................................................................................................................... 2,252 4,302 4,419 2.7

Bed size (urban):

0–99 beds .................................................................................................................. 716 4,721 4,862 3.0

100–199 beds ............................................................................................................ 938 5,939 6,112 2.9

200–299 beds ............................................................................................................ 577 6,521 6,722 3.1

300–499 beds ............................................................................................................ 479 7,410 7,660 3.4

500 or more beds ...................................................................................................... 168 9,150 9,457 3.4

Bed Size (rural):

0–49 beds .................................................................................................................. 1,173 3,540 3,639 2.8

50–99 beds ................................................................................................................ 663 3,996 4,108 2.8

100–149 beds ............................................................................................................ 241 4,462 4,593 2.9

150–199 beds ............................................................................................................ 99 4,582 4,713 2.8

200 or more beds ...................................................................................................... 76 5,417 5,537 2.2

Urban by Census div.:

New England ............................................................................................................. 160 7,508 7,686 2.4

Middle Atlantic ........................................................................................................... 434 7,686 7,953 3.5

South Atlantic ............................................................................................................ 419 6,664 6,887 3.3

East North Central ..................................................................................................... 483 6,742 6,940 2.9

East South Central .................................................................................................... 163 6,185 6,395 3.4

West North Central .................................................................................................... 193 6,652 6,880 3.4

West South Central ................................................................................................... 375 6,524 6,756 3.6

Mountain .................................................................................................................... 125 6,774 6,996 3.3

Pacific ........................................................................................................................ 478 8,077 8,313 2.9

Puerto Rico ................................................................................................................ 48 2,584 2,652 2.6

Rural by Census div.:

New England ............................................................................................................. 53 5,236 5,344 2.1

Middle Atlantic ........................................................................................................... 85 4,695 4,785 1.9

South Atlantic ............................................................................................................ 297 4,476 4,591 2.6

East North Central ..................................................................................................... 304 4,328 4,454 2.9

East South Central .................................................................................................... 278 3,960 4,048 2.2

West North Central .................................................................................................... 525 4,008 4,121 2.8

West South Central ................................................................................................... 351 3,876 4,001 3.2

Mountain .................................................................................................................... 213 4,575 4,712 3.0

Pacific ........................................................................................................................ 141 5,306 5,519 4.0

Puerto Rico ................................................................................................................ 5 2,042 2,118 3.8

(By Payment Categories)

Urban hospitals ................................................................................................................. 2,978 6,960 7,184 3.2

Large urban areas ............................................................................................................ 1,793 7,352 7,586 3.2

Other urban areas ............................................................................................................ 1,185 6,322 6,528 3.3

Rural areas ....................................................................................................................... 2,152 4,269 4,379 2.6

Teaching status:

Non-teaching ............................................................................................................. 4,057 5,293 5,458 3.1

Fewer than 100 residents ......................................................................................... 841 6,900 7,118 3.2

100 or more residents ............................................................................................... 232 10,565 10,901 3.2

Disproportionate Share Hospitals (DSH):

Non-DSH ................................................................................................................... 3,200 5,602 5,779 3.2

Urban DSH:

100 beds or more ............................................................................................... 1,410 7,595 7,835 3.2

Fewer than 100 beds ......................................................................................... 111 4,811 4,929 2.5

Rural DSH:

Sole community (SCH) ...................................................................................... 146 4,478 4,625 3.3

Referral centers (RRC) ...................................................................................... 25 5,216 5,409 3.7

Other rural DSH hosp.:

100 beds or more ............................................................................................... 89 4,235 4,280 1.1

Fewer than 100 beds ......................................................................................... 149 3,412 3,497 2.5

Urban Teaching and DSH:

Both teaching and DSH ............................................................................................ 682 8,576 8,843 3.1

Teaching and no DSH ............................................................................................... 337 7,094 7,324 3.2
27576 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE II.—IMPACT ANALYSIS OF CHANGES FOR FY 1997 OPERATING PROSPECTIVE PAYMENT SYSTEM—Continued

[Payments per case]

Number of

hospitals

Average FY

1996 payment

percase

Average FY

1997 payment

percase

All changes

(1) (2) 1 (3) 1 (4)

No Teaching and DSH .............................................................................................. 839 6,093 6,292 3.3

No teaching and no DSH .......................................................................................... 1,120 5,479 5,663 3.4

Rural hospital types:

Nonspecial Status Hospitals ..................................................................................... 1,382 3,901 3,984 2.1

RRC ........................................................................................................................... 90 5,068 5,249 3.6

SCH/Each .................................................................................................................. 641 4,415 4,536 2.7

SCH/Each and RRC .................................................................................................. 39 5,200 5,345 2.8

Type of ownership:

Voluntary ................................................................................................................... 3,084 6,634 6,846 3.2

Proprietary ................................................................................................................. 691 5,917 6,093 3.0

Government ............................................................................................................... 1,355 6,030 6,207 2.9

Medicare utilization as a percent of inpatient days

0–25 ........................................................................................................................... 256 8,577 8,803 2.6

25–50 ......................................................................................................................... 1,285 7,877 8,124 3.1

50–65 ......................................................................................................................... 2,105 5,944 6,133 3.2

Over 65 ...................................................................................................................... 1,353 5,062 5,220 3.1

Unknown .................................................................................................................... 131 7,372 7,597 3.1

Hospitals Reclassified by the Medicare Geographic Review Board

Reclassification status during FY96 and FY97:

Reclassified during both FY96 and FY97 ................................................................. 381 5,864 6,046 3.1

Urban .................................................................................................................. 133 6,750 6,976 3.4

Rural ................................................................................................................... 248 5,003 5,143 2.8

Reclassified during FY97 only .................................................................................. 103 6,150 6,679 8.6

Urban .................................................................................................................. 34 7,091 7,658 8.0

Rural ................................................................................................................... 69 4,374 4,831 10.5

Reclassified during FY96 only .................................................................................. 251 5,658 5,630 ¥0.5

Urban .................................................................................................................. 88 7,131 7,189 0.8

Rural ................................................................................................................... 163 4,515 4,421 ¥2.1

FY 97 Reclassifications: All reclassified hosp. 484 5,922 6,176 4.3

Stand. amt. Only ................................................................................................ 120 5,764 5,944 3.1

Wage index only ................................................................................................ 274 5,839 6,065 3.9

Both .................................................................................................................... 90 6,205 6,571 5.9

Nonreclass. ........................................................................................................ 4,619 6,548 6,745 3.0

All urban reclass. ....................................................................................................... 167 6,837 7,150 4.6

Stand. amt. only ................................................................................................. 63 6,230 6,433 3.3

Wage index only ................................................................................................ 30 9,311 9,728 4.5

Both .................................................................................................................... 74 6,370 6,727 5.6

Nonreclass. ........................................................................................................ 2,711 7,018 7,235 3.1

All rural reclass. ......................................................................................................... 317 4,909 5,096 3.8

Stand. amt. only ................................................................................................. 57 4,623 4,749 2.7

Wage index only ................................................................................................ 244 4,968 5,146 3.6

Both .................................................................................................................... 16 4,898 5,345 9.1

Nonreclass. ........................................................................................................ 1,908 4,063 4,152 2.2

Other reclassifed:

Hospitals (section 1886(d)(8)(B)) .............................................................................. 27 4,611 4,756 3.1

1These payment amounts per case do not reflect any estimates of annual case-mix increases.

Table II presents the projected impact

of the proposed changes for FY 1997 for

urban and rural hospitals and for the

different categories of hospitals shown

in Table I. It compares the projected

payments per case for FY 1997 with the

average estimated per case payments for

FY 1996, as calculated under our

models. Thus, this table presents, in

terms of the average dollar amounts

paid per discharge, the combined effects

of the changes presented in Table I. The

percentage changes shown in the last

column of Table I equal the percentage

changes in average payments from

column 5 of Table I.

VII. Impact of Proposed Changes in the

Capital Prospective Payment System

A. General Considerations

We now have data that were

unavailable in previous impact analyses

for the capital prospective payment

system. Specifically, we have cost report

data for the third year of the capital

prospective payment system (cost

reports beginning in FY 1994) available

through the March 1996 update of the

Hospital Cost Report Information

System (HCRIS). We also have updated

information on the projected aggregate

amount of obligated capital approved by

the fiscal intermediaries. However, our

impact analysis of payment changes for

capital-related costs is still limited by

the lack of hospital-specific data on

several items. These are the hospital’s

projected new capital costs for each

year, its projected old capital costs for
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27577

each year, and the actual amounts of

obligated capital that will be put in use

for patient care and recognized as

Medicare old capital costs in each year.

The lack of such information affects our

impact analysis in the following ways:

• Major investment in hospital capital

assets (for example in building and

major fixed equipment) occurs at

irregular intervals. As a result, there can

be significant variation in the growth

rates of Medicare capital-related costs

per case among hospitals. We do not

have the necessary hospital-specific

budget data to project the hospital

capital growth rate for individual

hospitals.

• Moreover, our policy of recognizing

certain obligated capital as old capital

makes it difficult to project future

capital-related costs for individual

hospitals. Under § 412.302(c), a hospital

is required to notify its intermediary

that it has obligated capital by the later

of October 1, 1992, or 90 days after the

beginning of the hospital’s first cost

reporting period under the capital

prospective payment system. The

intermediary must then notify the

hospital of its determination whether

the criteria for recognition of obligated

capital have been met by the later of the

end of the hospital’s first cost reporting

period subject to the capital prospective

payment system or 9 months after the

receipt of the hospital’s notification.

The amount that is recognized as old

capital is limited to the lesser of the

actual allowable costs when the asset is

put in use for patient care or the

estimated costs of the capital

expenditure at the time it was obligated.

We have substantial information

regarding intermediary determinations

of projected aggregate obligated capital

amounts. However, we still do not know

when these projects will actually be put

into use for patient care, the actual

amount that will be recognized as

obligated capital when the project is put

into use, or the Medicare share of the

recognized costs. Therefore, we do not

know actual obligated capital

commitments for purposes of the FY

1997 capital cost projections. We

discuss in Appendix B the assumptions

and computations we employ to

generate the amount of obligated capital

commitments for use in the FY 1997

capital cost projections.

In Table III of this appendix, we

present the redistributive effects that are

expected to occur between ‘‘holdharmless’’ hospitals and ’’fully

prospective’’ hospitals in FY 1997. In

addition, we have integrated sufficient

hospital-specific information into our

actuarial model to project the impact of

the proposed FY 1997 capital payment

policies by the standard prospective

payment system hospital groupings. We

caution that while we now have actual

information on the effects of the

transition payment methodology and

interim payments under the capital

prospective payment system and cost

report data for most hospitals, we need

to randomly generate numbers for the

change in old capital costs, new capital

costs for each year, and obligated

amounts that will be put in use for

patient care services and recognized as

old capital each year. We continue to be

unable to predict accurately FY 1997

capital costs for individual hospitals,

but with the more recent data on the

experience to date under the capital

prospective payment system, there is

adequate information to estimate the

aggregate impact on most hospital

groupings.

We present the transition payment

methodology by hospital grouping in

Table IV. In Table V we present the

results of the cross-sectional analysis

using the results of our actuarial model.

This table presents the aggregate impact

of the FY 1997 payment policies.

B. Projected Impact Based on the

Proposed FY 1997Actuarial Model

1. Assumptions

In this impact analysis, we model

dynamically the impact of the capital

prospective payment system from FY

1996 to FY 1997 using a capital

acquisition model. The FY 1997 model,

described in Appendix B of this

proposed rule, integrates actual data

from individual hospitals with

randomly generated capital cost

amounts. We have capital cost data from

cost reports beginning in FY 1989

through FY 1994 received through the

March 1996 update of the Hospital Cost

Reporting Information System (HCRIS),

interim payment data for hospitals

already receiving capital prospective

payments through PRICER, and data

reported by the intermediaries that

include the hospital-specific rate

determinations that have been made

through January 1, 1996 in the ProviderSpecific file. We used this data to

determine the proposed FY 1997 capital

rates. However, we do not have

individual hospital data on old capital

changes, new capital formation, and

actual obligated capital costs. We have

data on costs for capital in use in FY

1993, and we age that capital by a

formula described in Appendix B. We

therefore need to randomly generate

only new capital acquisitions for any

year after FY 1993. All Federal rate

payment parameters are assigned to the

applicable hospital.

For purposes of this impact analysis,

the FY 1997 actuarial model includes

the following assumptions:

• Medicare inpatient capital costs per

discharge will increase at the following

rates during these periods:

AVERAGE PERCENTAGE INCREASE IN

CAPITAL

Fiscal year Costs per

discharge

1995 .......................................... ¥1.50

1996 .......................................... 5.05

1997 .......................................... 5.21

• The Medicare case-mix index will

increase by 1.6 percent in FY 1996 and

FY 1997.

• The Federal capital rate as well as

the hospital-specific rate is updated in

FY 1996 by an analytical framework that

considers changes in the prices

associated with capital-related costs,

and adjustments to account for forecast

error, changes in the case-mix index,

allowable changes in intensity, and

other factors. The proposed FY 1997

update for inflation is 1.00 percent (see

Addendum, Part III).

2. Results

We have used the actuarial model to

estimate the change in payment for

capital-related costs from FY 1996 to FY

1997. Table III shows the effect of the

capital prospective payment system on

low capital cost hospitals and high

capital cost hospitals. We consider a

hospital to be a low capital cost hospital

if, based on a comparison of its initial

hospital-specific rate and the applicable

Federal rate, it will be paid under the

fully prospective payment methodology.

A high capital cost hospital is a hospital

that, based on its initial hospitalspecific rate, will be paid under the

hold-harmless payment methodology.

Based on our actuarial model, the

breakdown of hospitals is as follows:
27578 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

CAPITAL TRANSITION PAYMENT METHODOLOGY

Type of hospital Percent of

hospitals

FY 1997

percent of

discharges

FY 1997

percent of

capital costs

FY 1997

percent of

capital payments

Low Cost Hospital ............................................................................................................ 66 62 53 56

High Cost Hospital ............................................................................................................ 34 38 47 44

A low capital cost hospital may

request to have its hospital-specific rate

redetermined based on old capital costs

in the current year, through the later of

the hospital’s cost reporting period

beginning in FY 1994 or the first cost

reporting period beginning after

obligated capital comes into use (within

the limits established in § 412.302(e) for

putting obligated capital in use for

patient care). If the redetermined

hospital-specific rate is greater than the

adjusted Federal rate, these hospitals

will be paid under the hold-harmless

payment methodology. Regardless of

whether the hospital became a holdharmless payment hospital as a result of

a redetermination, we have continued to

show these hospitals as low capital cost

hospitals in Table III.

Assuming no behavioral changes in

capital expenditures, Table III displays

the percentage change in payments from

FY 1996 to FY 1997 using the above

described actuarial model.
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27579

TABLE III.—IMPACT OF PROPOSED CHANGES FOR FY 1997 ON PAYMENTS PER DISCHARGE

FY 1996 payments per discharge

Number of

hospitals Discharges

Adjusted

federal

payment

Average

federal

percent

Hospital

specific

payment

Hold harmless payment

Exceptions

payment

Total

payment

Low Cost Hospitals ............................................................. 3,367 6,543,036 $413.51 55.01 $200.60 $15.30 $16.59 $646.01

Fully Prospective ......................................................... 1,472 2,953,665 373.96 50.00 236.94 .................. 11.59 622.49

Rebase—Fully Prospective ......................................... 1,561 2,777,809 373.98 50.00 220.57 .................. 23.17 617.72

Rebase—100% Federal Rate ..................................... 237 633,924 798.96 100.00 .................. .................. 0.05 799.00

Rebase—Hold Harmless ............................................. 97 177,638 313.93 44.64 .................. 563.62 55.92 933.48

High Cost Hospitals ............................................................ 1,737 4,044,123 665.47 85.61 .................. 152.51 16.36 834.35

100% Federal Rate ..................................................... 1,126 2,842,423 788.87 100.00 .................. .................. 2.30 791.18

Hold Harmless ............................................................. 611 1,201,700 373.59 49.81 .................. 513.26 49.61 936.46

Total Hospitals ......................................................... 5,104 10,587,159 509.76 66.94 123.98 67.71 16.50 717.95

FY 1997 payments per discharge

Number of

hospitals Discharges

Adjusted

federal

payment

Average

federal

percent

Hospital

specific

payment

Hold harmless payment

Exceptions

payment

Total

payment

Percent

change

Low Cost Hospitals ....................................... 3,367 6,720,494 $472.14 64.07 $157.08 $12.37 $38.44 $680.03 5.27

Fully Prospective ................................... 1,472 3,033,773 438.87 60.00 185.55 .................. 34.06 658.48 5.78

Rebase—Fully Prospective ................... 1,561 2,853,148 440.66 60.00 172.70 .................. 45.15 658.50 6.60

Rebase—100% Federal Rate ................ 243 657,828 785.22 100.00 .................. .................. 0.58 785.81 -1.65

Rebase—Hold Harmless ....................... 91 175,744 385.79 55.77 .................. 473.19 146.68 1,005.66 7.73

High Cost Hospitals ...................................... 1,737 4,153,806 691.63 89.42 .................. 123.03 48.28 862.93 3.43

100% Federal Rate ................................ 1,164 2,988,949 780.85 100.00 .................. .................. 11.02 791.87 0.09

Hold Harmless ....................................... 573 1,164,856 462.69 61.34 .................. 438.70 143.88 1,045.27 11.62

Total Hospitals ................................... 5,104 10,874,300 555.98 74.04 97.08 54.64 42.20 749.90 4.45
27580 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

Under section 1886(g)(1)(A) of the

Act, aggregate payments under the

capital prospective payment system for

FY 1992 through 1995 respectively,

were projected to equal 90 percent of

payments that would have been payable

on a reasonable cost basis in each year.

With the expiration of the capital budget

neutrality provision, we now estimate

that there was an aggregate 27.73

percent increase in FY 1996 Medicare

capital payments over the FY 1995

payments. With the proposed Federal

rate, we estimate aggregate Medicare

capital payments will increase by 7.28

percent in FY 1997.

We project that low capital cost

hospitals paid under the fully

prospective payment methodology will

experience an average increase in

payments per case of 5.27 percent, and

high capital cost hospitals will

experience an average increase of 3.43

percent.

For hospitals paid under the fully

prospective payment methodology, the

Federal rate payment percentage will

increase from 50 percent to 60 percent

and the hospital-specific rate payment

percentage will decrease from 50 to 40

percent in FY 1997. The Federal rate

payment percentage for hospitals paid

under the hold-harmless payment

methodology is based on the hospital’s

ratio of new capital costs to total capital

costs. The average Federal rate payment

percentage for hospitals receiving a

hold-harmless payment for old capital

will increase from 49.81 percent to

61.34 percent. We estimate the

percentage of hold-harmless hospitals

paid based on 100 percent of the Federal

rate will increase from 65.8 percent to

67.9 percent.

We expect that the average hospitalspecific rate payment per discharge will

decrease from $123.98 in FY 1996 to

$97.08 in FY 1997. This is partly due to

the 3.68 percent decrease in the FY 1997

hospital-specific rate compared to FY

1996.

We are proposing no changes in our

exceptions policies for FY 1997. As a

result, the minimum payment levels

would be:

• 90 percent for sole community

hospitals;

• 80 percent for urban hospitals with

100 or more beds and a disproportionate

share patient percentage of 20.2 percent

or more; or,

• 70 percent for all other hospitals.

We estimate that exceptions payments

will increase from 2.30 percent of total

capital payments in FY 1996 to 5.63

percent of payments in FY 1997. The

number and amount of exceptions

payments is expected to increase

throughout the transition period. The

projected distribution of the payments is

shown in the table below:

ESTIMATED FY 1997 EXCEPTIONS

PAYMENTS

Type of hospital Number of

hospitals

Percent of

exceptions

payments

Low Capital Cost 450 58

High Capital

Cost ............... 331 42

Total ........... 781 100

C. Cross-Sectional Comparison of

Capital Prospective Payment

Methodologies

Table IV presents a cross-sectional

summary of hospital groupings by

capital prospective payment

methodology. This distribution is

generated by our actuarial model.

TABLE IV.—DISTRIBUTION BY METHOD OF PAYMENT (HOLD-HARMLESS/FULLY PROSPECTIVE) OF HOSPITALS RECEIVING

CAPITAL PAYMENTS

(1)

Total Number 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 ............................................................................................................... 5,104 13.0 27.6 59.4

Large urban areas (populations over 1 million) ........................................................ 1,584 15.6 34.5 49.9

Other urban areas (populations of 1 million or fewer) .............................................. 1,271 15.1 33.4 51.5

Rural areas ................................................................................................................ 2,249 10.0 19.4 70.6

Urban hospitals ......................................................................................................... 2,855 15.4 34.0 50.6

0–99 beds .......................................................................................................... 698 16.2 27.7 56.2

100–199 beds .................................................................................................... 933 19.3 36.8 43.9

200–299 beds .................................................................................................... 577 13.9 37.3 48.9

300–499 beds .................................................................................................... 479 11.5 32.6 55.9

500 or more beds ............................................................................................... 168 6.5 37.5 56.0

Rural hospitals ........................................................................................................... 2,249 10.0 19.4 70.6

0–49 beds .......................................................................................................... 1,171 7.1 14.3 78.7

50–99 beds ........................................................................................................ 662 12.8 21.9 65.3

100–149 beds .................................................................................................... 241 14.5 30.3 55.2

150–199 beds .................................................................................................... 99 16.2 22.2 61.6

200 or more beds ............................................................................................... 76 7.9 39.5 52.6

By Region:

Urban by Region ....................................................................................................... 2,855 15.4 34.0 50.6

New England ...................................................................................................... 160 7.5 25.0 67.5

Middle Atlantic .................................................................................................... 434 9.9 30.0 60.1

South Atlantic ..................................................................................................... 417 19.2 41.0 39.8

East North Central ............................................................................................. 480 11.3 28.5 60.2

East South Central ............................................................................................. 162 19.8 36.4 43.8

West North Central ............................................................................................ 190 17.4 28.4 54.2

West South Central ............................................................................................ 366 25.7 47.5 26.8

Mountain ............................................................................................................. 124 15.3 42.7 41.9

Pacific ................................................................................................................. 474 13.3 30.4 56.3

Puerto Rico ........................................................................................................ 48 18.8 16.7 64.6

Rural by Region ........................................................................................................ 2,249 10.0 19.4 70.6
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27581

TABLE IV.—DISTRIBUTION BY METHOD OF PAYMENT (HOLD-HARMLESS/FULLY PROSPECTIVE) OF HOSPITALS RECEIVING

CAPITAL PAYMENTS—Continued

(1)

Total Number of Hospitals

(2)

Hold-harmless (3)

Percentage

paid fully

prospective

rate

Percentage

paid holdharmless

(A)

Percentage

paid fully

federal

(B)

New England ...................................................................................................... 53 7.5 15.1 77.4

Middle Atlantic .................................................................................................... 84 6.0 19.0 75.0

South Atlantic ..................................................................................................... 297 13.1 25.3 61.6

East North Central ............................................................................................. 304 8.6 13.5 78.0

East South Central ............................................................................................. 278 10.1 30.6 59.4

West North Central ............................................................................................ 525 7.2 15.0 77.7

West South Central ............................................................................................ 349 10.0 24.1 65.9

Mountain ............................................................................................................. 213 15.5 12.7 71.8

Pacific ................................................................................................................. 141 11.3 15.6 73.0

Large urban areas (populations over 1 million) ........................................................ 1,780 15.3 34.3 50.4

Other urban areas (populations of 1 million or fewer) .............................................. 1,175 15.4 32.3 52.3

Rural areas ................................................................................................................ 2,149 9.8 19.4 70.8

Teaching Status:

Non-teaching ...................................................................................................... 4,031 13.7 26.6 59.7

Fewer than 100 Residents ................................................................................. 841 11.1 32.0 57.0

100 or more Residents ...................................................................................... 232 7.8 28.4 63.8

Disproportionate share hospitals (DSH):

Non-DSH ............................................................................................................ 3,175 12.7 23.8 63.5

Urban DSH:

100 or more beds ....................................................................................... 1,410 15.0 36.2 48.8

Less than 100 beds .................................................................................... 110 11.8 25.5 62.7

Rural DSH:

Sole Community (SCH/EACH) ........................................................................... 146 9.6 20.5 69.9

Referral Center (RRC/EACH) ............................................................................ 25 8.0 32.0 60.0

Other Rural:

100 or more beds ................................................................................ 89 13.5 39.3 47.2

Less than 100 beds ............................................................................. 149 6.7 25.5 67.8

Urban teaching and DSH:

Both teaching and DSH ..................................................................................... 682 9.1 32.8 58.1

Teaching and no DSH ....................................................................................... 337 13.6 27.6 58.8

No teaching and DSH ........................................................................................ 838 19.3 37.6 43.1

No teaching and no DSH ................................................................................... 1,098 16.7 32.7 50.6

Rural Hospital Types:

NON special status hospitals ............................................................................. 1,379 7.6 19.5 72.9

RRC/EACH ......................................................................................................... 90 8.9 37.8 53.3

SCH/EACH ......................................................................................................... 641 14.5 16.4 69.1

SCH, RRC and EACH ....................................................................................... 39 12.8 20.5 66.7

Type of Ownership:

Voluntary:

Voluntary ............................................................................................................ 3,058 12.8 27.7 59.5

Proprietary .......................................................................................................... 691 23.6 46.2 30.2

Government ........................................................................................................ 1,355 8.1 17.9 74.0

Medicare Utilization as a Percent of Inpatient Days:

0–25 ................................................................................................................... 256 14.8 25.0 60.2

25–50 ................................................................................................................. 1,285 14.6 33.1 52.3

50–65 ................................................................................................................. 2,105 12.9 27.8 59.3

Over 65 .............................................................................................................. 1,353 10.4 22.2 67.3

As we explain in Appendix B, we

were not able to determine a hospitalspecific rate for 26 of the 5,130 hospitals

in our data base. Consequently, the

payment methodology distribution is

based on 5,104 hospitals. This data

should be fully representative of the

payment methodologies that will be

applicable to hospitals.

The cross-sectional distribution of

hospital by payment methodology is

presented by: (1) geographic location,

(2) region, and (3) payment

classification. This provides an

indication of the percentage of hospitals

within a particular hospital grouping

that will be paid under the fully

prospective payment methodology and

under the hold-harmless methodology.

The percentage of hospitals paid fully

Federal (100 percent of the Federal rate)

as hold-harmless hospitals is expected

to increase to 27.6 percent in FY 1997.

Table IV indicates that 59.4 percent of

hospitals are paid under the fully

prospective payment methodology.

(This figure, unlike the figure of 66

percent for low cost capital hospitals in

the previous section, takes account of

the effects of redeterminations. In other

words, this figure does not include low

cost hospitals that, following a hospitalspecific rate redetermination, are now

paid under the hold-harmless

methodology.) As expected, a relatively

higher percentage of rural and

governmental hospitals (70.8 percent

and 74.0 percent, respectively by

payment classification) are being paid

under the fully prospective

methodology. This is a reflection of

their lower than average capital costs
27582 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

per case. In contrast, only 30.2 percent

of proprietary hospitals are being paid

under the fully prospective

methodology. This is a reflection of

their higher than average capital costs

per case. (We found at the time of the

August 30, 1991 final rule (56 FR 43430)

that 62.7 percent of proprietary

hospitals had a capital cost per case

above the national average cost per

case.)

D. Cross-Sectional Analysis of Changes

in Aggregate Payments

We used our FY 1997 actuarial model

to estimate the potential impact of our

proposed changes for FY 1997 on total

capital payments per case, using a

universe of 5,104 hospitals. The

individual hospital payment parameters

are taken from the best available data,

including: the January 1, 1996 update to

the Provider-Specific file, cost report

data, and audit information supplied by

intermediaries. Table V presents

estimates of payments per case under

our model for FY 1996 and FY 1997

(columns 2 and 3). Column 4 shows the

total percentage change in payments

from FY 1996 to FY 1997. Column 5

presents the percentage change in

payments that can be attributed to

Federal rate changes alone.

Federal rate changes represented in

Column 5 include the 4.36 percent

decrease in the Federal rate, a 1.6

percent increase in case mix, changes in

the adjustments to the Federal rate (for

example, the effect of the new hospital

wage index on the geographic

adjustment factor), and reclassifications

by the Medicare Geographic

Classification Review Board. Column 4

includes the effects of the Federal rate

changes represented in Column 3.

Column 4 also reflects the effects of all

other changes, including: the change

from 50 percent to 60 percent in the

portion of the Federal rate for fully

prospective hospitals, the hospitalspecific rate update, changes in the

proportion of new to total capital for

hold-harmless hospitals, changes in old

capital (for example, obligated capital

put in use), hospital-specific rate

redeterminations, and exceptions. The

comparisons are provided by: (1)

geographic location and (2) payment

classification and payment region.

The simulation results show that, on

average, capital payments per case can

be expected to increase 4.4 percent in

FY 1997. The results show that the

effect of the Federal rate changes alone

is to decrease payments by 0.9 percent.

The decrease attributable to the Federal

rate changes is more than offset by a 5.3

percent increase is attributable to the

effects of all other changes.

Our comparison by geographic

location shows that capital payments

per case to urban and rural hospitals

experience similar rates of increase (4.4

percent and 4.8 percent, respectively).

Payments per case for urban hospitals

will decrease at about the same rate as

payments per case for rural hospitals

(0.8 percent and 1.3 percent,

respectively) from the Federal rate

changes alone. Urban hospitals will gain

slightly less than rural hospitals (5.2

percent compared to 6.1 percent) from

the effects of all other changes.

By region, there is relatively little

variation compared to some previous

years. All regions are estimated to

receive increases in total capital

payments per case, due to the increased

share of payments that is based on the

Federal rate (from 50 to 60 percent).

Changes by region vary from a low of

2.1 percent increase (Middle Atlantic

rural region) to a high of 15.6 percent

increase (rural hospitals of the New

England region).

By type of ownership, government

hospitals are projected to have the

largest rate of increase (5.1 percent, -1.1

percent due to Federal rate changes and

a 6.2 percent positive offset from the

effects of all other changes). Payments to

voluntary hospitals will increase 4.5

percent (a 0.9 percent decrease due to

Federal rate changes and a 5.4 percent

positive offset from the effects of all

other changes) and payments to

proprietary hospitals will increase 3.8

percent (a 0.7 percent decrease due to

Federal rate changes and a 4.5 percent

positive offset from the effects of all

other changes).

Section 1886(d)(10) of the Act

established the Medicare Geographic

Classification Review Board (MGCRB).

Hospitals may apply for reclassification

for purposes of the standardized

amount, wage index, or both. Although

the Federal capital rate is not affected,

a hospital’s geographic classification for

purposes of the operating standardized

amount does affect a hospital’s capital

payments as a result of the large urban

adjustment factor and the

disproportionate share adjustment for

urban hospitals with 100 or more beds.

Reclassification for wage index

purposes affects the geographic

adjustment factor since that factor is

constructed from the hospital wage

index.

To present the effects of the hospitals

being reclassified for FY 1997 compared

to the effects of reclassification for FY

1996, we show the average payment

percentage increase for hospitals

reclassified in each fiscal year and in

total. For FY 1997 reclassifications, we

indicate those hospitals reclassified for

standardized amount purposes only, for

wage index purposes only, and for both

purposes. The reclassified groups are

compared to all other nonreclassified

hospitals. These categories are further

identified by urban and rural

designation.

Hospitals reclassified during FY 1997

as a whole are projected to experience

a 5.3 percent increase in payments (a 0.3

percent decrease attributable to Federal

rate changes and a 5.6 percent positive

offset attributable to the effects of all

other changes). Payments to

nonreclassified hospitals will increase

slightly less (4.3 percent) than

reclassified hospitals (5.3 percent)

overall. Payments to nonreclassified

hospitals will decrease slightly more

than reclassified hospitals from the

Federal rate changes (1.0 percent

compared to 0.3 percent), but they will

gain about the same from the effects of

all other changes (5.3 percent compared

to 5.6 percent).

TABLE V.—COMPARISON OF TOTAL PAYMENTS PER CASE

[FY 1996 Payments Compared to FY 1997 Payments]

Number of

hospitals

Average FY

1996 payments/case

Average FY

1997 payments/caseAll changes

Portion

attibutable

to federal

rate change

By Geographic Location:

All hospitals ....................................................................................... 5,104 718 750 4.4 ¥0.9

Large urban areas (populations over 1 million) ................................ 1,584 823 858 4.3 ¥0.9

Other urban areas (populations of 1 million of fewer) ...................... 1,271 714 747 4.5 ¥0.8

Rural areas ........................................................................................ 2,249 479 503 4.8 ¥1.3

Urban hospitals .................................................................................. 2,855 776 810 4.4 ¥0.8
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27583

TABLE V.—COMPARISON OF TOTAL PAYMENTS PER CASE—Continued

[FY 1996 Payments Compared to FY 1997 Payments]

Number of

hospitals

Average FY

1996 payments/case

Average FY

1997 payments/caseAll changes

Portion

attibutable

to federal

rate change

0–99 beds ................................................................................... 698 570 594 4.3 ¥0.9

100–199 beds ............................................................................. 933 703 731 4.1 ¥1.0

200–299 beds ............................................................................. 577 744 776 4.2 ¥0.9

300–499 beds ............................................................................. 479 800 838 4.8 ¥0.8

500 or more beds ....................................................................... 168 944 984 4.3 ¥0.5

Rural hospitals ................................................................................... 2,249 479 503 4.8 ¥1.3

0–49 beds ................................................................................... 1,171 368 389 5.8 ¥1.5

50–99 beds ................................................................................. 662 445 468 5.0 ¥1.2

100–149 beds ............................................................................. 241 512 536 4.7 ¥1.3

150–199 beds ............................................................................. 99 517 543 4.9 ¥1.0

200 or more beds ....................................................................... 76 609 633 3.9 ¥1.5

By Region:

Urban by Region ............................................................................... 2,855 776 810 4.4 ¥0.8

New England .............................................................................. 160 780 818 4.9 ¥1.5

Middle Atlantic ............................................................................ 434 816 855 4.8 ¥0.8

South Atlantic ............................................................................. 417 777 809 4.2 ¥0.8

East North Central ...................................................................... 480 730 759 4.0 ¥0.7

East South Central ..................................................................... 162 707 744 5.3 ¥0.5

West North Central ..................................................................... 190 768 807 5.1 ¥0.8

West South Central .................................................................... 366 794 825 3.8 ¥0.3

Mountain ..................................................................................... 124 774 804 3.8 ¥1.1

Pacific ......................................................................................... 474 856 890 4.1 ¥1.3

Puerto Rico ................................................................................. 48 291 313 7.5 ¥1.1

Rural by Region ................................................................................. 2,249 479 503 4.8 ¥1.3

New England .............................................................................. 53 605 699 15.6 ¥1.8

Middle Atlantic ............................................................................ 84 489 499 2.1 ¥2.4

South Atlantic ............................................................................. 297 501 518 3.4 ¥1.5

East North Central ...................................................................... 304 479 506 5.7 ¥0.9

East South Central ..................................................................... 278 453 471 4.0 ¥1.5

West North Central ..................................................................... 525 449 471 5.0 ¥1.4

West South Central .................................................................... 349 447 467 4.4 ¥0.9

Mountain ..................................................................................... 213 507 540 6.4 ¥0.5

Pacific ......................................................................................... 141 549 582 6.1 ¥0.9

By Payment Classification:

All hospitals ....................................................................................... 5,104 718 750 4.4 ¥0.9

Large urban areas (populations over 1 million) ................................ 1,780 808 842 4.3 ¥0.9

Other urban areas (populations of 1 million of fewer) ...................... 1,175 714 747 4.6 ¥0.8

Rural areas ........................................................................................ 2,149 473 495 4.8 ¥1.4

Teaching Status:

Non-teaching .............................................................................. 4,031 623 647 3.9 ¥1.0

Fewer than 100 Residents ......................................................... 841 756 791 4.7 ¥0.9

100 or more Residents ............................................................... 232 1,039 1,096 5.5 ¥0.7

Urban DSH:

100 or more beds ................................................................ 1,410 814 850 4.5 ¥0.9

Less than 100 beds ............................................................ 110 557 587 5.4 ¥1.1

Rural DSH:

Sole Community (SCH/EACH) ............................................ 146 458 495 8.1 ¥1.9

Referral Center (RRC/EACH) ............................................. 25 544 560 2.9 ¥0.2

Other Rural:

100 or more beds ................................................................ 89 501 519 3.6 ¥1.9

Less than 100 beds ............................................................ 149 365 385 5.5 ¥1.6

Urban teaching and DSH:.

Both teaching and DSH ............................................................. 682 879 919 4.6 ¥0.8

Teaching and no DSH ................................................................ 337 786 827 5.3 ¥0.8

No teaching and DSH ................................................................ 838 712 743 4.4 ¥0.9

No teaching and no DSH ........................................................... 1,098 672 695 3.4 ¥0.8

Rural Hospital Types:

Non special status hospitals ...................................................... 1,379 439 458 4.3 ¥1.7

RRC/EACH ................................................................................. 90 559 574 2.5 ¥0.8

SCH/EACH ................................................................................. 641 471 506 7.4 ¥1.2

SCH, RRC and EACH ................................................................ 39 577 608 5.4 ¥1.0

Hospitals Reclassified by the Medicare Geographic Classification

Review Board:

Reclassification Status During FY96 and FY97:

Reclassified During Both FY96 and FY97 .......................... 381 668 698 4.5 ¥1.1

Reclassified During FY97 Only ........................................... 103 678 736 8.6 2.9

Reclassified During FY96 Only ........................................... 228 631 640 1.4 ¥3.6

FY97 Reclassifications:

All Reclassified Hospitals .................................................... 484 670 706 5.3 ¥0.3
27584 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

TABLE V.—COMPARISON OF TOTAL PAYMENTS PER CASE—Continued

[FY 1996 Payments Compared to FY 1997 Payments]

Number of

hospitals

Average FY

1996 payments/case

Average FY

1997 payments/caseAll changes

Portion

attibutable

to federal

rate change

All Nonreclassified Hospitals ............................................... 4,593 725 756 4.3 ¥1.0

All Urban Reclassified Hospitals ......................................... 167 762 799 4.9 ¥0.3

Urban Nonreclassified Hospitals ......................................... 2,688 777 811 4.3 ¥0.9

All Reclassified Rural Hospitals .......................................... 317 568 602 6.0 ¥0.3

Rural Nonreclassified Hospitals .......................................... 1,905 443 463 4.3 ¥1.8

Other Reclassified Hospitals (Section 1886 (D)(8)(B)) .............. 27 552 575 4.1 ¥1.3

Type of Ownership:

Voluntary .................................................................................... 3,058 732 765 4.5 ¥0.9

Proprietary .................................................................................. 691 748 776 3.8 ¥0.7

Government ................................................................................ 1,355 618 649 5.1 ¥1.1

Medicare Utilization as a Percent of Inpatient Days:

0–25 ............................................................................................ 256 793 847 6.8 ¥1.4

25–50 .......................................................................................... 1,285 844 880 4.2 ¥0.8

50–65 .......................................................................................... 2,105 675 706 4.6 ¥0.9

Over 65 ....................................................................................... 1,353 603 628 4.1 ¥1.0

Appendix B: Technical Appendix on

the Capital Acquisition Model and

Required Adjustments

Under section 1886(g)(1)(A) of the

Act, we set capital prospective payment

rates for FY 1992 through FY 1995 so

that aggregate prospective payments for

capital costs were projected to be 10

percent lower than the amount that

would have been payable on a

reasonable cost basis for capital-related

costs in that year. To implement this

requirement, we developed the capital

acquisition model to determine the

budget neutrality adjustment factor.

Even though the budget neutrality

requirement expires effective with FY

1996, we must continue to determine

the recalibration and geographic

reclassification budget neutrality

adjustment factor, and the reduction in

the Federal and hospital-specific rates

for exceptions payments. We continue

to use the capital acquisition model to

determine these factors.

The following data are used in the

capital acquisition model for FY 1997:

the March 8, 1996 update of the cost

reports for PPS–IX (cost reporting

periods beginning in FY 1992), PPS–X

(cost reporting periods beginning in FY

1993) and PPS–XI (cost reporting

periods beginning in FY 1994), the

January 1, 1996 update of the providerspecific file, and the March 1994 update

of the intermediary audit file. The

available data still lack certain items

that were required for the determination

of budget neutrality, including each

hospital’s projected new capital costs

for each year, its projected old capital

costs for each year, and the projected

obligated capital amounts that will be

put in use for patient care services and

recognized as old capital each year.

Since hospitals under alternative

payment system waivers (that is,

hospitals in Maryland) are currently

excluded from the capital prospective

payment system, we excluded these

hospitals from our model.

We then developed FY 1992, FY 1993,

FY 1994, FY 1995, and FY 1996

hospital-specific rates using the

provider-specific file, the intermediary

audit file, and, when available, cost

reports. (We used the cumulative

provider-specific file, which includes

all updates to each hospital’s records,

and chose the latest record for each

fiscal year.) We checked the consistency

between the provider-specific file and

the intermediary audit file. We also

ensured that the FY 1993 increase in the

hospital-specific rate was at least 0.62

percent (the net FY 1993 update), that

the FY 1994 hospital-specific rate was at

least as large as the FY 1993 hospitalspecific rate decreased by 2.16 percent

(the net FY 1994 update), that the FY

1995 increase in the hospital-specific

rate was at least 0.05 percent (the net FY

1995 update), and that the FY 1996

increase in the hospital-specific rate was

at least 21.10 percent (the net FY 1996

update). We were able to match

hospitals to the files as shown in the

following table.

Source Number of

hospitals

Provider-Specific File Only ....... 101

Provider-Specific and Audit File 5029

Total ............................... 5130

Sixty-eight of these hospitals had

unusable or missing data. We were able

to backfill a hospital-specific rate for 42

of these hospitals from the cost reports

as shown in the following table.

Source Number of

hospitals

PPS–VII Cost Reports .............. 1

PPS–VIII Cost Reports ............. 2

PPS–IX Cost Reports ............... 3

PPS–X Cost Reports ................ 7

PPS–XI Cost Reports ............... 29

Total ............................... 42

We did not have data for 26 hospitals,

and had to eliminate them from the

capital analysis. These hospitals likely

are new hospitals or hospitals with very

few Medicare admissions. This leaves

us with 5104 hospitals and should not

affect the precision of the required

adjustment factors.

Next, we determined old and new

capital amounts for FY 1992 using the

PPS–IX cost reports as the first source

of data. For FY 1993 amounts, we used

PPS–IX and PPS–X cost reports as the

first source of data, weighting each cost

report by the number of days in FY

1993. For FY 1994 amounts, we used

PPS–X and PPS–XI cost reports as the

first source of data, weighting each cost

report by the number of days in FY

1994. We were able to match 5,049 PPS–

IX cost reports, 5,062 PPS–X cost

reports, and 4,654 PPS–XI cost reports.

In cases where cost reports could not be

matched, we used the provider-specific

file for old capital information. Even in

cases where a cost report was available,

the breakout of old and new capital was

not always available. In these cases, we

used the old capital amounts and new

capital ratios from the provider-specific

file. If these were missing, we derived
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27585

the old capital amount from the

hospital-specific rate.

Finally, we used the intermediary

audit file to develop obligated capital

amounts. Since the obligated amounts

are aggregate projected amounts, we

computed a Medicare capital cost per

admission associated with these

amounts. We adjusted the aggregate

amounts by the following factors:

(1) Medicare inpatient share of

capital. This was derived from cost

reports and was limited to the Medicare

share of total inpatient days. It was

necessary to limit the Medicare share

because of data integrity problems.

Medicare share of inpatient days is a

reasonably good proxy for allocating

capital. However, it may be understated

if Medicare utilization is high, and may

be overstated because it does not reflect

the outpatient share of capital.

(2) Capitalization factor. This factor

allocates the aggregate amount of

obligated capital to depreciation and

interest amounts. Consistent with the

assumptions in the capital input price

index, we used a 25-year life for fixed

capital and a 10-year life for movable

capital, and an average projected

interest rate of 6.7 percent. We also

assumed that fixed capital acquisitions

are about one-half of total capital. In

conjunction with the useful life and

interest rate assumptions, the resulting

capitalized fixed capital is about onehalf of total capitalization. This is

consistent with the allocations between

fixed and movable capital found on the

cost reports. The ratio we developed is

0.137, which produces the first year

capitalization based on the aggregate

amount.

(3) A divisor of Medicare admissions

to derive the capital costs per discharge

amount. Since we must project capital

amounts for each hospital, we

continued to use a Monte Carlo

simulation to develop these amounts.

(This model is described in detail in the

August 30, 1991 final rule (56 FR

43517).) The Monte Carlo simulation is

now used only to project capital costs

per discharge amounts for each hospital.

We analyzed the distributions of capital

increases, and noted a slightly negative

correlation between the dollar level of

capital cost per admission, and the rate

of increase in capital. To determine the

rate of increase in capital cost per

admission, we multiplied the lesser of

$3,000 or the capital cost per admission

by .00006 and subtracted this result

from 1.2. (Increases for capital levels

over $3,000 were not influenced by the

level of capital, so this part of the

calculation was capped at $3,000.) We

selected a random number from the

normal distribution, multiplied it by

0.17 (the standard deviation) and added

it to ¥0.04 (the mean) and then added

1 to create a multiplier. This random

result was multiplied by the previous

result to assign a rate of increase factor

which was multiplied by the prior

year’s capital per discharge amount to

develop a capital per discharge amount

for the projected year.

To model a projected year, we used

the old and new capital for the prior

year multiplied by 0.85 (aging factor).

The 0.85 aging factor is the average of

changes in capital over its life due to the

gradual decrease in interest payments

and the retirement of fully

depreciatiated capital. The aged new

and old capital is subtracted from the

projected capital described in the

previous paragraph. The difference

represents newly acquired capital. If the

hospital has obligated capital, any

increase in ‘‘old’’ capital up to the total

amount of obligated capital in FY 1993

and FY 1994 is assigned to obligated

capital. Any remaining obligated capital

is assigned to FY 1995 up to the amount

of the modeled increase in capital for

FY 1995. Even though obligated capital

must be put in use for patient care by

October 1, 1994, the use of the obligated

capital may have started late in FY 1994

with only part of the ‘‘first year’’

depreciation and interest realized in FY

1994. The remainder of the ‘‘first year’’

depreciation and interest would be

realized in FY 1995. With the exception

of certain hospitals about whom we

have information to the contrary, we

assume that hospitals would meet the

expiration dates provided under the

obligated capital provision. Hence, no

obligated capital is assigned to years FY

1996 and later. Once obligated capital is

assigned, it is included with the ‘‘old’’

capital and is capitalized into future

years as part of ‘‘old’’ capital. The online obligated amounts are added to old

capital and subtracted from the newly

acquired capital to yield residual newly

acquired capital, which is then added to

new capital. The residual newly

acquired capital is never permitted to be

less than zero.

Next, we computed the average total

capital cost per discharge from the

capital costs that were generated by the

model and compared the results to total

capital costs per discharge that we had

projected independently of the model.

We adjusted the newly acquired capital

amounts proportionately, so that the

total capital costs per discharge

generated by the model match the

independently projected capital costs

per discharge.

Once each hospital’s capital-related

costs are generated, the model projects

capital payments. We use the actual

payment parameters (for example, the

case-mix index and the geographic

adjustment factor) that are applicable to

the specific hospital.

To project capital payments, the

model first assigns the applicable

payment methodology (fully prospective

or hold-harmless) to the hospital. If

available, the model uses the payment

methodology indicated in the PPS–IX

cost reports or the provider-specific file.

Otherwise, the model determines the

methodology by comparing the

hospital’s FY 1992 hospital-specific rate

to the adjusted Federal rate applicable

to the hospital. The model simulates

Federal rate payments using the

assigned payment parameters and

hospital-specific estimated outlier

payments. The case-mix index for a

hospital is derived from the FY 1995

MedPAR file using the FY 1997 DRG

relative weights published in this

proposed rule. The case-mix index is

increased each year after FY 1995 based

on analysis of past experiences in casemix increases.

We analyzed the case-mix increases

for the recent past and found that casemix increases have decelerated to about

1.53 percent in FY 1992, 0.80 percent in

FY 1993, and 0.75 percent in FY 1994.

It appears that the case-mix increase for

FY 1995 accelerated to around 1.6

percent. Early indications show that FY

1996 case-mix is increasing at FY 1995

level, around 1.6 percent. It appears that

the deceleration of case-mix increases in

FY 1993 and FY 1994 were anomalous,

rather than the beginning of a trend.

Therefore, in the model we are using the

recent experience and have used a casemix increase of 1.6 percent in FY 1995

and a projected case-mix increase of 1.6

percent in both FY 1996 and FY 1997.

(Since we are using FY 1995 cases for

our analysis, the FY 1995 increase in

case mix has no effect on projected

capital payments.)

Changes in geographic classification

and revisions to the hospital wage data

used to establish the hospital wage

index affect the geographic adjustment

factor. Changes in the DRG classification

system and the relative weights affect

the case-mix index.

Section 1886(g)(1)(A) of the Act

requires that, for discharges occurring

after September 30, 1993, the

unadjusted standard Federal rate be

reduced by 7.4 percent. Consequently,

the model reduces the unadjusted

standard Federal rate by 7.4 percent

effective in FY 1994. Since budget

neutrality expires effective with FY

1996, this adjustment affects the

adjusted Federal rate starting in FY

1996.
27586 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

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

the estimated aggregate payments for the

fiscal year, based on the Federal rate

after any changes resulting from DRG

reclassifications and recalibration and

the geographic adjustment factor, equal

the estimated aggregate payments based

on the Federal rate that would have

been made without such changes. For

FY 1996, the budget neutrality

adjustment factor was 1.0025. To

determine the factor for FY 1997, we

first determined the portion of the

Federal rate that would be paid for each

hospital in FY 1997 based on its

applicable payment methodology. Using

our model, we then compared estimated

aggregate Federal rate payments based

on the FY 1996 DRG relative weights

and the FY 1996 geographic adjustment

factor to estimated aggregate Federal

rate payments based on the FY 1997

relative weights and the FY 1997

geographic adjustment factor. In making

the comparison, we held the FY 1997

Federal rate portion constant and set the

other budget neutrality adjustment

factor and the exceptions reduction

factor to 1.00. We determined that to

achieve budget neutrality for the

changes in the geographic adjustment

factor and DRG classifications and

relative weights, an incremental budget

neutrality adjustment of 0.9992 for FY

1997 should be applied to the previous

cumulative FY 1996 adjustment of

1.0025 (the product of the FY 1993

incremental adjustment of 0.9980, the

FY 1994 incremental adjustment of

1.0053, the FY 1995 incremental

adjustment of 0.9998, and the FY 1996

incremental adjustment of 0.9994),

yielding a cumulative adjustment of

1.0017 through FY 1997.

The methodology used to determine

the recalibration and geographic (DRG/

GAF) budget neutrality adjustment

factor is similar to that used in

establishing budget neutrality

adjustments under the prospective

payment system for operating costs. One

difference is that under the operating

prospective payment system, the budget

neutrality adjustments for the effect of

geographic reclassifications are

determined separately from the effects

of other changes in the hospital wage

index and the DRG relative weights.

Under the capital prospective payment

system, there is a single DRG/GAF

budget neutrality adjustment factor for

changes in the geographic adjustment

factor (including geographic

reclassification) and the DRG relative

weights. In addition, there is no

adjustment for the effects that

geographic reclassification has on the

other payment parameters, such as the

payments for serving low income

patients or the large urban add-on.

In addition to computing the DRG/

GAF budget neutrality adjustment

factor, we used the model to simulate

total payments under the prospective

payment system.

Additional payments under the

exceptions process are accounted for

through a reduction in the Federal and

hospital-specific rates. Therefore, we

used the model to calculate the

exceptions reduction factor. This

exceptions reduction factor ensures that

aggregate payments under the capital

prospective payment system, including

exceptions payments, are projected to

equal the aggregate payments that

would have been made under the

capital prospective payment system

without an exceptions process. Since

changes in the level of the payment

rates change the level of payments

under the exceptions process, the

exceptions reduction factor must be

determined through iteration.

In the August 30, 1991 final rule (56

FR 43517), we indicated that we would

publish each year the estimated

payment factors generated by the model

to determine payments for the next 5

years. The table below provides the

actual factors for FY 1992, FY 1993, FY

1994, FY 1995, FY 1996, the proposed

FY 1997 factor, and the estimated

factors that would be applicable through

FY 2001. We caution that, except with

respect to FY 1992, FY 1993, FY 1994,

FY 1995 and FY 1996, these are

estimates only, and are subject to

revisions resulting from continued

methodological refinements, more

recent data, and any payment policy

changes that may occur. In this regard,

we note that in making these projections

we have assumed that the cumulative

DRG/GAF adjustment factor will remain

at 1.0017 for FY 1997 and later because

we do not have sufficient information to

estimate the change that will occur in

the factor for years after FY 1997.

The projections are as follows:

Fiscal year Update

factor

Exceptions

reduction

factor

Budget neutrality factor

Federal

rate (after

outlier)

reduction)

1992 .................................................................................................................................. N/A 0.9813 0.9602 415.59

1993 .................................................................................................................................. 6.07 .9756 .9162 1 417.29

1994 .................................................................................................................................. 3.04 .9485 .8947 2 378.34

1995 .................................................................................................................................. 3.44 .9734 .8432 3 376.83

1996 .................................................................................................................................. 1.20 .9849 N/A 4 461.96

1997 .................................................................................................................................. 1.00 .9393 N/A 5 441.84

1998 .................................................................................................................................. 1.00 .9161 N/A 435.23

1999 .................................................................................................................................. 1.00 .9228 N/A 442.80

2000 .................................................................................................................................. 1.10 .9155 N/A 444.13

2001 .................................................................................................................................. 1.10 N/A6 N/A 490.46

1 Note: Includes the DRG/GAF adjustment factor of 0.9980 and the change in the outlier adjustment from 0.9497 in FY 1992 to 0.9496 in FY

1993. 2 Note: Includes the 7.4 percent reduction in the unadjusted standard Federal rate. Also includes the DRG/GAF adjustment factor of 1.0033

and the change in the outlier adjustment from 0.9496 in FY 1993 to 0.9454 in FY 1994. 3 Note: Includes the DRG/GAF adjustment factor of 1.0031 and the change in the outlier adjustment from 0.9454 in FY 1994 to 0.9414 in FY

1995. 4 Note: Includes the the transfer adjustment of .9972. Also includes the DRG/GAF adjustment factor of 1.0025 and the change in the outlier

adjustment from 0.9414 in FY 1995 to 0.9536 in FY 1996. 5 Note: Includes the DRG/GAF adjustment factor of 1.0017 and the change in the outlier adjustment from 0.9536 in FY 1996 to 0.9476 in FY

1997. Future adjustments are, for purposes of this projection, assumed to remain at the same level. 6 Note: We are unable to estimate exceptions payments for the year under the special exceptions provision (§ 412.348(g) of the regulations)

because the regular exceptions provision (§ 412.348(e)) expires.
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27587

Appendix C: Rebased Market Basket

Data Sources I. Data Sources Used To

Determine the Market Basket Relative

Weights and Choice of Price Proxy

Variables for the Operating Hospital

Input Price Indexes

As discussed in section IV of the

preamble to this proposed rule, we are

rebasing and revising the hospital

market baskets. This appendix describes

the technical features of the 1992-based

indexes that we are proposing in this

rule. For both the prospective payment

and excluded hospital market baskets,

the differences between the proposed

1992-based market basket and the

previous 1987-based market basket are

noted. In the September 4, 1990 final

rule (55 FR 36170), we discussed in

detail the 1987-based hospital market

baskets.

We present this description of the

hospital operating market baskets in

three steps:

• A synopsis of the structural

differences between the 1987-based

market baskets and the proposed 1992-

based market baskets.

• A description of the methodology

used to develop the cost category

weights in the 1992-based market

baskets, making note of the differences

from the methodology used to develop

the 1987-based market baskets.

• A description of the data sources

used to measure price change for each

component of the 1992-based market

baskets, making note of the differences

from the price proxies used in the 1987-

based hospital market baskets.

A. Synopsis of Structural Changes

Adopted in the Rebased 1992 Operating

Hospital Market Baskets

Three major structural differences

exist between the 1987-based and the

proposed 1992-based operating hospital

market baskets.

• The proposed hospital market

baskets are based on more recent

hospital expenditure data. The 1987-

based market baskets contained skeletal

cost shares that were derived from the

1987 cost data from the 1988 Annual

Survey of the American Hospital

Association (AHA). The 1992-based

market baskets use data from the

hospital cost reports for cost reporting

periods beginning on or after October 1,

1991 and before October 1, 1992.

• Some cost categories have been

combined, namely Fuel, Oil, Coal, and

Other Fuel with Motor Gasoline, and

Blood Services with Chemicals. These

category mergers reflect the Bureau of

Economic Analysis (BEA)

reclassification decisions in the 1987

update of the BEA Input-Output Tables.

• In the proposed 1992-based market

basket, the sample of excluded hospitals

is restricted to more closely reflect the

average Medicare length of stay in

excluded hospitals. We have used cost

report data for excluded hospitals from

only those hospitals in which the

Medicare average length of stay is

within 15 percent of the total average

length of stay to more accurately reflect

the structure of costs for Medicare cases.

This is a change from the FY 1987-based

market basket, for which data from all

excluded hospitals were used.

B. Methodology for Developing the Cost

Category Weights

Cost category weights for the 1992-

based market baskets were developed in

four stages. First, base weights for three

(Wages and Salaries, Employee Benefits,

Pharmaceuticals) of the six main

categories were derived from the 1992

Medicare cost reports for operating

costs. Second, the weight for

Nonmedical Professional Fees was

developed by subtracting Medical

Professional Fees reported in the

Hospital Cost Report Information

System (HCRIS) file from AHA Annual

Survey Total Professional Fees to obtain

Nonmedical Professional Fees, and the

weight for Professional Liability

Insurance was developed using 1989

HCRIS data trended forward to 1992,

using the relative importance values in

the previous market baskets. Third, the

sum of Wages and Salaries, Employee

Benefits, Pharmaceuticals, Nonmedical

Professional Fees, and Professional

Liability Insurance was subtracted from

total expenses to obtain All Other

Expenses. Finally, the weight for All

Other Expenses was divided into

subcategories using cost shares from the

1987 Input-Output Table for the

hospital industry, produced by the U.S.

Department of Commerce, Bureau of

Economic Analysis, aged to 1992 using

price changes. We will incorporate 1992

data from the U.S. Department of

Commerce into the final market basket

if the data are released in time to be

analyzed in developing the final rule.

Below, we describe the source of the

six main category weights and their

subcategories in the 1992-based market

baskets. We make note of the differences

between the methodologies used to

develop the 1987-based and the 1992-

based market baskets.

1. Wages and Salaries: The cost

weight for the Wages and Salaries

category was derived using the 1992

Medicare cost reports. Contract Labor,

which is also derived from the 1992

Medicare cost reports, is split between

the Wages and Salaries and Employee

Benefits cost categories, using the

relationship for employed workers.

Examples of Contract Labor are

registered nurses and workers in

hospital food service or security who are

employed and paid by firms that

contract for their work with the

hospital. The Wages and Salaries cost

category was disaggregated into nine

occupational subcategories (professional

and technical, managers and

administration, sales, clerical, craft and

kindred, operatives excluding transport,

transport equipment operatives,

nonfarm laborers and service workers)

to reflect the mix of occupational inputs

used by hospitals. The Contract Labor

wages and salaries component was

allocated proportionally to ProfessionalTechnical and Service occupations. The

1987-based weights were developed

from the 1987 Current Population

Survey, while the 1992-based weights

were developed from the 1992 Current

Population Survey.

2. Employee Benefits: The cost weight

for the employee benefits category was

derived from the 1992 cost reports. Like

wages and salaries, the employee benefit

weight in each 1992-based market

basket is a composite of nine labor

subcategories. The employee benefits

categories in the 1987-based market

baskets were developed from the 1987

AHA Annual Survey and used the 1987

Current Population Survey. In 1987

Contract Labor’s implied fringe benefits

were allocated proportionally to

Professional and Technical occupations,

while in 1992 they were allocated to

Professional-Technical and Service

occupations.

3. Nonmedical Professional Fees: The

cost weight for the nonmedical

professional fees category was derived

from the 1992 Medicare Cost Reports

and AHA Annual Survey data. Total

professional fees were split into the

subcategories medical and other

(nonmedical) fees using AHA Total

Professional Fees minus HCRIS Medical

Professional Fees to equal Nonmedical

Professional Fees. The 1987-based

nonmedical professional fees cost

category was derived from the 1987

AHA Annual Survey and American

Medical Association (AMA) data. It was

split into the subcategories medical and

other fees using data derived from the

American Medical Association. The

medical professional fees category is

excluded from the hospital market

basket since it is paid under Medicare

Part B.

4. Professional Liability Insurance:

The 1987-based market baskets have

weights for professional liability

insurance that were derived from the

June 30 and December 31, 1987 HAS/

Monitrend surveys. The cost weight for
27588 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

the 1992-based professional liability

insurance category was derived from

1989 HCRIS cost shares trended to 1992

using the change in the relative

importance factor for professional

liability insurance (malpractice) from

the previous 1987-based prospective

payment hospital and excluded hospital

market baskets.

5. Utilities: For the 1987-based market

baskets, the cost weight for utilities was

derived by extrapolating the 1985 AHA

Annual Survey utilities cost weight

forward to 1987 using the rate of growth

in the HAS/Monitrend cost weight for

utilities between 1985 and 1987. The

1987 Utility subcategory weights were

aged from their 1982-based index

subcategory weights using price changes

from 1982 to 1987. The 1992-based

market basket cost weights for the

subcategories (fuel, oil and gasoline;

electricity; natural gas; and water and

sewage) were derived from the Bureau

of Economic Analysis’ 1987 InputOutput table for the hospital industry,

aged forward to 1992 by price changes

and summed to a weight for utilities.

6. All Other Goods and Services: The

all other goods and services category has

more subcategories than any other

market basket category. Goods found in

this category include: direct service

food, contract service food,

pharmaceuticals, chemicals, medical

instruments, photo supplies, rubber and

plastics, paper products, apparel,

machinery and equipment and

miscellaneous products. Services found

in this category include: business

services, computer services,

transportation and shipping, telephone,

postage, other labor-intensive services,

and other nonlabor-intensive services.

The share for pharmaceuticals was

derived from the 1992 Medicare cost

reports. Relative shares for the other

subcategories were derived from the

1987 Bureau of Economic Analysis’

Input-Output table for the hospital

industry and were aged forward to 1992

using price changes. As noted above, if

more recent U.S. Department of

Commerce data become available for

these categories and we have time to

analyze these data before the

publication of the final rule, they will be

incorporated into the final market

baskets.

C. Price Proxies Used to Measure Cost

Category Growth

1. Wages and Salaries: For measuring

price growth in the 1992-based market

basket, 10 price proxies are applied to

the 9 occupational subcategories within

the wages and salaries component. As in

the 1987-based market basket, the

professional and technical subcategory

was split in half. An Employee Cost

Index (ECI) for hourly wages paid to

civilian hospital workers was applied to

one half. An ECI of hourly wages and

salaries paid to professional and

technical workers in private industry

was applied to the other half of the

professional and technical component.

The other eight occupations

subcategories of the wages and salaries

component were proxied using ECIs for

wages and salaries for private industry

workers in their respective occupational

categories.

2. Employee Benefits: The 1992-based

hospital market baskets use occupationspecific ECIs for employee benefits. The

distribution of weights and price

proxies is the same as for wages and

salaries discussed above, but

occupation-specific employee benefit

ECIs replace occupation-specific wages

and salaries ECIs. The components are

summed into a composite index, just as

was done for the 1987-based market

basket.

3. Nonmedical Professional Fees: The

ECI for compensation for professional

and technical workers in private

industry is applied to this category. This

is a revision from the 1987-based market

basket in which the ECI for wages and

salaries for professional and technical

workers in private industry was used.

4. Fuel, Oil, and Gasoline: The

percentage change in the price of

refined petroleum products as measured

by the Producer Price Index (PPI)

(Commodity Code #057) was applied to

this component. This is a revision from

the 1987-based indexes in which the

PPIs for Light Fuel Oil (Commodity

Code #0573) and Gasoline (Commodity

Code #0571) were used.

5. Electricity: The percentage change

in the price of commercial electric

power as measured by the PPI

(Commodity Code #0542) was applied to

this component. This is a revision from

the 1987-based indexes in which the PPI

for industrial power (Commodity Code

#0543) was used.

6. Natural Gas: The percentage change

in the price of gas fuels as measured by

the PPI (Commodity Code #0552) was

applied to this component. This is a

revision from the 1987-based indexes in

which the PPI for Natural Gas

(Commodity Code #0531) was used.

7. Water and Sewerage: The

percentage change in the price of water

and sewerage maintenance as measured

by the Consumer Price Index (CPI) for

all urban consumers was applied to this

component. The same price measure

was used in the 1987-based market

baskets.

8. Professional Liability Insurance:

The percentage change in the hospital

professional liability insurance price as

estimated by hospital industry

professional liability insurance

premium increase was applied to this

component. The same price measure

was used in the 1987-based market

baskets.

9. Pharmaceuticals: The percentage

change in the price of ethical

preparations as measured by the PPI

(Commodity Code #0635) was applied to

this variable. The same price measure

was used in the 1987-based market

baskets.

10. Food, Direct Purchases: The

percentage change in the price of

processed foods and feeds as measured

by the PPI (Commodity Code #02) was

applied to this component. The same

price measure was used in the 1987-

based market baskets.

11. Food, Contract Services: The

percentage change in the price of food

purchased away from home as measured

by the CPI for all urban consumers was

applied to this component. The same

price measure was used in the 1987-

based market baskets.

12. Chemicals: The percentage change

in the price of industrial chemical

products as measured by the PPI

(Commodity Code #061) was applied to

this component. The same price

measure was used in the 1987-based

market baskets.

13. Surgical and Medical Equipment:

The percentage change in the price of

medical and surgical instruments as

measured by the PPI (Commodity Code

#1562) was applied to this component.

The same price measure was used in the

1987-based market baskets.

14. Photographic Supplies: The

percentage change in the price of

photographic supplies as measured by

the PPI (Commodity Code #1542) was

applied to this component. The same

price measure was used in the 1987-

based market baskets.

15. Rubber and Plastics: The

percentage change in the price of rubber

and plastic products as measured by the

PPI (Commodity Code #07) was applied

to this component. The same price

measure was used in the 1987-based

market baskets.

16. Paper Products: The percentage

change in the price of converted paper

and paperboard products as measured

by the PPI (Commodity Code # 0915)

was used. This is a revision from the

1987-based indexes in which a weighted

average of the percentage change in the

price of converted paper and

paperboard products and the percentage

change in the price of paper excluding

newsprint and packaging paper

(Commodity Code #091301) was used.
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27589

17. Apparel: The percentage change in

the price of apparel as measured by the

PPI (Commodity Code #381) was

applied to this component. This is a

revision from the 1987-based indexes in

which the PPI for textile house

furnishings (Commodity Code #0382)

was used.

18. Minor Machinery and Equipment:

The percentage change in the price of

machinery and equipment as measured

by the PPI (Commodity Code #11) was

applied to this component. The same

price measure was used in the 1987-

based market baskets.

19. Miscellaneous Products: The

percentage change in the price of all

finished goods as measured by the PPI

was applied to this component. The

same price measure was used in the

1987-based market baskets.

20. Business Services: The ECI for

compensation for workers in the

business services industry was applied

to this component. This is a revision

from the 1987-based indexes in which

the percentage change in the AHE for

wages and salaries for production and

nonsupervisory workers in the business

services industry as measured by the

Bureau of Labor Statistics (SIC Code 73)

was used.

21. Computer and Data Processing

Services: The percentage change in the

AHE of production and nonsupervisory

workers engaged in firms furnishing

computer data processing services (SIC

Code 737) was applied to this

component. The same price measure

was used in the 1987-based market

baskets.

22. Transportation and Shipping: The

percentage change in the transportation

component of the CPI for all urban

consumers was applied to this

component. The same price measure

was used in the 1987-based market

baskets.

23. Telephone: The percentage change

in the price of telephone services as

measured by the CPI for all urban

consumers was applied to this

component. The same price measure

was used in the 1987-based market

baskets.

24. Postage: The percentage change in

the price of postage as measured by the

CPI for all urban consumers was applied

to this component. The same price

measure was used in the 1987-based

market baskets.

25. All Other Services, Labor

Intensive: The percentage change in the

ECI for compensation paid to service

workers employed in private industry

was applied to this component. This is

a revision from the 1987-based indexes

in which the ECI for wages and salaries

paid to service workers employed in

private industry was used.

26. All Other Services, Nonlabor

Intensive: The percentage change in the

all-items component of the CPI for all

urban consumers was applied to this

component. The same price measure

was used in the 1987-based market

baskets.

For further discussion of the rationale

for choosing specific price proxies, we

refer the reader to the September 3, 1986

final rule (51 FR 31582).

II. Data Sources Used to Determine the

Cost Category Weights and Vintage

Weights, and Choices of Price Proxy

Variables for the Hospital Capital Input

Price Index

In the preamble to this proposed rule,

we discuss the rebasing of the capital

input price index (CIPI). This appendix

describes certain technical features of

the 1992-based index that we are

proposing in this rule, as well as

differences between the proposed 1992-

based CIPI and the current 1987-based

CIPI. We discussed the 1987-based CIPI

in the September 1, 1995 final rule (60

FR 45817.)

This discussion has the following

three parts:

• A synopsis of the differences

between the 1987-based CIPI and the

proposed 1992-based CIPI.

• A description of the methodology

used to develop the cost category

weights and vintage weights in the

1992-based CIPI, making note of the

differences from the methodology used

to develop the 1987-based CIPI.

• A description of the data sources

used to measure price change for each

component of the 1992-based CIPI,

making note of the differences from the

price proxies used in the 1987-based

CIPI.

A. Synopsis of Changes Adopted in the

Rebased 1992 CIPI

We made no structural changes in the

1992-based CIPI. The only major change

is the use of more recent hospital capital

expenditure data in the proposed 1992-

based CIPI.

The 1987-based CIPI contained cost

category weights that were derived from

1987 Medicare cost report data and the

1987 Annual Survey of the AHA. The

1992-based CIPI uses data from the

hospital Medicare cost reports for cost

periods beginning between October 1,

1991 and September 30, 1992. The

1992-based CIPI also uses data from the

1992 Annual Survey of the AHA.

The 1987-based CIPI contained

vintage weights that were derived from

1987 Medicare cost report data, the

1963-1987 Panel Survey of the AHA,

and the 1980–1989 Securities Data

Corporation data on hospital bonds. The

1992-based CIPI uses data from the 1992

Medicare cost reports, the 1963–1992

Panel Survey of the AHA, and 1980–

1992 Securities Data Corporation data

on hospital bonds.

B. Methodology for Developing Cost

Category Weights and Vintage Weights

for the 1992-based CIPI

There are five cost categories in the

CIPI: building and fixed equipment

depreciation, movable equipment

depreciation, capital-related interest

expense from government/nonprofit

debt instruments, capital-related interest

expense from for-profit debt

instruments, and other capital-related

expenses, such as taxes and insurance.

The methodology for developing each of

these cost category weights is described

below:

1. Building and Fixed Equipment

Depreciation: The 1992-based cost

weight for building and fixed equipment

depreciation was derived using the 1992

Medicare cost reports. The proportion of

lease expenses attributable to building

and fixed equipment was included in

the cost weight based on the proportion

of overall capital expenses allocated to

building and fixed equipment

depreciation. The 1987-based weight

was developed from the 1987 Medicare

cost reports and the 1987 AHA Annual

Survey.

2. Movable Equipment Depreciation:

The 1992-based cost weight for movable

equipment depreciation was derived

using the 1992 Medicare Cost Reports.

The proportion of lease expenses

attributable to movable equipment was

included in the cost weight based on the

proportion of overall capital expenses

allocated to movable equipment

depreciation. The 1987-based weight

was developed from the 1987 Medicare

cost reports and the 1987 AHA Annual

Survey.

3. Government/Nonprofit Interest:

The 1992-based cost weight for

government/nonprofit interest was

derived using the 1992 AHA Annual

Survey data. The government/nonprofit

interest is 85 percent of total interest,

reflecting the relative debts of the

government/nonprofit hospital sector

and the for-profit hospital sector. The

proportion of lease expenses attributable

to government/nonprofit interest was

included in the cost weight based on the

proportion of overall capital expenses

allocated to government/non-profit

interest expense. The 1987-based weight

was developed from the 1987 AHA

Annual Survey.

4. For-Profit Interest: The 1992-based

cost weight of for-profit interest was
27590 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

derived using the 1992 AHA Annual

Survey data. The for-profit interest is 15

percent of total interest, reflecting the

relative debts of the government/

nonprofit hospital sector and the forprofit hospital sector. The proportion of

lease expenses attributable to for-profit

interest was included in the cost weight

based on the proportion of overall

capital expenses allocated to for-profit

interest expense. The 1987-based weight

was developed from the 1987 AHA

Annual Survey.

5. Other Capital-Related Expenses:

The 1992-based cost weight for other

capital-related expenses was derived

using 1992 Medicare cost reports. The

proportion of lease expenses attributable

to other capital-related expenses was

included in the cost weight based on the

proportion of overall capital expenses

allocated to other capital-related

expenses. The 1987-based weight was

developed from the 1987 Medicare cost

reports and the 1987 Capital

Expenditure Survey.

There are three sets of vintage weights

in the CIPI: building and fixed

equipment depreciation, movable

equipment depreciation, and interest

expense. The methodology for

developing each of these vintage

weights is described below.

1. Building and Fixed Equipment: The

1992-based building and fixed

equipment vintage weights were derived

from the 1992 Medicare cost reports and

the 1963–1992 AHA Panel Survey. The

1987-based weights were developed

from the 1987 Medicare cost reports and

the 1963–1987 AHA Panel Survey.

2. Movable Equipment: The 1992-

based movable equipment vintage

weights were derived from the 1992

Medicare cost reports and the 1963–

1992 AHA Panel Survey. The 1987-

based weights were developed from the

1987 Medicare cost reports and the

1963–1987 AHA Panel Survey.

3. Capital-Related Interest: The 1992-

based movable equipment vintage

weights were derived from the 1980–

1992 Securities Data Corporation data

on hospital bonds and the 1963–1992

AHA Panel Survey. The 1987-based

weights were developed from the 1980–

1989 Securities Data Corporation data

on hospital bonds and the 1963–1987

AHA Panel Survey.

C. Price Proxies Used to Measure Cost

Category Growth in the CIPI

1. Building and Fixed Equipment

Depreciation: The percentage change in

the vintage-weighted price of building

and fixed equipment depreciation as

measured by the Boeckh institutional

construction index was applied to this

category in the 1992-based CIPI. The

same price proxy was used in the 1987-

based CIPI.

2. Movable Equipment Depreciation:

The percentage change in the vintageweighted price of movable equipment

depreciation as measured by the

Producer Price Index (PPI) for

machinery and equipment was applied

to this category in the 1992-based CIPI.

The same price proxy was used in the

1987-based CIPI.

3. Government/Nonprofit Interest

Expense: The percentage change in the

vintage-weighted price of government/

nonprofit interest expense as measured

by the Average yield on Domestic

Municipal Bonds from the Bond Buyer

index of 20 bonds was applied to this

category in the 1992-based CIPI. The

same price proxy was used in the 1987-

based CIPI.

4. For-Profit Interest Expense: The

percentage change in the vintageweighted price of for-profit interest

expense as measured by the Average

yield on Moody’s AAA Bonds was

applied to this category in the 1992-

based CIPI. The same price proxy was

used in the 1987-based CIPI.

5. Other Capital-Related Expenses:

The percentage change in the price of

other capital-related expenses as

measured by the CPI for all urban

consumers for residential rent was

applied to this category in the 1992-

based CIPI. The same price proxy was

used in the 1987-based CIPI.

We provided more detailed

discussion of the rationale for the choice

of these price proxies in the June 2,

1995 proposed rule (60 FR 29227) and

in the September 1, 1995 final rule (60

FR 45815).

The Honorable Albert Gore, Jr.

President of the Senate

Washington, D.C. 20510

Dear Mr. President: Section 1886(e)(3)(B) of

the Social Security Act (the Act) requires me

to report to Congress the initial estimate of

the applicable percentage increase in

inpatient hospital payment rates for Federal

Fiscal Year (FY) 1997 that I will recommend

for hospitals subject to the Medicare

prospective payment system (PPS) and for

hospitals and units excluded from PPS. This

submission constitutes the required report.

Current law mandates an update for all

PPS hospitals of the market basket rate of

increase minus 0.5 percentage points. The

President’s FY 1997 budget includes an

update for PPS hospitals in both large urban

areas and other areas equal to the market

basket rate of increase minus 1.5 percentage

points. The President’s FY 1997 budget

estimated the PPS market basket rate of

increase for FY 1997 to be 3.6 percent. Based

on this estimate, we recommend an update

for hospitals in both large urban and other

areas of 2.1 percent. However, recent data

from ProPAC and other sources suggest that

the final PPS market basket rate of increase

for FY 1997 will be lower.

Sole community hospitals (SCHs) are the

sole source of care in their area and are

afforded special payment protection to

maintain access to services for Medicare

beneficiaries. SCHs are paid the higher of a

hospital-specific rate or the Federal PPS rate.

Current law mandates an update for sole

community hospitals of the market basket

rate of increase minus 0.5 percentage points.

Consistent with the President’s FY 1997

budget, we recommend an update to

hospital-specific rates equal to the increase

for all PPS hospitals; that is, the market

basket rate of increase of 3.6 percent minus

1.5 percentage points, or 2.1 percent.

Hospitals and distinct part hospital units

excluded from PPS are paid based on their

reasonable costs subject to a limit under the

Tax Equity and Fiscal Responsibility Act

(TEFRA) of 1982. Current law mandates an

update for all hospitals and distinct part

hospital units excluded from PPS equal to

the rate of increase in the excluded hospital

market basket minus 1.0 percentage point,

although the update can be higher for certain

hospitals and units with costs that are greater

than their target amounts. The President’s FY

1997 budget incorporates an increase in the

TEFRA limit equal to the rate of increase in

the excluded hospital market basket (3.6

percent) minus 1.5 percentage points.

Therefore, we recommend an increase in the

TEFRA limit of 2.1 percent.

My recommendation for the updates is

based on cost projections used in the

President’s FY 1997 budget. A final

recommendation on the appropriate

percentage increases for FY 1997 will be

made nearer the beginning of the new

Federal Fiscal Year based on the most current

market basket projection available at that

time. The final recommendation will

incorporate our analysis of the latest

estimates of all relevant factors, including

recommendations by the Prospective

Payment Assessment Commission (ProPAC).

We currently expect that the final estimate of

the market basket rate of increase will be

lower than the estimate used in the

President’s FY 1997 budget.

Section 1886(d)(4)(C)(iv) of the Act also

requires that I include in my report

recommendations with respect to

adjustments to the diagnosis-related group

(DRG) weighting factors. At this time I do not

anticipate recommending any adjustment to

the DRG weighting factors for FY 1997.

I am pleased to provide this

recommendation to you. I am also sending a

copy of this letter to the Speaker of the House

of Representatives.

Sincerely,

Donna E. Shalala

The Honorable Newt Gingrich

Speaker of the House of Representatives

Washington, D.C. 20515

Dear Mr. Speaker: Section 1886(e)(3)(B) of

the Social Security Act (the Act) requires me

to report to Congress the initial estimate of

the applicable percentage increase in

inpatient hospital payment rates for Federal

Fiscal Year (FY) 1997 that I will recommend

for hospitals subject to the Medicare

prospective payment system (PPS) and for

hospitals and units excluded from PPS. This

submission constitutes the required report.
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27591

Current law mandates an update for all

PPS hospitals of the market basket rate of

increase minus 0.5 percentage points. The

President’s FY 1997 budget includes an

update for PPS hospitals in both large urban

areas and other areas equal to the market

basket rate of increase minus 1.5 percentage

points. The President’s FY 1997 budget

estimated the PPS market basket rate of

increase for FY 1997 to be 3.6 percent. Based

on this estimate, we recommend an update

for hospitals in both large urban and other

areas of 2.1 percent. However, recent data

from ProPAC and other sources suggest that

the final PPS market basket rate of increase

for FY 1997 will be lower.

Sole community hospitals (SCHs) are the

sole source of care in their area and are

afforded special payment protection to

maintain access to services for Medicare

beneficiaries. SCHs are paid the higher of a

hospital-specific rate or the Federal PPS rate.

Current law mandates an update for sole

community hospitals of the market basket

rate of increase minus 0.5 percentage points.

Consistent with the President’s FY 1997

budget, we recommend an update to

hospital-specific rates equal to the increase

for all PPS hospitals; that is, the market

basket rate of increase of 3.6 percent minus

1.5 percentage points, or 2.1 percent.

Hospitals and distinct part hospital units

excluded from PPS are paid based on their

reasonable costs subject to a limit under the

Tax Equity and Fiscal Responsibility Act

(TEFRA) of 1982. Current law mandates an

update for all hospitals and distinct part

hospital units excluded from PPS equal to

the rate of increase in the excluded hospital

market basket minus 1.0 percentage point,

although the update can be higher for certain

hospitals and units with costs that are greater

than their target amounts. The President’s FY

1997 budget incorporates an increase in the

TEFRA limit equal to the rate of increase in

the excluded hospital market basket (3.6

percent) minus 1.5 percentage points.

Therefore, we recommend an increase in the

TEFRA limit of 2.1 percent.

My recommendation for the updates is

based on cost projections used in the

President’s FY 1997 budget. A final

recommendation on the appropriate

percentage increases for FY 1997 will be

made nearer the beginning of the new

Federal Fiscal Year based on the most current

market basket projection available at that

time. The final recommendation will

incorporate our analysis of the latest

estimates of all relevant factors, including

recommendations by the Prospective

Payment Assessment Commission (ProPAC).

We currently expect that the final estimate of

the market basket rate of increase will be

lower than the estimate used in the

President’s FY 1997 budget.

Section 1886(d)(4)(C)(iv) of the Act also

requires that I include in my report

recommendations with respect to

adjustments to the diagnosis-related group

(DRG) weighting factors. At this time I do not

anticipate recommending any adjustment to

the DRG weighting factors for FY 1997.

I am pleased to provide this

recommendation to you. I am also sending a

copy of this letter to the President of the

Senate.

Sincerely,

Donna E. Shalala

Appendix E: Recommendation of

Update Factors for Operating Cost

Rates of Payment for Inpatient Hospital

Services

I. Background

Several provisions of the Social

Security Act (the Act) address the

setting of update factors for inpatient

services furnished in FY 1997 by

hospitals subject to the prospective

payment system and those excluded

from the prospective payment system.

Section 1886(b)(3)(B)(i)(XII) of the Act

sets the FY 1997 percentage increase in

the operating cost standardized amounts

equal to the rate of increase in the

hospital market basket minus 0.5

percentage points for prospective

payment hospitals in all areas. Section

1886(b)(3)(B)(iv) of the Act sets the FY

1997 percentage increase in the

hospital-specific rates applicable to sole

community hospitals equal to the rate

set forth in section 1886(b)(3)(B)(i) of

the Act, that is, the same update factor

as all other hospitals subject to the

prospective payment system, or the rate

of increase in the market basket minus

0.5 percentage points. Section

1886(b)(3)(B)(ii) of the Act sets the FY

1997 percentage increase in the rate of

increase limits for hospitals excluded

from the prospective payment system

equal to the rate of increase in the

excluded hospital market basket minus

the applicable reduction or, in the case

of a hospital in a fiscal year for which

the hospital’s update adjustment

percentage is at least 10 percent, the

excluded hospital market basket

percentage increase. Under section

1886(b)(3)(B)(v) of the Act, a hospital’s

update adjustment percentage increase

for FY 1997 is the percentage increase

by which the hospital’s allowable

operating costs of inpatient hospital

services recognized under this title for

the cost reporting period beginning in

FY 1990 exceed the hospital’s target

amount for such cost reporting period,

increased for each fiscal year (beginning

with FY 1994) by the sum of any of the

hospital’s applicable reductions for

previous years. The applicable

reduction with respect to a hospital for

FY 1997 is the lesser of 1 percentage

point or the percentage point difference

between 10 percent and the hospital’s

update adjustment percentage for FY

1997.

In accordance with section

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

proposing to update the standardized

amounts, the hospital-specific rates, and

the rate-of-increase limits for hospitals

excluded for the prospective payment

system as provided in section

1886(b)(3)(B) of the Act. Based on the

first quarter 1996 forecast of the FY

1997 rebased market basket increase of

2.7 percent for hospitals subject to the

prospective payment system, the

proposed updates in the standardized

amounts are 2.2 percent for hospitals in

both large urban and other areas. The

proposed update in the hospital-specific

rate applicable to sole community

hospitals is 2.2 percent (that is, the

market basket rate of increase of 2.7

percent minus 0.5 percentage points).

The proposed update for hospitals

excluded from the prospective payment

system is based on the percentage

increase in the excluded hospital market

basket (currently estimated at 2.7

percent) minus the applicable reduction

factor. The applicable reduction factor is

the lesser of 1 percentage point or the

percentage point difference between 10

percent and the hospital’s update

adjustment percentage. Therefore, for

excluded hospitals, the hospital-specific

proposed update can vary between 1.7

and 2.7 percent.

Sections 1886(e)(2)(A) and (3)(A) of

the Act require that the Prospective

Payment Assessment Commission

(ProPAC) recommend to the Congress by

March 1, 1996 an update factor that

takes into account changes in the market

basket rate of increase index, hospital

productivity, technological and

scientific advances, the quality of health

care provided in hospitals, and longterm cost effectiveness in the provision

of inpatient hospital services.

In its March 1, 1996 report, ProPAC

recommended update factors to the

standardized amounts equal to the

percentage increase in the market basket

minus 0.7 to 2.0 percentage points for

hospitals in both large urban and other

areas (Recommendation 10). Based on

its market basket rate of increase

estimate of 2.7 percent, ProPAC’s

recommended update to the

standardized amounts equals 2.0 to 0.7

percent for hospitals in both large urban

and other areas. (ProPAC’s market

basket is still using the 1987-based

weights.) ProPAC did not make a

separate recommendation for the

hospital-specific rates applicable to sole

community hospitals. The components

of ProPAC’s update factor

recommendations are described in

detail in the ProPAC report, which is

published as Appendix F to this

document. We discuss ProPAC’s

recommendations concerning the

update factors and our responses to

these recommendations below.

Section 1886(e)(4) of the Act requires

that the Secretary, taking into
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consideration the recommendations of

ProPAC, recommend update factors for

each fiscal year that take into account

the amounts necessary for the efficient

and effective delivery of medically

appropriate and necessary care of high

quality. Under section 1886(e)(5) of the

Act, we are required to publish the

update factors recommended under

section 1886(e)(4) of the Act.

Accordingly, this appendix provides the

recommendations of appropriate update

factors, the analysis underlying our

recommendations, and our responses to

the ProPAC recommendations

concerning the update factors.

II. Secretary’s Recommendations

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

we are recommending that the

standardized amounts be increased by

an amount equal to the market basket

rate of increase minus 1.5 percentage

points for hospitals located in large

urban and other areas. We are also

recommending an update of the market

basket rate of increase minus 1.5

percentage points to the hospitalspecific rate for sole community

hospitals. These figures are consistent

with the President’s FY 1997 budget

recommendation, which continues the

reductions imposed by section 13501 of

the Omnibus Budget Reconciliation Act

of 1993 (Public Law 103–66), that is,

reductions in the hospital market basket

of 2.5 percentage points for FYs 1994

and 1995 and 2.0 percentage points for

FY 1996. We believe these

recommended changes in the update

factor would ensure that Medicare acts

as a prudent purchaser and provide

incentives to hospitals for increased

efficiency, thereby contributing to the

solvency of the Medicare Part A Trust

Fund. When the President’s budget was

submitted, the market basket rate of

increase was projected at 3.6 percent. As

noted above, this proposed

recommendation is based on the most

recent forecast of the proposed rebased

market basket. (See section IV of the

preamble to this proposed rule for a

detailed discussion of the market

basket.)

We recommend that hospitals

excluded from the prospective payment

system receive an update equal to the

percentage increase in the proposed

rebased market basket that measures

input price increases for services

furnished by excluded hospitals minus

1.5 percentage points. That market

basket rate of increase is currently

forecast at 2.7 percent. Subtracting 1.5

percentage points would result in an

update for hospitals excluded from the

prospective payment system of 1.2

percent. This recommendation is

consistent with the President’s budget,

acknowledging that the market basket

rate of increase for these hospitals also

was forecast at 3.6 percent at the time

the budget was submitted.

As required by section 1886(e)(4) of

the Act, we have taken into

consideration the recommendations of

ProPAC in setting these recommended

update factors. Our responses to the

ProPAC recommendations concerning

the update factors are discussed below.

III. ProPAC Recommendation for

Updating the Prospective Payment

System Standardized Amounts

For FY 1997, ProPAC’s update

framework would support an update

between 0.7 percentage points and 2.0

percentage points less than the increase

in the hospital market basket index. The

methodology employed by the

Commission in previous years would

lead to a recommendation of about

market basket minus 1.5 percentage

points, roughly corresponding to the

midpoint of that range. In light of the

significant changes occurring in health

care delivery, the Commission believes

that the increase in the prospective

payment system rates could be held to

market basket minus 2.0 percentage

points for the next year or two.

However, it is concerned about the

potential effects of continuing updates

at that level on hospitals’ financial

health. Low updates over an extended

period of time could affect a hospital’s

ability to provide quality care to

Medicare beneficiaries, compromise

access, and impede the diffusion of

quality-enhancing technological

advances.

Based on the market basket estimate

of 2.7 percent, ProPAC recommends that

hospitals in large urban and other areas

receive an update between 0.7 to 2.0

percent.

Response: We are recommending an

update that is consistent with the

Administration’s budget proposal. Our

recommendation is that the update for

FY 1997 for prospective payment

system hospitals located in large urban

and other areas be equal to the market

basket rate of increase forecast minus

1.5 percentage points. Based on HCFA’s

current forecast of the market basket rate

of increase (2.7 percent), we recommend

an update for FY 1997 for large urban

and other hospitals equal to 1.2 percent.

Our recommendation is supported by

the following analyses that measure

changes in hospital productivity,

scientific and technological advances,

practice pattern changes, and changes in

case mix:

• Productivity: Service level

productivity is defined as the ratio of

total service output to full-time

equivalent employees (FTEs). While we

recognize that productivity is a function

of many variables (for example, labor,

nonlabor material, and capital inputs),

we use a labor productivity measure

since this update framework applies to

operating payment. To recognize that

we are apportioning the short run

output changes to the labor input and

not considering the nonlabor inputs, we

weight our productivity measure for

operating costs by the share of direct

labor services in the market basket rate

of increase to determine the expected

effect on cost per case.

Our recommendation for the service

productivity component is based on

historical trends in productivity and

total output for both the hospital

industry and the general economy, and

projected levels of future hospital

service output. ProPAC has also

estimated cumulative service

productivity growth to be 4.9 percent

from 1985–1989, or 1.2 percent

annually. At the same time, the

Commission estimates total output

growth at 3.4 percent annually,

implying a ratio of service productivity

growth to output growth of 0.35. Our

Medicare Provider Analysis and Review

(MedPAR) file analysis indicates total

Medicare service output (charges per

admission, adjusted for CPI change)

increased 10.7 percent from 1987–1995,

or an approximate average annual

increase of 1.2 percent. Since it is not

possible at this time to develop a

productivity measure specific to

Medicare patients, we examined

productivity (output per hour) and

output (gross domestic product) for the

economy. Depending on the exact time

period, annual changes in productivity

range from 0.3 to 0.35 percent of the

change in output (that is, a 1.0 percent

increase in output would be correlated

with an 0.3 to 0.35 percent change in

output per hour).

Under our framework, the

recommended update is based in part

on expected productivity—that is,

projected service output during the year

multiplied by the historical ratio of

service productivity to total service

output, multiplied by the share of labor

in total operating inputs, as calculated

in the hospital market basket rate of

increase. This method estimates an

expected labor productivity

improvement in the same proportion to

expected total service growth that has

occurred in the past and assumes that,

at a minimum, growth in FTEs changes

proportionally to the growth in total

service output. Thus, the

recommendation allows for unit

productivity to be smaller than the
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historical averages in years that output

growth is relatively low and higher in

years that output growth is larger than

the historical trend. Based on the above

estimates from both the hospital

industry and the economy, we have

chosen to employ the range of ratios of

productivity change to output change of

0.30 to 0.35.

The expected change in total hospital

service output is the product of

projected growth in total admissions

(adjusted for outpatient usage),

projected real case-mix growth, and

expected quality enhancing intensity

growth, net of expected decline in

intensity due to reduction of cost

ineffective practice. Case-mix growth

and intensity numbers for Medicare are

used as proxies for those of the total

hospital, since case-mix increases (used

in the intensity measure as well) are

unavailable for non-Medicare patients.

Thus, expected output growth is simply

the sum of the expected change in

intensity (0.0 percent), projected

admissions change (2.7 percent for FY

1997), and projected real case-mix

growth (1.6 percent), or 4.3 percent. The

share of direct labor services in the

market basket rate of increase

(consisting of wages, salaries, and

employee benefits) is 61.4 percent.

Multiplying the expected change in total

hospital service output (4.3 percent) by

the ratio of historical service

productivity change to total service

growth of 0.30 to 0.35 and by the direct

labor share percentage (0.614) provides

our productivity standard of 0.8 to 0.9

percent.

ProPAC also believes hospitals should

be given an incentive for additional

productivity improvement. ProPAC

measures productivity as the ratio of

hospital admissions (adjusted for case

mix and outpatient services) per FTE

employee (adjusted for changes in skill

mix). ProPAC includes in its

productivity measurement the effect of

changes in practice patterns. We treat

practice pattern changes as a portion of

our intensity adjustment, described

below. ProPAC’s latest estimate indicate

that hospital productivity increased as

much as 2.3 percent in 1994. Given this

improvement, ProPAC believes a

productivity adjustment in the range of

–0.7 to –1.2 percentage points would be

reasonable in fiscal year 1997. The

adjustment is intended to share

productivity equally between hospitals

and Medicare. In the near future,

ProPAC believes there may be even

greater productivity improvements, as

hospitals strive to stay competitive and

financially viable.

• Intensity: We base our intensity

standard on the combined effect of three

separate factors: changes in the use of

quality enhancing services, changes in

the use of services due to shifts in

within-DRG severity, and changes in the

use of services due to reductions of costineffective practices. For FY 1997, we

recommend an adjustment of 0.0

percent. The basis of this

recommendation is discussed below.

We have no empirical evidence that

accurately gauges the level of qualityenhancing technology changes.

Typically, a specific new technology

increases cost in some uses and

decreases cost in other uses.

Concurrently, health status is improved

in some situations while in other

situations it may be unaffected or even

worsened using the same technology. It

is difficult to separate out the relative

significance of each of the cost

increasing effects for individual

technologies and new technologies.

The quality enhancing technology

component is intended to recognize the

use of services that increase cost but

whose value in terms of enhanced

health-status is commensurate with

these costs. Such services may result

from technological change, or in some

cases, increased use of existing

technologies. The latter recognizes that

as cost and medical effectiveness

studies become available, some

increased use of existing, as well as

new, services may be warranted.

The component for reduction of costineffective practice recognizes that some

improvements in practice patterns could

be made so that the intensity of services

provided is more consistent with the

efficient use of limited resources. That

is, improvements could be made so that

the number of services provided during

an inpatient stay, and their complexity,

produce an improvement in health

status that is consistent with the cost of

care. This component of our update

recommendation is intended to

encourage both hospitals and physicians

to more carefully consider the costeffectiveness of medical care. This

component of the framework also

accounts for real within-DRG change,

since that should be directly reflected in

the CMI-adjusted growth in real charges

per case.

Following methods developed by

HCFA’s Office of the Actuary for

deriving hospital output estimates from

total hospital charges, we have

developed Medicare-specific intensity

measures based on a 5-year average

using FY 1991–1995 MedPAR billing

data. Case-mix constant intensity is

calculated as the change in total

Medicare charges per discharge adjusted

for changes in the average charge per

unit of service as measured by the

Medical CPI hospital component and

changes in real case mix. Thus, in order

to measure changes in intensity, one

must measure changes in real case mix.

For FY 1991 and FY 1992, we

estimate that 1.0 to 1.4 percent of

observed case-mix increase was real.

This estimate is supported by past

studies of case-mix change by the RAND

Corporation. The most recent study was

≥Has DRG Creep Crept Up?

Decomposing the Case Mix Index

Change Between 1987 and 1988≥ by

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

Relles, R–4098–HCFA/ProPAC (1991).

The study suggests that real case-mix

change was not dependent on total

change, but was rather a fairly steady

1.0 to 1.5 percent per year. In the past

we have used 1.4 percent as the upper

bound because the RAND study did not

take into account that hospitals may

have induced doctors to document

medical records more completely in

order to improve payment. For FY 1993

and FY 1994, we assumed that all of the

observed case-mix increases of 0.9 and

0.8 percent, respectively, were real. For

FY 1995, we assumed that all of the

observed case-mix increase of 1.6

percent was real. We note that this

assumed increase in real case mix is

higher than our previously assumed

upper bound of 1.4 percent. Based on its

analysis of the FY 1995 MedPAR data,

the Office of the Actuary has concluded

that the apparent shifting of some cases

to the outpatient setting and activity in

the cardiovascular DRGs has

contributed to a higher than expected

increase in real case mix.

Given estimates of real case-mix

increase of 1.0 percent for FY 1991–

1992, 0.9 percent for FY 1993, 0.8

percent for FY 1994, and 1.6 percent for

FY 1995, we estimate case-mix constant

intensity declined by an average 1.1

percent during FY 1991 through 1995,

for a cumulative decrease of 5.6 percent.

If we assume that real case-mix increase

was 1.4 percent for FYs 1991 and 1992,

0.9 percent for FY 1993, 0.8 percent for

FY 1994, and 1.6 percent for FY 1995,

we estimate case-mix constant intensity

declined by an average of 1.2 percent

during FY 1991 through 1994, for a

cumulative decrease of 5.9 percent.

Since we estimate that intensity has

declined during FY 1991–1995 period,

we are recommending a 0.0 percent

intensity adjustment for FY 1997.

• Quality Enhancing New Science

and Technology: For FY 1997, ProPAC

has computed the adjustment for

scientific and technological advances to

be a future-oriented policy target

intended to provide additional funds for

hospitals to adopt quality-enhancing,

cost increasing health care innovations.
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While in the past the Commission has

included an adjustment ranging from

0.3 to 1.0 percentage points, the current

range is lower because there is little

evidence of significant new costincreasing advances ready for

implementation. Moreover, the costcompetitive environment now faced by

hospitals may dampen the adoption of

new technologies as they closely

evaluate their relative costs and

benefits. Therefore, the Commission

recommends an adjustment of 0.1 to 0.6

percentage points for the increase in

operating costs due to scientific and

technological advances.

• Change in Case Mix: Our analysis

takes into account projected changes in

case mix, adjusted for changes

attributable to improved coding

practices. For our FY 1997 update

recommendation, we are projecting a 1.6

percent increase in the case-mix index.

We define real case-mix increase as

actual changes in the mix (and resource

requirements) of Medicare patients as

opposed to changes in coding behavior

that result in assignment of cases to

higher-weighted DRGs but do not reflect

greater resource requirements. For FY

1997, we believe that real case-mix

increase is equal to our projected change

in case mix. We do not see any changes

in coding behavior in our projected

case-mix change. Our net adjustment to

case-mix change for FY 1997 is 0.0

percentage points.

The ¥1.0 to ¥0.9 percent figure used

in the ProPAC framework represents

ProPAC’s projection for observed casemix change. ProPAC projects a 0.8 to 0.9

percentage points increase in real casemix change across DRG’s and a 0.0 to

0.2 percentage points increase in

within-DRG case-complexity change.

ProPAC’s net adjustment for case mix is

¥0.2 to 0.0 percentage points.

• Effect of FY 1995 DRG

Reclassification and Recalibration: We

estimate that DRG reclassification and

recalibration for FY 1995 resulted in a

0.0 percent increase in the case-mix

index when compared with the casemix index that would have resulted if

we had not made the reclassification

and recalibration changes to the

GROUPER. ProPAC does not make an

adjustment for DRG reclassification and

recalibration in its update

recommendation.

• Correction for Market Basket

Forecast Error: The estimated market

basket percentage increase used to

update the FY 1995 payment rates was

3.6 percent. Our most recent data

indicate the actual FY 1995 increase

was 3.0 percent, reflecting that the

actual increase in wages was lower than

projected. The resulting forecast error in

the FY 1995 market basket rate of

increase is 0.6 percentage points. Under

our update framework, we make a

forecast error correction if our estimate

is off by 0.25 percentage points or more.

Therefore, we are recommending an

adjustment of ¥0.6 percentage points to

reflect this overestimation of the FY

1995 market basket rate of increase. The

following is a summary of the update

ranges supported by our analyses

compared to ProPAC’s framework.

TABLE 1.—COMPARISON OF FY 1997 UPDATE RECOMMENDATIONS

HHS ProPAC

Market Basket ...................................................................................................................................... MB MB

Difference Between HCFA & ProPAC Market Baskets ....................................................................... .................................. –0.1 to 0.0

Subtotal ..................................................................................................................................... MB MB to MB–0.1

Policy Adjustment Factors

Productivity ........................................................................................................................................... –0.9 to –0.8 –1.2 to –0.7

Intensity: 0.0 ..................................

Science and Technology .............................................................................................................. .................................. 0.1 to 0.6

Practice Patterns ........................................................................................................................... .................................. (1)

Real Within DRG Change ............................................................................................................. .................................. (2)

Subtotal ..................................................................................................................................... –0.9 to –0.8 –1.1 to –0.1

Case-Mix Adjustment Factors

Projected Case-Mix Change ......................................................................................................... –1.6 –1.0 to –0.9

Real Across DRG Change ............................................................................................................ 1.6 0.8 to 0.9

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

Subtotal ..................................................................................................................................... 0.0 –0.2 to 0.0

Effect of 1995 Reclassification and Recalibration ........................................................................ 0.0 ..................................

Forecast Error Correction .................................................................................................................... –0.6 –0.6

Total Recommended Update .................................................................................................... MB–1.5 to MB–1.4 MB–2.0 to MB–0.7

1 Included in ProPAC’s Productivity Measure.

2 Included in ProPAC’s Case-Mix Adjustment.

3 Included in HHS’ Intensity Factor.

The above analysis would support a

recommendation that the update be

between market basket minus 1.4 and

market basket minus 1.5 percentage

points. We are recommending an update

of market basket minus 1.5 percentage

points, consistent with President

Clinton’s FY 1997 budget proposal. We

also recommend that the hospitalspecific rates applicable to sole

community hospitals be increased by

the same update, market basket minus

1.5 percentage points.

V. ProPAC Recommendation for

Updating the Rate-of-Increase Limits

for Excluded Hospitals

ProPAC recommends an update factor

equal to the market basket rate of

increase minus 0.6 percentage points for

excluded hospitals and units

(Recommendation 12). The 0.6

percentage points reduction represents a
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reduction of 0.6 percentage points to

account for the forecast error in the FY

1995 market basket rate of increase for

excluded units, no increase to reflect the

different compensation price proxies

used by ProPAC, and no allowance for

new technology. ProPAC believes that

major changes in the excluded

hospitals’ target amounts should not be

made at this time. Rather, a prospective

payment system for excluded hospitals

and units should be implemented as

soon as possible.

Response: We recommend that

hospitals excluded from the prospective

payment system receive an update equal

to the percentage increase in the market

basket that measures input price

increases for services furnished by

excluded hospitals minus 1.5

percentage points. The reduction is

consistent with the updates provided

under President Clinton’s budget

proposal. The market basket rate of

increase for excluded hospitals is

currently forecast at 2.7 percent.

Subtracting 1.5 percentage points would

result in an update of 1.2 percent for

excluded hospitals and units.

As noted by ProPAC, HCFA has

contracted with the RAND Corporation

to analyze a classification system for

rehabilitation patients that appears to

have the potential to serve as the basis

for a prospective payment system for

rehabilitation hospitals and units.

However, even if this classification

system is found to be suitable, it would

be several years before we could fully

implement any prospective payment

system for these facilities. In addition,

we have been less successful in our

pursuit of a suitable classification

system for the other types of excluded

hospitals. Therefore, as an interim

measure, the President’s budget

contains a proposal to rebase the target

amounts for excluded hospitals and

units on more recent cost data. Changes

would also be made to the conditions

under which facilities would receive

additional payment when they exceed

their limits. Incentive payments for

facilities whose costs are below their

target amounts would be eliminated.

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Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27681
27682 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27683
27684 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27685
27686 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27687
27688 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27689
27690 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27691
27692 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27693
27694 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27695
27696 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27697
27698 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27699
27700 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27701
27702 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27703
27704 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27705
27706 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules
Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules 27707
27708 Federal Register / Vol. 61, No. 106 / Friday, May 31, 1996 / Proposed Rules

[FR Doc. 96–13613 Filed 5–30–96; 8:45 am]

BILLING CODE 4120–01–C