162 
(b) ESTABLISHMENT
OF SEPARATE CONVERSION 
FACTORS
FOR EACH SERVICE CATEGORY.—Subsection 
(d)(1) of section 1848 of the Social Security Act (42 
U.S.C. 1395w–4) is amended— 
(1) in subparagraph (A)— 
(A) by designating the sentence beginning 
‘‘The conversion factor’’ as clause (i) with the 
heading ‘‘APPLICATION OF SINGLE CONVERSION 
FACTOR’’ and with appropriate indentation; 
(B) by striking ‘‘The conversion factor’’ 
and inserting ‘‘Subject to clause (ii), the con-
version factor’’; and 
(C) by adding at the end the following new 
clause: 
‘‘(ii) APPLICATION OF MULTIPLE CON-
VERSION
FACTORS
BEGINNING
WITH 
2008.— 
‘‘(I) IN
GENERAL.—In applying 
clause (i) for years beginning with 
2008, separate conversion factors 
shall be established for each service 
category of physicians’ services (as de-
fined in subsection (j)(5)) and any 
reference in this section to a conver-
sion factor for such years shall be 
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163 
deemed to be a reference to the con-
version factor for each of such cat-
egories. 
‘‘(II) INITIAL CONVERSION FAC-
TORS; 
SPECIAL
RULE
FOR
ANES-
THESIA SERVICES.— Such factors for 
2008 shall be based upon the single 
conversion factor for 2007 multiplied 
by the update established under para-
graph (8) for such category for 2008. 
In the case of the service category de-
scribed in subsection (j)(5)(F) (relat-
ing to anesthesia services), the conver-
sion factor for 2008 shall be based on 
the separate conversion factor speci-
fied in subparagraph (D) for 2007 
multiplied by the update established 
under paragraph (8) for such category 
for 2008. 
‘‘(III) UPDATING
OF
CONVER-
SION FACTORS.— Such factor for a 
service category for a subsequent year 
shall be based upon the conversion 
factor for such category for the pre-
vious year and adjusted by the update 
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164 
established for such category under 
paragraph (8) for the year involved.’’; 
and 
(2) in subparagraph (D), by inserting ‘‘(before 
2008)’’ after ‘‘for a year’’. 
(c) ESTABLISHING UPDATES FOR CONVERSION FAC-
TORS FOR SERVICE CATEGORIES.—Section 1848(d) of the 
Social Security Act (42 U.S.C. 1395w–4(d)) is amended— 
(1) in paragraph (4)(B), by striking ‘‘and (6)’’ 
and inserting ‘‘, (6), and (8)’’; 
(2) in paragraph (4)(C)(iii), by striking ‘‘The 
allowed’’ and inserting ‘‘Subject to paragraph 
(8)(B), the allowed’’; 
(3) in paragraph (4)(D), by striking ‘‘The up-
date’’ and inserting ‘‘Subject to paragraph (8)(E), 
the update’’; and 
(4) by adding at the end the following new 
paragraphs: 
‘‘(8) UPDATES FOR SERVICE CATEGORIES BE-
GINNING WITH 2008.— 
‘‘(A) IN GENERAL.—In applying paragraph 
(4) for a year beginning with 2008, the fol-
lowing rules apply: 
‘‘(i) APPLICATION OF SEPARATE UP-
DATE ADJUSTMENTS FOR EACH SERVICE 
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CATEGORY.—Pursuant 
to 
paragraph 
(1)(A)(ii)(I), the update shall be made to 
the conversion factor for each service cat-
egory (as defined in subsection (j)(5)) 
based upon an update adjustment factor 
for the respective category and year and 
the update adjustment factor shall be com-
puted, for a year, separately for each serv-
ice category. 
‘‘(ii) COMPUTATION OF ALLOWED AND 
ACTUAL EXPENDITURES BASED ON SERV-
ICE CATEGORIES.—In computing the prior 
year adjustment component and the cumu-
lative adjustment component under clauses 
(i) and (ii) of paragraph (4)(B), the fol-
lowing rules apply: 
‘‘(I) APPLICATION
BASED
ON 
SERVICE
CATEGORIES.—The allowed 
expenditures and actual expenditures 
shall be the allowed and actual ex-
penditures for the service category, as 
determined under subparagraph (B). 
‘‘(II) LIMITATION TO PHYSICIAN 
FEE-SCHEDULE
SERVICES.—Actual 
expenditures shall only take into ac-
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166 
count expenditures for services fur-
nished under the physician fee sched-
ule. 
‘‘(III) APPLICATION
OF
CAT-
EGORY
SPECIFIC
TARGET
GROWTH 
RATE.—The 
growth 
rate 
applied 
under clause (ii)(II) of such para-
graph shall be the target growth rate 
for the service category involved under 
subsection (f)(5). 
‘‘(IV) ALLOCATION
OF
CUMU-
LATIVE
OVERHANG.—There shall be 
substituted for the difference de-
scribed in subparagraph (B)(ii)(I) of 
such paragraph the amount described 
in subparagraph (C)(i) for the service 
category involved. 
‘‘(B) DETERMINATION
OF
ALLOWED
EX-
PENDITURES.—In applying paragraph (4) for a 
year beginning with 2008, notwithstanding sub-
paragraph (C)(iii) of such paragraph, the al-
lowed expenditures for a service category for a 
year is an amount computed by the Secretary 
as follows: 
‘‘(i) FOR 2008.—For 2008: 
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167 
‘‘(I) TOTAL
2007
ALLOWED
EX-
PENDITURES.—Compute the total al-
lowed expenditures for services fur-
nished under the physician fee sched-
ule under such paragraph for 2007. 
‘‘(II) 
INCREASE
BY
GROWTH 
RATE.—Increase the total under sub-
clause (I) by the target growth rate 
for such category under subsection (f) 
for 2008. 
‘‘(III) ALLOCATION TO SERVICE 
CATEGORY.—Multiply the increased 
total under subclause (II) by the over-
hang allocation factor for the service 
category (as defined in subparagraph 
(C)(iii)). 
‘‘(ii) FOR SUBSEQUENT YEARS.—For 
a subsequent year, take the amount of al-
lowed expenditures for such category for 
the preceding year (under clause (i) or this 
clause) and increase it by the target 
growth rate determined under subsection 
(f) for such category and year. 
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168 
‘‘(C) COMPUTATION AND APPLICATION OF 
CUMULATIVE
OVERHANG
AMONG
CAT-
EGORIES.— 
‘‘(i) IN
GENERAL.—For purposes of 
applying paragraph (4)(B)(ii)(II) under 
clause (ii)(IV), the amount described in 
this clause for a year (beginning with 
2008) is the sum of the following: 
‘‘(I) 
PRE-2008 
CUMULATIVE 
OVERHANG.—The amount of the pre- 
2008 cumulative excess spending (as 
defined in clause (ii)) multiplied by 
the overhang allocation factor for the 
service category (under clause (iii)). 
‘‘(II) POST-2007 
CUMULATIVE 
AMOUNTS.—For a year beginning 
with 2009, the difference (which may 
be positive or negative) between the 
amount of the allowed expenditures 
for physicians’ services (as determined 
under paragraph (4)(C)) in the serv-
ice category from January 1, 2008, 
through the end of the prior year and 
the amount of the actual expenditures 
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169 
for such services in such category dur-
ing that period. 
‘‘(ii) PRE-2008 CUMULATIVE EXCESS 
SPENDING
DEFINED.—For purposes of 
clause (i)(I), the term ‘pre-2008 cumu-
lative excess spending’ means the dif-
ference 
described 
in 
paragraph 
(4)(B)(ii)(I) as determined for the year 
2008, taking into account expenditures 
through December 31, 2007. Such dif-
ference takes into account expenditures in-
cluded in subsection (f)(4)(A). 
‘‘(iii) OVERHANG
ALLOCATION
FAC-
TOR.—For purposes of this paragraph, the 
term ‘overhang allocation factor’ means, 
for a service category, the proportion, as 
determined by the Secretary of total actual 
expenditures under this part for items and 
services in such category during 2007 to 
the total of such actual expenditures for all 
the service categories. In calculating such 
proportion, the Secretary shall only take 
into account services furnished under the 
physician fee schedule. 
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170 
‘‘(D) FLOOR FOR UPDATES FOR 2008 AND 
2009.—The update to the conversion factors for 
each service category for each of 2008 and 
2009 shall be not less than 0.5 percent. 
‘‘(E) CHANGE IN RESTRICTION ON UPDATE 
ADJUSTMENT FACTOR FOR 2010 AND 2011.—The 
update adjustment factor determined under 
subparagraph (4)(B), as modified by this para-
graph, for a service category for a year (begin-
ning with 2010 and ending with 2011) may be 
less than –0.07, but may not be less than 
–0.14.’’. 
(d) APPLICATION OF SEPARATE TARGET GROWTH 
RATES FOR EACH CATEGORY.— 
(1) IN GENERAL.—Section 1848(f) of the Social 
Security Act (42 U.S.C. 1395w–4(f)) is amended by 
adding at the end the following new paragraph: 
‘‘(5) APPLICATION
OF
SEPARATE
TARGET 
GROWTH RATES FOR EACH SERVICE CATEGORY BE-
GINNING WITH 2008.—The target growth rate for a 
year beginning with 2008 shall be computed and ap-
plied separately under this subsection for each serv-
ice category (as defined in subsection (j)(5)) and 
shall be computed using the same method for com-
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171 
puting the sustainable growth rate except for the fol-
lowing: 
‘‘(A) The reference in paragraphs (2)(A) 
and (2)(D) to ‘all physicians’ services’ is 
deemed a reference to the physicians’ services 
included in such category but shall not take 
into account items and services included in phy-
sicians’ services through the operation of para-
graph (4)(A). 
‘‘(B) The factor described in paragraph 
(2)(C) for the service category described in sub-
section (j)(5)(A) shall be increased by 0.03. 
‘‘(C) A national coverage determination (as 
defined in section 1869(f)(1)(B)) shall be treat-
ed as a change in regulation described in para-
graph (2)(D).’’. 
(2) USE OF TARGET GROWTH RATES.—Section 
1848 of such Act is further amended— 
(A) in subsection (d)— 
(i) in paragraph (1)(E)(ii), by insert-
ing ‘‘or target’’ after ‘‘sustainable’’; and 
(ii) in paragraph (4)(B)(ii)(II), by in-
serting ‘‘or target’’ after ‘‘sustainable’’; 
and 
(B) in subsection (f)— 
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172 
(i) in the heading by inserting ‘‘; TAR-
GET GROWTH RATE’’ after ‘‘SUSTAINABLE 
GROWTH RATE’’ 
(ii) in paragraph (1)— 
(I) by striking ‘‘and’’ at the end 
of subparagraph (A); 
(II) in subparagraph (B), by in-
serting ‘‘before 2008’’ after ‘‘each 
succeeding year’’ and by striking the 
period at the end and inserting ‘‘; 
and’’; and 
(III) by adding at the end the 
following new subparagraph: 
‘‘(C) November 1 of each succeeding year 
the target growth rate for such succeeding year 
and each of the 2 preceding years.’’; and 
(iii) in paragraph (2), in the matter 
before subparagraph (A), by inserting after 
‘‘beginning with 2000’’ the following: ‘‘and 
ending with 2007’’ . 
(e) REPORTS
ON EXPENDITURES
FOR PART B 
DRUGS
AND
CLINICAL
DIAGNOSTIC
LABORATORY 
TESTS.— 
(1) REPORTING REQUIREMENT.—The Secretary 
of Health and Human Services shall include infor-
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173 
mation in the annual physician fee schedule pro-
posed rule on the change in the annual rate of 
growth of actual expenditures for clinical diagnostic 
laboratory tests or drugs, biologicals, and radio-
pharmaceuticals for which payment is made under 
part B of title XVIII of the Social Security Act. 
(2) 
RECOMMENDATIONS.—The 
report 
sub-
mitted under paragraph (1) shall include an analysis 
of the reasons for such excess expenditures and rec-
ommendations for addressing them in the future. 
SEC. 302. IMPROVING ACCURACY OF RELATIVE VALUES 
UNDER 
THE 
MEDICARE 
PHYSICIAN 
FEE 
SCHEDULE. 
(a) 
USE
OF
EXPERT
PANEL
TO
IDENTIFY 
MISVALUED PHYSICIANS’ SERVICES.—Section 1848(c) of 
the Social Security Act (42 U.S.C. 1395w(c)) is amended 
by adding at the end the following new paragraph: 
‘‘(7) USE
OF
EXPERT
PANEL
TO
IDENTIFY 
MISVALUED PHYSICIANS’ SERVICES.— 
‘‘(A) IN
GENERAL.—The Secretary shall 
establish an expert panel (in this paragraph re-
ferred to as the ‘expert panel’)— 
‘‘(i) to identify, through data analysis, 
physicians’ services for which the relative 
value under this subsection is potentially 
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174 
misvalued, particularly those services for 
which such relative value may be over-
valued; 
‘‘(ii) 
to 
assess 
whether 
those 
misvalued services warrant review using 
existing processes (referred to in para-
graph (2)(J)(ii)) for the consideration of 
coding changes; and 
‘‘(iii) to advise the Secretary con-
cerning the exercise of authority under 
clauses (ii)(III) and (vi) of paragraph 
(2)(B). 
‘‘(B) COMPOSITION
OF
PANEL.—The ex-
pert panel shall be appointed by the Secretary 
and composed of— 
‘‘(i) members with expertise in med-
ical economics and technology diffusion; 
‘‘(ii) members with clinical expertise; 
‘‘(iii) physicians, particularly physi-
cians (such as a physician employed by the 
Veterans Administration or a physician 
who has a full time faculty appointment at 
a medical school) who are not directly af-
fected by changes in the physician fee 
schedule under this section; 
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175 
‘‘(iv) carrier medical directors; and 
‘‘(v) representatives of private payor 
health plans. 
‘‘(C) APPOINTMENT CONSIDERATIONS.—In 
appointing members to the expert panel, the 
Secretary shall assure racial and ethnic diver-
sity on the panel and may consider appointing 
a liaison from organizations with experience in 
the consideration of coding changes to the 
panel.’’. 
(b) EXAMINATION OF SERVICES WITH SUBSTANTIAL 
CHANGES.—Such section is further amended by adding at 
the end the following new paragraph: 
‘‘(8) EXAMINATION
OF
SERVICES
WITH
SUB-
STANTIAL CHANGES.—The Secretary, in consultation 
with the expert panel under paragraph (7), shall— 
‘‘(A) conduct a five-year review of physi-
cians’ services in conjunction with the RUC 5- 
year review, particularly for services that have 
experienced substantial changes in length of 
stay, site of service, volume, practice expense, 
or other factors that may indicate changes in 
physician work; 
‘‘(B) identify new services to determine if 
they are likely to experience a reduction in rel-
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176 
ative value over time and forward a list of the 
services so identified for such five-year review; 
and 
‘‘(C) for physicians’ services that are oth-
erwise unreviewed under the process the Sec-
retary has established, periodically review a 
sample of relative value units within different 
types of services to assess the accuracy of the 
relative values contained in the Medicare physi-
cian fee schedule.’’. 
(c) AUTHORITY TO REDUCE WORK COMPONENT FOR 
SERVICES WITH ACCELERATED VOLUME GROWTH.— 
(1) IN GENERAL.—Paragraph (2)(B) of such 
section is amended— 
(A) in clause (v), by adding at the end the 
following new subclause: 
‘‘(III) REDUCTIONS
IN
WORK 
VALUE UNITS FOR SERVICES WITH AC-
CELERATED
VOLUME
GROWTH.—Ef-
fective January 1, 2009, reduced ex-
penditures 
attributable 
to 
clause 
(vi).’’; and 
(B) by adding at the end the following new 
clauses: 
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177 
‘‘(vi) AUTHORIZING
REDUCTION
IN 
WORK VALUE UNITS FOR SERVICES WITH 
ACCELERATED
VOLUME
GROWTH.—The 
Secretary may provide (without using ex-
isting processes the Secretary has estab-
lished for review of relative value) for a re-
duction in the work value units for a par-
ticular physician’s service if the annual 
rate of growth in the expenditures for such 
service for which payment is made under 
this part for individuals for 2006 or a sub-
sequent year exceeds the average annual 
rate of growth in expenditures of all physi-
cians’ services for which payment is made 
under this part by more than 10 percent-
age points for such year. 
‘‘(vii) CONSULTATION
WITH
EXPERT 
PANEL
AND
BASED
ON
CLINICAL
EVI-
DENCE.—The Secretary shall exercise au-
thority under clauses (ii)(III) and (vi) in 
consultation with the expert panel estab-
lished under paragraph (7) and shall take 
into account clinical evidence supporting or 
refuting the merits of such accelerated 
growth’’. 
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178 
(2) EFFECTIVE DATE.—The amendments made 
by paragraph (1) shall apply with respect to pay-
ment for services furnished on or after January 1, 
2009. 
(d) ADJUSTMENT
AUTHORITY
FOR
EFFICIENCY 
GAINS FOR NEW PROCEDURES.—Paragraph (2)(B)(ii) of 
such section is amended by adding at the end the following 
new subclause: 
‘‘(III) ADJUSTMENT AUTHORITY 
FOR
EFFICIENCY
GAINS
FOR
NEW 
PROCEDURES.—In carrying out sub-
clauses (I) and (II), the Secretary 
may apply a methodology, based on 
supporting 
evidence, 
under 
which 
there is imposed a reduction over a 
period of years in specified relative 
value units in the case of a new (or 
newer) procedure to take into account 
inherent efficiencies that are typically 
or likely to be gained during the pe-
riod of initial increased application of 
the procedure.’’. 
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179 
SEC. 303. PHYSICIAN FEEDBACK MECHANISM ON PRACTICE 
PATTERNS. 
By not later than July 1, 2008, the Secretary of 
Health and Human Services shall develop and implement 
a mechanism to measure resource use on a per capita and 
an episode basis in order to provide confidential feedback 
to physicians in the Medicare program on how their prac-
tice patterns compare to physicians generally, both in the 
same locality as well as nationally. Such feedback shall 
not be subject to disclosure under section 552 of title 5, 
United States Code). 
SEC. 304. PAYMENTS FOR EFFICIENT PHYSICIANS. 
Section 1833 of the Social Security Act (42 U.S.C. 
1395l) is amended by adding at the end the following new 
subsection: 
‘‘(v) INCENTIVE PAYMENTS FOR EFFICIENT PHYSI-
CIANS.— 
‘‘(1) IN GENERAL.—In the case of physicians’ 
services furnished on or after January 1, 2009, and 
before January 1, 2011, by a participating physician 
in an efficient area (as identified under paragraph 
(2)), in addition to the amount of payment that 
would otherwise be made for such services under this 
part, there also shall be paid an amount equal to 5 
percent of the payment amount for the services 
under this part. 
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180 
‘‘(2) IDENTIFICATION OF EFFICIENT AREAS.— 
‘‘(A) IN GENERAL.—Based upon available 
data, the Secretary shall identify those counties 
or equivalent areas in the United States in the 
lowest fifth percentile of utilization based on 
per capita spending for services provided in 
2007 under this part and part A. 
‘‘(B) 
IDENTIFICATION
OF
COUNTIES 
WHERE
SERVICE
IS
FURNISHED..—For pur-
poses of paying the additional amount specified 
in paragraph (1), if the Secretary uses the 5- 
digit postal ZIP Code where the service is fur-
nished, the dominant county of the postal ZIP 
Code (as determined by the United States Post-
al Service, or otherwise) shall be used to deter-
mine whether the postal ZIP Code is in a coun-
ty described in subparagraph (A). 
‘‘(C) JUDICIAL REVIEW.— There shall be 
no administrative or judicial review under sec-
tion 1869, 1878, or otherwise, respecting— 
‘‘(i) the identification of a county or 
other area under subparagraph (A); or 
‘‘(ii) the assignment of a postal ZIP 
Code to a county or other area under sub-
paragraph (B). 
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181 
‘‘(D) PUBLICATION OF LIST OF COUNTIES; 
POSTING ON WEBSITE.—With respect to a year 
for which a county or area is identified under 
this paragraph, the Secretary shall identify 
such counties or areas as part of the proposed 
and final rule to implement the physician fee 
schedule under section 1848 for the applicable 
year. The Secretary shall post the list of coun-
ties identified under this paragraph on the 
Internet website of the Centers for Medicare & 
Medicaid Services.’’. 
SEC. 305. RECOMMENDATIONS ON REFINING THE PHYSI-
CIAN FEE SCHEDULE. 
(a) RECOMMENDATIONS ON CONSOLIDATED CODING 
FOR SERVICES COMMONLY PERFORMED TOGETHER.— 
Not later than December 31, 2008, the Comptroller Gen-
eral of the United States shall— 
(1) complete an analysis of codes paid under 
the Medicare physician fee schedule to determine 
whether the codes for procedures that are commonly 
furnished together should be combined; and 
(2) submit to Congress a report on such anal-
ysis and include in the report recommendations on 
whether an adjustment should be made to the rel-
ative value units for such combined code. 
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182 
(b) RECOMMENDATIONS
ON INCREASED USE
OF 
BUNDLED PAYMENTS.—Not later than December 31, 
2008, the Comptroller General of the United States 
shall— 
(1) complete an analysis of those procedures 
under the Medicare physician fee schedule for which 
no global payment methodology is applied but for 
which a ‘‘bundled’’ payment methodology would be 
appropriate; and 
(2) submit to Congress a report on such anal-
ysis and include in the report recommendations on 
increasing the use of ‘‘bundled’’ payment method-
ology under such schedule. 
(c) MEDICARE PHYSICIAN FEE SCHEDULE.—In this 
section, the term ‘‘Medicare physician fee schedule’’ means 
the fee schedule established under section 1848 of the So-
cial Security Act (42 U.S.C. 1395w–4). 
SEC. 306. IMPROVED AND EXPANDED MEDICAL HOME DEM-
ONSTRATION PROJECT. 
(a) IN GENERAL.—The Secretary of Health and 
Human Services (in this section referred to as the ‘‘Sec-
retary’’) shall establish under title XVIII of the Social Se-
curity Act an expanded medical home demonstration 
project (in this section referred to as the ‘‘expanded 
project’’) under this section. The expanded project super-
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183 
sedes the project that was initiated under section 204 of 
the Medicare Improvement and Extension Act of 2006 (di-
vision B of Public Law 109–432). The purpose of the ex-
panded project is— 
(1) to guide the redesign of the health care de-
livery system to provide accessible, continuous, com-
prehensive, and coordinated, care to Medicare bene-
ficiaries; and 
(2) to provide care management fees to per-
sonal physicians delivering continuous and com-
prehensive care in qualified medical homes. 
(b) NATURE AND SCOPE OF PROJECT.— 
(1) DURATION; SCOPE.—The expanded project 
shall operate during a period of three years, begin-
ning not later than October 1, 2009, and shall in-
clude a nationally representative sample of physi-
cians serving urban, rural, and underserved areas 
throughout the United States. 
(2) ENCOURAGING
PARTICIPATION
OF
SMALL 
PHYSICIAN PRACTICES.— 
(A) IN GENERAL.—The expanded project 
shall be designed to include the participation of 
physicians in practices with fewer than four 
full-time equivalent physicians, as well as physi-
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184 
cians in larger practices particularly in rural 
and underserved areas. 
(B) TECHNICAL ASSISTANCE.— In order to 
facilitate the participation under the expanded 
project of physicians in such practices, the Sec-
retary shall make available additional technical 
assistance to such practices during the first 
year of the expanded project. 
(3) SELECTION OF HOMES TO PARTICIPATE.— 
The Secretary shall select up to 500 medical homes 
to participate in the expanded project and shall give 
priority to— 
(A) the selection of up to 100 HIT-en-
hanced medical homes; and 
(B) the selection of other medical homes 
that serve communities whose populations are 
at higher risk for health disparities, 
(4) BENEFICIARY
PARTICIPATION.—The Sec-
retary shall establish a process for any Medicare 
beneficiary who is served by a medical home partici-
pating in the expanded project to elect to participate 
in the project. Each beneficiary who elects to so par-
ticipate shall be eligible— 
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(A) for enhanced medical home services 
under the project with no cost sharing for the 
additional services; and 
(B) for a reduction of up to 50 percent in 
the coinsurance for services furnished under the 
physician fee schedule under section 1848 of 
the Social Security Act by the medical home. 
The Secretary shall develop standard recruitment 
materials and election processes for Medicare bene-
ficiaries who are electing to participate in the ex-
panded project. 
(c) STANDARDS
FOR MEDICAL HOMES, HIT-EN-
HANCED MEDICAL HOMES.— 
(1) STANDARD
SETTING
AND
CERTIFICATION 
PROCESS.—The Secretary shall establish a process 
for selection of a qualified standard setting and cer-
tification organization— 
(A) to establish standards, consistent with 
this section, for medical practices to qualify as 
medical homes or as HIT-enhanced medical 
homes; and 
(B) to provide for the review and certifi-
cation of medical practices as meeting such 
standards. 
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