Part II

As Enacted ( Federal Register)

Cited authorities 16

Cited in

[Federal Register: May 3, 2007 (Volume 72, Number 85)]

[Proposed Rules]

[Page 24679-25135]

From the Federal Register Online via GPO Access [wais.access.gpo.gov]

[DOCID:fr03my07-14]

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Part II

Department of Health and Human Services

Centers for Medicare & Medicaid Services

42 CFR Parts 411, 412, 413, and 489

Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates; Proposed Rule

[[Page 24680]]

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 411, 412, 413, and 489

[CMS-1533-P]

RIN 0938-AO70

Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates

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

ACTION: Proposed rule.

SUMMARY: We are proposing to revise the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs to implement changes arising from our continuing experience with these systems, and to implement certain provisions made by the Deficit Reduction Act of 2005 (Pub. L. 109-171), the Medicare Improvements and Extension Act under Division B, Title I of the Tax Relief and Health Care Act of 2006 (Pub. L. 109-432), and the Pandemic and All-Hazards Preparedness Act (Pub. L. 109-417). In addition, in the Addendum to this proposed rule, we describe the proposed changes to the amounts and factors used to determine the rates for Medicare hospital inpatient services for operating costs and capital-related costs. We also are setting forth proposed rate-of-increase limits for certain hospitals and hospital units excluded from the IPPS that are paid in full or in part on a reasonable cost basis subject to these limits or that have a portion of a prospective payment system payment based on reasonable cost principles. These proposed changes would be applicable to discharges occurring on or after October 1, 2007.

In this proposed rule, we discuss our proposals to further refine the diagnosis-related group (DRG) system under the IPPS to better recognize severity of illness among patients--for FY 2008, we are proposing to adopt a Medicare Severity DRG (MS-DRG) classification system for the IPPS. We are also proposing to use the structure of the proposed MS-DRG system for the LTCH prospective payment system (referred to as MS-LTC-DRGs) for FY 2008.

Among the other policy changes that we are proposing to make are changes related to: Limited revisions of the reclassification of cases to proposed MS-DRGs, the proposed relative weights for the proposed MS- LTC-DRGs; the wage data, including the occupational mix data, used to compute the wage index; applications for new technologies and medical services add-on payments; payments to hospitals for the indirect costs of graduate medical education; submission of hospital quality data; provisions governing application of sanctions relating to the Emergency Medical Treatment and Labor Act of 1986 (EMTALA); provisions governing disclosure of physician ownership in hospitals and patient safety measures; and provisions relating to services furnished to beneficiaries in custody of penal authorities.

DATES: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on June 12, 2007.

ADDRESSES: In commenting, please refer to file code CMS-1533-P. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

You may submit comments in one of three ways (no duplicates, please):

1. Electronically. You may submit electronic comments on specific issues in this regulation to http://www.cms.hhs.gov/eRulemaking. Click

on the link ``Submit electronic comments on CMS regulations with an open comment period''. (Attachments should be in Microsoft Word, WordPerfect, or Excel; however, we prefer Microsoft Word.)

2. By regular mail. You may mail written comments (one original and two copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1533-P, P.O. Box 8011, Baltimore, MD 21244-1850.

Please allow sufficient time for mailed comments to be received before the close of the comment period.

3. By express or overnight mail. You may send written comments (one original and two copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1533-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

4. By hand or courier. If you prefer, you may deliver (by hand or courier) your written comments (one original and two copies) before the close of the comment period to one of the following addresses. If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 786-7195 in advance to schedule your arrival with one of our staff members. Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201, or 7500 Security Boulevard, Baltimore, MD 21244-1850.

(Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without Federal Government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp- in clock is available for persons wishing to retain proof of filing by stamping in and retaining an extra copy of the comments being filed.)

Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period.

Submission of comments on paperwork requirements. You may submit comments on this document's paperwork requirements by mailing your comments to the addresses provided at the end of the ``Collection of Information Requirements'' section in this document.

For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Marc Hartstein, (410) 786-4548, Operating Prospective Payment, Diagnosis-Related Groups (DRGs), Wage Index, New Medical Services and Technology Add-On Payments, and Hospital Geographic Reclassifications Issues Tzvi Hefter, (410) 786-4487, Capital Prospective Payment, Excluded Hospitals, Graduate Medical Education, Critical Access Hospitals, and Long-Term Care (LTC)-DRG Issues Siddhartha Mazumdar, (410) 786-6673, Rural Community Hospital Demonstration Issues Sheila Blackstock, (410) 786-3502, Quality Data for Annual Payment Update Issues Thomas Valuck, (410) 786-7479, Hospital Value-Based Purchasing Issues Jacqueline Proctor, (410) 786-8852, Disclosure of Physician Ownership in Hospitals and Patient Safety Measures Issues Fred Grabau, (410) 786-0206, Services to Beneficiaries in Custody of Penal Authorities Issues

SUPPLEMENTARY INFORMATION:

Submitting Comments: We welcome comments from the public on all issues set forth in this rule to assist us in fully considering issues and developing policies. You can assist us by referencing the file code CMS-1533-P

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and the specific ``issue identifier'' that precedes the section on which you choose to comment.

Inspection of Public Comments: All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all comments received before the close of the comment period on the following Web site as soon as possible after they have been received: http://www.cms.hhs.gov/eRulemaking. Click on the link ``Electronic Comments on

CMS Regulations'' on that Web site to view public comments.

Comments received timely will also be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-743-3951.

Electronic Access

This Federal Register document is also available from the Federal Register online database through GPO Access, a service of the U.S. Government Printing Office. Free public access is available on a Wide Area Information Server (WAIS) through the Internet and via asynchronous dial-in. Internet users can access the database by using the World Wide Web; the Superintendent of Documents' home page address is http://www.gpoaccess.gov/, by using local WAIS client software, or

by telnet to swais.access.gpo.gov, then login as guest (no password required). Dial-in users should use communications software and modem to call (202) 512-1661; type swais, then login as guest (no password required).

Acronyms

AHA American Hospital Association AHIMA American Health Information Management Association AHRQ Agency for Health Care Research and Quality AMI Acute myocardial infarction AOA American Osteopathic Association APR DRG All Patient Refined Diagnosis Related Group System ASC Ambulatory surgical center ASP Average sales price AWP Average wholesale price BBA Balanced Budget Act of 1997, Pub. L. 105-33 BBRA Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Balanced Budget Refinement Act of 1999, Pub. L. 106-113 BIPA Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Benefits Improvement and Protection Act of 2000, Pub. L. 106-554 BLS Bureau of Labor Statistics CAH Critical access hospital CART CMS Abstraction & Reporting Tool CBSAs Core-based statistical areas CC Complication or comorbidity CCR Cost-to-charge ratio CDAC Clinical Data Abstraction Center CIPI Capital input price index CPI Consumer price index CMI Case-mix index CMS Centers for Medicare & Medicaid Services CMSA Consolidated Metropolitan Statistical Area COBRA Consolidated Omnibus Reconciliation Act of 1985, Pub. L. 99- 272 CPI Consumer price index CY Calendar year DRA Deficit Reduction Act of 2005, Pub. L. 109-171 DRG Diagnosis-related group DSH Disproportionate share hospital ECI Employment cost index EMR Electronic medical record EMTALA Emergency Medical Treatment and Labor Act of 1986, Pub. L. 99-272 FDA Food and Drug Administration FFY Federal fiscal year FIPS Federal information processing standards FQHC Federally qualified health center FTE Full-time equivalent FY Fiscal year GAAP Generally Accepted Accounting Principles GAF Geographic Adjustment Factor GME Graduate medical education HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems HCFA Health Care Financing Administration HCRIS Hospital Cost Report Information System HHA Home health agency HHS Department of Health and Human Services HIC Health insurance card HIPAA Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-191 HIPC Health Information Policy Council HIS Health information system HIT Health information technology HMO Health maintenance organization HSA Health savings account HSCRC Maryland Health Services Cost Review Commission HSRV Hospital-specific relative value HSRVcc Hospital-specific relative value cost center HQA Hospital Quality Alliance HQI Hospital Quality Initiative ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification ICD-10-PCS International Classification of Diseases, Tenth Edition, Procedure Coding System IHS Indian Health Service IME Indirect medical education IOM Institute of Medicine IPF Inpatient psychiatric facility IPPS Acute care hospital inpatient prospective payment system IRF Inpatient rehabilitation facility JCAHO Joint Commission on Accreditation of Healthcare Organizations LAMCs Large area metropolitan counties LTC-DRG Long-term care diagnosis-related group LTCH Long-term care hospital MAC Medicare Administrative Contractor MCC Major complication or comorbidity MCE Medicare Code Editor MCO Managed care organization MCV Major cardiovascular condition MDC Major diagnostic category MDH Medicare-dependent, small rural hospital MedPAC Medicare Payment Advisory Commission MedPAR Medicare Provider Analysis and Review File MEI Medicare Economic Index MGCRB Medicare Geographic Classification Review Board MIEA-TRHCA Medicare Improvements and Extension Act, Division B of the Tax Relief and Health Care Act of 2006, Pub. L. 109-432 MMA Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. 108-173 MPN Medicare provider number MRHFP Medicare Rural Hospital Flexibility Program MSA Metropolitan Statistical Area NAICS North American Industrial Classification System NCD National coverage determination NCHS National Center for Health Statistics NCQA National Committee for Quality Assurance NCVHS National Committee on Vital and Health Statistics NECMA New England County Metropolitan Areas NQF National Quality Forum NTIS National Technical Information Service NVHRI National Voluntary Hospital Reporting Initiative OES Occupational employment statistics OIG Office of the Inspector General OMB Executive Office of Management and Budget O.R. Operating room OSCAR Online Survey Certification and Reporting (System) PRM Provider Reimbursement Manual PPI Producer price index PMSAs Primary metropolitan statistical areas PPS Prospective payment system PRA Per resident amount ProPAC Prospective Payment Assessment Commission PRRB Provider Reimbursement Review Board PS&R Provider Statistical and Reimbursement (System) QIG Quality Improvement Group, CMS QIO Quality Improvement Organization RHC Rural health clinic RHQDAPU Reporting hospital quality data for annual payment update RNHCI Religious nonmedical health care institution

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RRC Rural referral center RUCAs Rural-urban commuting area codes RY Rate year SAF Standard Analytic File SCH Sole community hospital SFY State fiscal year SIC Standard Industrial Classification SNF Skilled nursing facility SOCs Standard occupational classifications SOM State Operations Manual SSA Social Security Administration SSI Supplemental Security Income TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97- 248 UHDDS Uniform hospital discharge data set VBP Value-based purchasing

Table of Contents

I. Background

A. Summary

1. Acute Care Hospital Inpatient Prospective Payment System (IPPS)

2. Hospitals and Hospital Units Excluded From the IPPS

a. Inpatient Rehabilitation Facilities (IRFs)

b. Long-Term Care Hospitals (LTCHs)

c. Inpatient Psychiatric Facilities (IPFs)

3. Critical Access Hospitals (CAHs)

4. Payments for Graduate Medical Education (GME)

B. Provisions of the Deficit Reduction Act of 2005 (DRA)

C. Provisions of the Medicare Improvements and Extension Act Under Division B of the Tax Relief and Health Care Act of 2006

D. Provisions of the Pandemic and All-Hazards Preparedness Act

E. Major Contents of this Proposed Rule

1. Proposed DRG Reclassifications and Recalibrations of Relative Weights

2. Proposed Changes to the Hospital Wage Index

3. Other Decisions and Proposed Changes to the IPPS for Operating Costs and GME Costs

4. Proposed Changes to the IPPS for Capital-Related Costs

5. Proposed Changes to the Payment Rate for Excluded Hospitals and Hospital Units: Rate-of-Increase Percentages

6. Services Furnished to Beneficiaries in Custody of Penal Authorities

7. Determining Proposed Prospective Payment Operating and Capital Rates and Rate-of-Increase Limits

8. Impact Analysis

9. Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services

10. Discussion of Medicare Payment Advisory Commission Recommendations II. Proposed Changes to DRG Classifications and Relative Weights

A. Background

B. DRG Reclassifications

1. General

2. Yearly Review for Making DRG Changes

C. MedPAC Recommendations for Revisions to the IPPS DRG System

D. Refinement of DRGs Based on Severity of Illness

1. Evaluation of Alternative Severity-Adjusted DRG Systems

a. Overview of Alternative DRG Classification Systems

b. Comparative Performance in Explaining Variation in Resource Use

c. Payment Accuracy and Case-Mix Impact

d. Issues for Future Consideration

2. Development of Proposed Medicare Severity DRGs (MS-DRGs)

a. Comprehensive Review of the CC List

b. Chronic Diagnosis Codes

c. Acute Diagnosis Codes

d. Prior Research on Subdivisions of CCs Into Multiple Categories

e. Proposed Medicare Severity DRGs (MS-DRGs)

3. Dividing Proposed MS-DRGs on the Basis of the CCs and MCCs

4. Conclusion

5. Impact of the Proposed MS-DRGs

6. Changes to Case-Mix Index (CMI) from the Proposed MS-DRGs

7. Effect of the Proposed MS-DRGs on the Outlier Threshold

8. Effect of the Proposed MS-DRGs on the Postacute Care Transfer Policy

E. Refinement of the Relative Weight Calculation

1. Summary of RTI's Report on Charge Compression

2. RTI Recommendations

a. Short-Term Recommendations

b. Medium-Term Recommendations

c. Long-Term Recommendations

F. Hospital-Acquired Conditions, Including Infections

1. General

2. Legislative Requirements

3. Public Input

4. Collaborative Effort

5. Criteria for Selection of the Hospital-Acquired Conditions

6. Proposed Selection of Hospital-Acquired Conditions

7. Other Issues

G. Proposed Changes to the Specific DRG Classifications

1. Pre-MDC: Intestinal Transplantations

2. MDC 1 (Diseases and Disorders of the Nervous System)

a. Implantable Neurostimulators

b. Intracranial Stents

3. MDC 3 (Diseases and Disorders of the Ear, Nose, Mouth, and Throat)--Cochler Implants

4. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue)

a. Hip and Knee Replacements

b. Spinal Fusions

c. Spinal Disc Devices

d. Other Spinal DRGs

5. MDC 17 (Myeloproliferative Diseases and Disorders, Poorly Differentiated Neoplasm): Endoscopic Procedures

6. Medicare Code Editor (MCE) Changes

a. Non-Covered Procedure Edit: Code 00.62 (Percutaneous Angioplasty or Atherectomy of Intracranial Vessel(s))

b. Non-Specific Principal Diagnosis Edit 7 and Non-Specific O.R. Procedures Edit 10

c. Limited Coverage Edit 17

7. Surgical Hierarchies

8. CC Exclusion List Proposed for FY 2008

a. Background

b. Proposed CC Exclusions List for FY 2008

9. Review of Procedure Codes in CMS DRGs 468, 476, and 477

a. Moving Procedure Codes From CMS DRG 468 (Proposed MS-DRGs 981 Through 983) or CMS DRG 477 (Proposed MS-DRGs 987 Through 989) to MDCs

b. Reassignment of Procedures Among CMS DRGs 468, 476, and 477 (Proposed MS-DRG 981 Through 983, 984 Through 986, and 987 Through 989)

c. Adding Diagnosis or Procedure Codes to MDCs

10. Changes to the ICD-9-CM Coding System

11. Other Issues

a. Seizures and Headaches

b. Devices That Are Replaced Without Cost or Where Credit for a Replaced Device Is Furnished to the Hospital

H. Recalibration of DRG Weights

I. Proposed MS-LTC-DRG Reclassifications and Relative Weights for LTCHs for FY 2008

1. Background

2. Proposed Changes in the LTC-DRG Classifications

a. Background

b. Patient Classifications Into DRGs

3. Development of the Proposed FY 2008 MS-LTC-DRG Relative Weights

a. General Overview of Development of the Proposed MS-LTC-DRG Relative Weights

b. Data

c. Hospital-Specific Relative Value Methodology

d. Proposed Treatment of Severity Levels in Developing Relative Weights

e. Proposed Low-Volume MS-LTC-DRGs

4. Steps for Determining the Proposed FY 2008 MS-LTC-DRG Relative Weights

J. Proposed Add-On Payments for New Services and Technologies

1. Background

2. Public Input Before Publication of a Notice of Proposed Rulemaking on Add-On Payments

3. FY 2008 Status of Technologies Approved for FY 2007 Add-On Payments

a. Endovascular Graft Repair of the Thoracic Aorta

b. Restore[reg]Rechargeable Implantable Neurostimulators

c. X STOP Interspinous Process Decompression System

4. FY 2008 Application for New Technology Add-On Payments

5. Technical Correction III. Proposed Changes to the Hospital Wage Index

A. Background

B. Core-Based Statistical Areas for the Hospital Wage Index

C. Proposed Occupational Mix Adjustment to the Proposed FY 2008 Wage Index

1. Development of Data for the Proposed FY 2008 Occupational Mix Adjustment

2. Timeline for the Collection, Review, and Correction of the Occupational Mix Data

3. Calculation of the Proposed Occupational Mix Adjustment for FY 2008

4. Proposed 2007-2008 Occupational Mix Survey for the FY 2010 Wage Index

D. Worksheet S-3 Wage Data for the Proposed FY 2008 Wage Index

1. Included Categories of Costs

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2. Contract Labor for Indirect Patient Care Services

3. Excluded Categories of Costs

4. Use of Wage Index Data by Providers Other Than Acute Care Hospitals Under the IPPS

E. Verification of Worksheet S-3 Wage Data

F. Wage Index for Multicampus Hospitals

G. Computation of the Proposed FY 2008 Unadjusted Wage Index

1. Method for Computing the Proposed FY 2008 Unadjusted Wage Index

2. Expiration of the Imputed Floor

3. CAHs Reverting Back to IPPS Hospitals and Raising the Rural Floor

4. Application of Rural Floor Budget Neutrality

H. Analysis and Implementation of the Proposed Occupational Mix Adjustment and the Proposed FY 2008 Occupational Mix Adjusted Wage Index

I. Revisions to the Proposed Wage Index Based on Hospital Redesignations

1. General

2. Effects of Reclassification/Redesignation

3. FY 2008 MGCRB Reclassifications

4. Hospitals That Applied for Reclassification Effective in FY 2008 and Reinstating Reclassifications in FY 2008

5. Clarification of Policy on Reinstating Reclassifications

6. ``Fallback'' Reclassifications

7. Geographic Reclassification Issues for Multicampus Hospitals

8. Redesignations of Hospitals under Section 1886(d)(8)(B) of the Act

9. Reclassifications Under Section 1886(d)(8)(B) of the Act

10. New England Deemed Counties

11. Reclassifications under Section 508 of Pub. L. 108-173

12. Other Issues

J. Proposed FY 2008 Wage Index Adjustment Based on Commuting Patterns of Hospital Employees

K. Process for Requests for Wage Index Data Corrections

L. Labor-Related Share for the Proposed Wage Index for FY 2008

M. Wage Index Study Required Under Pub. L. 109-432

N. Proxy for the Hospital Market Basket IV. Other Decisions and Proposed Changes to the IPPS for Operating Costs and GME Costs

A. Reporting of Hospital Quality Data for Annual Hospital Payment Update

1. Background

2. FY 2008 Quality Measures

3. New Quality Measures and Data Submission Requirements for FY 2009 and Subsequent Years

a. Proposed New Quality Measures for FY 2009 and Subsequent Years

b. Data Submission

4. Retiring or Modifying RHQDAPU Program Quality Measures

5. Procedures for the RHQDAPU Program for FY 2008 and FY 2009

a. Procedures for Participating in the RHQDAPU Program

b. Chart Validation Requirements

c. Data Validation and Attestation

d. Public Display

e. Reconsideration and Appeal Procedures

f. RHQDAPU Program Withdrawal Requirements

6. Electronic Medical Records

7. New Hospitals

B. Development of the Medicare Hospital Value-Based Purchasing Plan

C. Rural Referral Centers (RRCs)

1. Proposed Annual Update of RRC Status Criteria

a. Case-Mix Index

b. Discharges

2. Acquired Rural Status of RRCs

D. Indirect Medical Education (IME) Adjustment

1. Background

2. IME Adjustment Factor for FY 2008

3. Time Spent by Residents on Vacation or Sick Leave and in Orientation

a. Background

b. Vacation and Sick Leave Time

c. Orientation Activities

d. Proposed Regulation Changes

E. Hospital Emergency Services Under EMTALA

1. Background

2. Recent Legislation Affecting EMTALA Implementation

a. Secretary's Authority to Waive Requirements During National Emergencies

b. Provisions of the Pandemic and All-Hazards Preparedness Act

c. Proposed Revisions to the EMTALA Regulations

F. Disclosure of Physician Ownership in Hospitals and Patient Safety Measures

1. Disclosure of Physician Ownership in Hospitals

2. Patient Safety Measures

G. Rural Community Hospital Demonstration Program V. Proposed Changes to the IPPS for Capital-Related Costs

A. Background

B. Proposed Policy Change VI. Proposed Changes for Hospitals and Hospital Units Excluded From the IPPS

A. Payments to Existing and New Excluded Hospitals and Hospital Units

B. Separate PPS for IRFs

C. Separate PPS for LTCHs

D. Separate PPS for IPFs

E. Determining Proposed LTCH Cost-to-Charge Ratios (CCRs) Under the LTCH PPS VII. Services Furnished to Beneficiaries in Custody of Penal Authorities VIII. MedPAC Recommendations IX. Other Required Information

A. Requests for Data From the Public

B. Collection of Information Requirements

C. Response to Public Comments

Regulation Text

Addendum--Proposed Schedule of Standardized Amounts, Update Factors, and Rate-of-Increase Percentages Effective With Cost Reporting Periods Beginning On or After October 1, 2007

I. Summary and Background II. Proposed Changes to the Prospective Payment Rates for Hospital Inpatient Operating Costs for FY 2008

A. Calculation of the Proposed Adjusted Standardized Amount

1. Standardization of Base-Year Costs or Target Amounts

2. Computing the Proposed Average Standardized Amount

3. Updating the Proposed Average Standardized Amount

4. Other Adjustments to the Average Standardized Amount

a. Proposed Recalibration of DRG Weights and Updated Wage Index--Budget Neutrality Adjustment

b. Reclassified Hospitals--Budget Neutrality Adjustment

c. Case-Mix Budget Neutrality Adjustment

d. Outliers

e. Proposed Rural Community Hospital Demonstration Program Adjustment (Section 410A of Pub. L. 108-173)

5. Proposed FY 2008 Standardized Amount

B. Proposed Adjustments for Area Wage Levels and Cost-of-Living

1. Proposed Adjustment for Area Wage Levels

2. Proposed Adjustment for Cost-of-Living in Alaska and Hawaii

C. Proposed DRG Relative Weights

D. Calculation of the Proposed Prospective Payment Rates for FY 2008

1. Federal Rate

2. Hospital-Specific Rate (Applicable Only to SCHs and MDHs)

a. Calculation of Hospital-Specific Rate

b. Updating the FY 1982, FY 1987, FY 1996, and FY 2002 Hospital- Specific Rates for FY 2008

3. General Formula for Calculation of Proposed Prospective Payment Rates for Hospitals Located in Puerto Rico Beginning On or After October 1, 2007 and Before October 1, 2008

a. Puerto Rico Rate

b. National Rate III. Proposed Changes to Payment Rates for Acute Care Hospital Inpatient Capital-Related Costs for FY 2008

A. Determination of Proposed Federal Hospital Inpatient Capital- Related Prospective Payment Rate Update

1. Projected Capital Standard Federal Rate Update

a. Description of the Update Framework

b. Comparison of CMS and MedPAC Update Recommendation

2. Proposed Outlier Payment Adjustment Factor

3. Proposed Budget Neutrality Adjustment Factor for Changes in DRG Classifications and Weights and the GAF

4. Proposed Exceptions Payment Adjustment Factor

5. Proposed Capital Standard Federal Rate for FY 2008

6. Proposed Special Capital Rate for Puerto Rico Hospitals

B. Calculation of the Proposed Inpatient Capital-Related Prospective Payments for FY 2008

C. Capital Input Price Index

1. Background

2. Forecast of the CIPI for FY 2008 IV. Proposed Changes to Payment Rates for Excluded Hospitals and Hospital Units: Rate-of-Increase Percentages

A. Payments to Existing Excluded Hospitals and Units

B. New Excluded Hospitals and Units

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V. Tables

Table 1A--National Adjusted Operating Standardized Amounts, Labor/Nonlabor (69.7 Percent Labor Share/30.3 Percent Nonlabor Share If Wage Index Is Greater Than 1)

Table 1B--National Adjusted Operating Standardized Amounts, Labor/Nonlabor (62 Percent Labor Share/38 Percent Nonlabor Share If Wage Index Is Less Than or Equal to 1)

Table 1C--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor

Table 1D--Capital Standard Federal Payment Rate

Table 2--Hospital Case-Mix Indexes for Discharges Occurring in Federal Fiscal Year 2006; Hospital Wage Indexes for Federal Fiscal Year 2008; Hospital Average Hourly Wages for Federal Fiscal Years 2006 (2002 Wage Data), 2007 (2003 Wage Data), and 2008 (2004 Wage Data); and 3-Year Average of Hospital Average Hourly Wages

Table 3A--FY 2008 and 3-Year Average Hourly Wage for Urban Areas by CBSA

Table 3B--FY 2008 and 3-Year Average Hourly Wage for Rural Areas by CBSA

Table 4A--Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas by CBSA--FY 2008

Table 4B--Wage Index and Capital Geographic Adjustment Factor (GAF) for Rural Areas by CBSA--FY 2008

Table 4C--Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified by CBSA--FY 2008

Table 4F--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) by CBSA--FY 2008

Table 4J--Out-Migration Wage Adjustment--FY 2008

Table 5--List of Proposed Medicare Severity Diagnosis-Related Groups (MS-DRGs), Relative Weighting Factors, and Geometric and Arithmetic Mean Length of Stay

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 Exclusion List (Available only through the Internet on the CMS Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS/ )

Table 6H--Deletions from the CC Exclusion List (Available only through the Internet on the CMS Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS/ )

Table 6I--Complete List of Complication and Comorbidity (CC) Exclusions (Available only through the Internet on the CMS Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS/)

Table 6J--Major Complication and Comorbidity (MCC) List

Table 6K--Complications and Comorbidity (CC) List

Table 7A--Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2006 MedPAR Update--December 2006 GROUPER V24.0 CMS-DRGs

Table 7B--Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2006 MedPAR Update--December 2006 GROUPER V25.0 CMS DRGs

Table 8A--Proposed Statewide Average Operating Cost-to-Charge Ratios--March 2007

Table 8B--Proposed Statewide Average Capital Cost-to-Charge Ratios--March 2007

Table 8C--Proposed Statewide Average Total Cost-to-Charge Ratios for LTCHs--March 2007

Table 9A--Hospital Reclassifications and Redesignations--FY 2008

Table 9C--Hospitals Redesignated as Rural under Section 1886(d)(8)(E) of the Act--FY 2008

Table 10--Geometric Mean Plus the Lesser of .75 of the National Adjusted Operating Standardized Payment Amount (Increased to Reflect the Difference Between Costs and Charges) or .75 of One Standard Deviation of Mean Charges by Proposed Medicare Severity Diagnosis- Related Groups (MS-DRGs)--March 2007

Table 11--Proposed FY 2008 MS-LTC-DRGs, Relative Weights, Geometric Average Length of Stay, and 5/6ths of the Geometric Average Length of Stay

Appendix A--Regulatory Impact Analysis

I. Overall Impact II. Objectives III. Limitations on Our Analysis IV. Hospitals Included In and Excluded From the IPPS V. Effects on Excluded Hospitals and Hospital Units VI. Quantitative Effects of the Proposed Policy Changes Under the IPPS for Operating Costs

A. Basis and Methodology of Estimates

B. Analysis of Table I

C. Effects of the Proposed Changes to the DRG Reclassifications and Relative Cost-Based Weights (Column 2)

D. Effects of Proposed Wage Index Changes (Column 3)

E. Combined Effects of Proposed DRG and Wage Index Changes (Column 4)

F. Effects of the Expiration of the 3-Year Provision Allowing Urban Hospitals That Were Converted to Rural as a Result of the FY 2005 Labor Market Area Changes to Maintain the Wage Index of the Urban Labor Market Area in Which They Were Formerly Located (Column 5)

G. Effects of MGCRB Reclassifications (Column 6)

H. Effects of the Adjustment to the Application of the Rural Floor (Column 7)

I. Effects of Expiration of the Imputed Rural Floor (Column 8)

J. Effects of the Expiration of Section 508 of Pub. L. 108-173 (Column 9)

K. Effects of the Proposed Wage Index Adjustment for Out- Migration (Column 10)

L. Effects of All Proposed Changes With CMI Adjustment Prior to Assumed Growth (Column 11)

M. Effects of All Proposed Changes With CMI Adjustment and Assumed Growth (Column 12)

N. Effects of Proposed Policy on Payment Adjustment for Low- Volume Hospitals

O. Impact Analysis of Table II VII. Effects of Other Proposed Policy Changes

A. Effects of Proposed Policy on Hospital-Acquired Conditions, Including Infections

B. Effects of Proposed MS-LTC-DRG Reclassifications and Relative Weights for LTCHs

C. Effects of Proposed New Technology Add-On Payments

D. Effects of Requirements for Hospital Reporting of Quality Data for Annual Hospital Payment Update

E. Effects of Proposed Policy on Cancellation of Classification of Acquired Rural Status and Rural Referral Centers

F. Effects of Proposed Policy Change on Payment for Indirect Graduate Medical Education

G. Effects of Proposed Policy Changes Relating to Emergency Services Under EMTALA

H. Effects of Proposed Policy on Disclosure of Physician Ownership in Hospitals and Patient Safety Measures

I. Effects of Implementation of Rural Community Hospital Demonstration Program

J. Effects of Proposed Policy Changes on Services Furnished to Beneficiaries in Custody of Penal Authorities VIII. Effects of Proposed Changes in the Capital IPPS

A. General Considerations

B. Results IX. Alternatives Considered X. Overall Conclusion XI. Accounting Statement XII. Executive Order 12866

Appendix B--Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services

I. Background II. Inpatient Hospital Update for FY 2008 III. Secretary's Recommendation IV. MedPAC Recommendation for Assessing Payment Adequacy and Updating Payments in Traditional Medicare

I. Background

A. Summary

1. Acute Care Hospital Inpatient Prospective Payment System (IPPS)

Section 1886(d) of the Social Security Act (the Act) sets forth a system of payment for the operating costs of acute care hospital inpatient stays under Medicare Part A (Hospital Insurance) based on prospectively set rates. Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of hospital inpatient stays under a prospective payment system (PPS). Under these PPSs, Medicare payment for hospital inpatient operating and capital-related costs is made at

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predetermined, specific rates for each hospital discharge. Discharges are classified according to a list of diagnosis-related groups (DRGs).

The base payment rate is comprised of a standardized amount that is divided into a labor-related share and a nonlabor-related share. The labor-related share is adjusted by the wage index applicable to the area where the hospital is located; and if the hospital is located in Alaska or Hawaii, the nonlabor-related share is adjusted by a cost-of- living adjustment factor. This base payment rate is multiplied by the DRG relative weight.

If the hospital treats a high percentage of low-income patients, it receives a percentage add-on payment applied to the DRG-adjusted base payment rate. This add-on payment, known as the disproportionate share hospital (DSH) adjustment, provides for a percentage increase in Medicare payments to hospitals that qualify under either of two statutory formulas designed to identify hospitals that serve a disproportionate share of low-income patients. For qualifying hospitals, the amount of this adjustment may vary based on the outcome of the statutory calculations.

If the hospital is an approved teaching hospital, it receives a percentage add-on payment for each case paid under the IPPS, known as the indirect medical education (IME) adjustment. This percentage varies, depending on the ratio of residents to beds.

Additional payments may be made for cases that involve new technologies or medical services that have been approved for special add-on payments. To qualify, a new technology or medical service must demonstrate that it is a substantial clinical improvement over technologies or services otherwise available, and that, absent an add- on payment, it would be inadequately paid under the regular DRG payment.

The costs incurred by the hospital for a case are evaluated to determine whether the hospital is eligible for an additional payment as an outlier case. This additional payment is designed to protect the hospital from large financial losses due to unusually expensive cases. Any outlier payment due is added to the DRG-adjusted base payment rate, plus any DSH, IME, and new technology or medical service add-on adjustments.

Although payments to most hospitals under the IPPS are made on the basis of the standardized amounts, some categories of hospitals are paid the higher of a hospital-specific rate based on their costs in a base year (the higher of FY 1982, FY 1987, FY 1996, or FY 2002) or the IPPS rate based on the standardized amount. For example, sole community hospitals (SCHs) are the sole source of care in their areas, and Medicare-dependent, small rural hospitals (MDHs) are a major source of care for Medicare beneficiaries in their areas. Both of these categories of hospitals are afforded this special payment protection in order to maintain access to services for beneficiaries. (Until FY 2007, an MDH has received the IPPS rate plus 50 percent of the difference between the IPPS rate and its hospital-specific rate if the hospital- specific rate is higher than the IPPS rate. In addition, an MDH does not have the option of using FY 1996 as the base year for its hospital- specific rate. As discussed below, for discharges occurring on or after October 1, 2007, but before October 1, 2011, an MDH will receive the IPPS rate plus 75 percent of the difference between the IPPS rate and its hospital-specific rate, if the hospital-specific rate is higher than the IPPS rate.)

Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of inpatient hospital services ``in accordance with a prospective payment system established by the Secretary.'' The basic methodology for determining capital prospective payments is set forth in our regulations at 42 CFR 412.308 and 412.312. Under the capital IPPS, payments are adjusted by the same DRG for the case as they are under the operating IPPS. Capital IPPS payments are also adjusted for IME and DSH, similar to the adjustments made under the operating IPPS. In addition, hospitals may receive outlier payments for those cases that have unusually high costs.

The existing regulations governing payments to hospitals under the IPPS are located in 42 CFR part 412, subparts A through M.

2. Hospitals and Hospital Units Excluded From the IPPS

Under section 1886(d)(1)(B) of the Act, as amended, certain specialty hospitals and hospital units are excluded from the IPPS. These hospitals and units are: rehabilitation hospitals and units; long-term care hospitals (LTCHs); psychiatric hospitals and units; children's hospitals; and cancer hospitals. Religious nonmedical health care institutions (RNHCIs) are also excluded from the IPPS. Various sections of the Balanced Budget Act of 1997 (Pub. L. 105-33), the Medicare, Medicaid and SCHIP [State Children's Health Insurance Program] Balanced Budget Refinement Act of 1999 (Pub. L. 106-113), and the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (Pub. L. 106-554) provide for the implementation of PPSs for rehabilitation hospitals and units (referred to as inpatient rehabilitation facilities (IRFs)), LTCHs, and psychiatric hospitals and units (referred to as inpatient psychiatric facilities (IPFs)), as discussed below. Children's hospitals, cancer hospitals, and RNHCIs continue to be paid solely under a reasonable cost-based system.

The existing regulations governing payments to excluded hospitals and hospital units are located in 42 CFR parts 412 and 413. a. Inpatient Rehabilitation Facilities (IRFs)

Under section 1886(j) of the Act, as amended, rehabilitation hospitals and units (IRFs) have been transitioned from payment based on a blend of reasonable cost reimbursement subject to a hospital-specific annual limit under section 1886(b) of the Act and the adjusted facility Federal prospective payment rate for cost reporting periods beginning on or after January 1, 2002 through September 30, 2002, to payment at 100 percent of the Federal rate effective for cost reporting periods beginning on or after October 1, 2002. IRFs subject to the blend were also permitted to elect payment based on 100 percent of the Federal rate. The existing regulations governing payments under the IRF PPS are located in 42 CFR part 412, subpart P. b. Long-Term Care Hospitals (LTCHs)

Under the authority of sections 123(a) and (c) of Pub. L. 106-113 and section 307(b)(1) of Pub. L. 106-554, the LTCH PPS was effective for a LTCH's first cost reporting period beginning on or after October 1, 2002. LTCHs that do not meet the definition of ``new'' under Sec. 412.23(e)(4) are paid, during a 5-year transition period, a LTCH prospective payment that is comprised of an increasing proportion of the LTCH Federal rate and a decreasing proportion based on reasonable cost principles. Those LTCHs that did not meet the definition of ``new'' could elect to be paid based on 100 percent of the Federal prospective payment rate instead of a blended payment in any year during the 5-year transition. For cost reporting periods beginning on or after October 1, 2006, all LTCHs are paid 100 percent of the Federal rate. The existing regulations governing payment under the LTCH PPS are located in 42 CFR part 412, subpart O. c. Inpatient Psychiatric Facilities (IPFs)

Under the authority of sections 124(a) and (c) of Pub. L. 106-113, inpatient

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psychiatric facilities (IPFs) (formerly psychiatric hospitals and psychiatric units of acute care hospitals) are paid under the IPF PPS. Under the IPF PPS, some IPFs are transitioning from being paid for inpatient hospital services based on a blend of reasonable cost-based payment and a Federal per diem payment rate, effective for cost reporting periods beginning on or after January 1, 2005. For cost reporting periods beginning on or after January 1, 2008, all IPFs will be paid 100 percent of the Federal per diem payment amount. The existing regulations governing payment under the IPF PPS are located in 42 CFR 412, subpart N. 3. Critical Access Hospitals (CAHs)

Under sections 1814, 1820, and 1834(g) of the Act, payments are made to critical access hospitals (CAHs) (that is, rural hospitals or facilities that meet certain statutory requirements) for inpatient and outpatient services based on 101 percent of reasonable cost. Reasonable cost is determined under the provisions of section 1861(v)(1)(A) of the Act and existing regulations under 42 CFR parts 413 and 415. 4. Payments for Graduate Medical Education (GME)

Under section 1886(a)(4) of the Act, costs of approved educational activities are excluded from the operating costs of inpatient hospital services. Hospitals with approved graduate medical education (GME) programs are paid for the direct costs of GME in accordance with section 1886(h) of the Act; the amount of payment for direct GME costs for a cost reporting period is based on the hospital's number of residents in that period and the hospital's costs per resident in a base year. The existing regulations governing payments to the various types of hospitals are located in 42 CFR part 413.

B. Provisions of the Deficit Reduction Act of 2005 (DRA)

The Deficit Reduction Act of 2005 (DRA), Pub. L. 109-171, made a number of changes to the Act relating to prospective payments to hospitals and other providers for inpatient services. This proposed rule would implement amendments made by (1) section 5001(a), which, effective for FY 2007 and subsequent years, expands the requirements for hospital quality data reporting; and (2) section 5001(c), which requires the Secretary to select, by October 1, 2007, at least two hospital-acquired conditions that meet certain specified criteria that will be subject to a quality adjustment in DRG payments during FY 2008.

In this proposed rule, we also discuss our development of a plan to implement, beginning with FY 2009, a value-based purchasing plan for section 1886(d) hospitals, in accordance with the requirements of section 5001(b) of Pub. L. 109-171.

C. Provisions of the Medicare Improvements and Extension Act Under Division B of the Tax Relief and Health Care Act of 2006

In this proposed rule, we discuss the provisions of section 106(b)(1) of the Medicare Improvements and Extensions Act under Division B, Title I of the Tax Relief and Health Care Act of 2006 (MIEA-TRHCA), Pub. L. 109-432, which requires MedPAC to submit to Congress, not later than June 30, 2007, a report on the Medicare wage index classification system applied under the Medicare Prospective Payment System. Section 106(b) of the MIEA-TRHCA requires the report to include any alternatives that MedPAC recommends to the method to compute the wage index under section 1886(d)(3)(E) of the Act.

In addition, we discuss the provisions of section 106(b)(2) of the MIEA-TRHCA, which instructs the Secretary of Health and Human Services, taking into account MedPAC's recommendations on the Medicare wage index classification system, to include in the FY 2009 IPPS proposed rule one or more proposals to revise the wage index adjustment applied under section 1886(d)(3)(E) of the Act for purposes of the IPPS.

We note that we published a notice in the Federal Register on March 23, 2007 (72 FR 13799) that addressed the provisions of section 106(a) of the MIEA-TRHCA relating to the extension of geographic reclassifications of hospitals under section 508 of Pub. L. 108-173 (that expired on March 31, 2007) through September 30, 2007.

D. Provisions of the Pandemic and All-Hazards Preparedness Act

On December 19, 2006, Congress enacted the Pandemic and All-Hazards Preparedness Act, Pub. L. 109-417. Section 302(b) of Pub. L. 109-417 makes two specific changes that affect EMTALA implementation in emergency areas during an emergency period. Specifically section 302(b)(1)(A) of Pub. L. 109-417 amended section 1135(b)(3)(B) of the Act to state that sanctions may be waived for the direction or relocation of an individual for screening where, in the case of a public health emergency that involves a pandemic infections disease, that direction or relocation occurs pursuant to a State pandemic preparedness plan. In addition, sections 302(b)(1)(B) and (b)(1)(C) of Pub. L. 109-417 amended section 1135(b)(3)(B) of the Act to state that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the duration of a waiver or modification under section 1135(b)(3) of the Act (relating to EMTALA) shall be determined in accordance with section 1135(e) of the Act as that subsection applies to public health emergencies.

In this proposed rule, we are proposing to make changes to the EMTALA regulations to conform them to the sanction waiver provisions of section 302(b) of Pub. L. 109-417.

E. Major Contents of This Proposed Rule

In this proposed rule, we are setting forth proposed changes to the Medicare IPPS for operating costs and for capital-related costs in FY 2008. We also are setting forth proposed changes relating to payments for IME costs and payments to certain hospitals and units that continue to be excluded from the IPPS and paid on a reasonable cost basis. The changes being proposed would be effective for discharges occurring on or after October 1, 2007, unless otherwise noted.

The following is a summary of the major changes that we are proposing to make: 1. Proposed DRG Reclassifications and Recalibrations of Relative Weights

We are proposing to adopt a Medicare Severity DRG (MS-DRG) classification system for the IPPS to better recognize severity of illness. We present the methodology we used to establish the proposed MS-DRGs and discuss our efforts to further analyze alternative severity-adjusted DRG systems and to refine the relative weight calculations for DRGs.

We present a proposed listing and discussion of hospital-acquired conditions, including infections, which we have evaluated and are considering for selection to be subject to the statutorily required quality adjustment in DRG payments for FY 2008.

We are proposing limited annual revisions to the DRG classification system in the following areas: intestinal transplants, neurostimulators, intracranial stents, cochlear implants, knee and hip replacements, spinal fusions and spinal disc devices, and endoscopic procedures.

We are presenting our reevaluation of certain FY 2007 applicants for add-on payments for high-cost new medical services and technologies, and our analysis of the FY 2008 applicant

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(including public input, as directed by Pub. L. 108-173, obtained in a town hall meeting).

We are proposing the annual update of the long-term care diagnosis- related group (LTC-DRG) classifications and relative weights for use under the LTCH PPS for FY 2008. We are proposing that the LTC-DRGs would be revised to mirror the proposed MS-DRGs for the IPPS. 2. Proposed Changes to the Hospital Wage Index

In section III. of the preamble to this proposed rule, we are proposing revisions to the wage index and the annual update of the wage data. Specific issues addressed include the following:

The FY 2008 wage index update, using wage data from cost reporting periods that began during FY 2004.

Analysis and implementation of the proposed FY 2008 occupational mix adjustment to the wage index.

Proposed changes relating to expiration of the imputed floor for the wage index and application of budget neutrality for the rural floor.

Proposed changes in determining the wage index for multicampus hospitals.

The proposed revisions to the wage index based on hospital redesignations and reclassifications, including reclassifications for multicampus hospitals.

The proposed adjustment to the wage index for FY 2008 based on commuting patterns of hospital employees who reside in a county and work in a different area with a higher wage index.

The timetable for reviewing and verifying the wage data that will be in effect for the proposed FY 2008 wage index.

The labor-related share for the FY 2008 wage index, including the labor-related share for Puerto Rico. 3. Other Decisions and Proposed Changes to the IPPS for Operating Costs and GME Costs

In section IV. of the preamble to this proposed rule, we discuss a number of provisions of the regulations in 42 CFR Parts 412, 413, and 489, including the following:

The reporting of hospital quality data as a condition for receiving the full annual payment update increase.

Development of the Medicare value-based purchasing plan and scheduled ``listening sessions.''

The proposed updated national and regional case-mix values and discharges for purposes of determining RRC status and a proposed policy change relating to the acquired rural status of RRCs.

The statutorily-required IME adjustment factor for FY 2008 and a proposed policy change relating to determining counts of residents on vacation or sick leave and in orientation for IME and direct GME purposes.

Proposed changes relating to waiver of sanctions for requirements for emergency services for hospitals under EMTALA during national emergency.

Proposed policy changes relating to disclosure to patients of physician ownership of hospitals and patient safety measures.

Discussion of the fourth year of implementation of the Rural Community Hospital Demonstration Program. 4. Proposed Changes to the IPPS for Capital-Related Costs

In section V. of the preamble to this proposed rule, we discuss the payment policy requirements for capital-related costs and capital payments to hospitals and propose changes relating to adjustments to the Federal capital rate to address continuous large positive margins. 5. Proposed Changes to the Payment Rates for Excluded Hospitals and Hospital Units: Rate-of-Increase Percentages

In section VI. of the preamble to this proposed rule, we discuss payments to excluded hospitals and hospital units, and proposed changes for determining LTCH CCRs under the LTCH PPS. 6. Services Furnished to Beneficiaries in Custody of Penal Authorities

In section VII. of the preamble to this proposed rule, we clarify when individuals are considered to be in ``custody'' for purposes of Medicare payment for services furnished to beneficiaries who are under penal authorities. 7. Determining Proposed Prospective Payment Operating and Capital Rates and Rate-of-Increase Limits

In the Addendum to this proposed rule, we set forth proposed changes to the amounts and factors for determining the FY 2008 prospective payment rates for operating costs and capital-related costs. We also establish the proposed threshold amounts for outlier cases. In addition, we address the proposed update factors for determining the rate-of-increase limits for cost reporting periods beginning in FY 2008 for hospitals and hospital units excluded from the PPS. 8. Impact Analysis

In Appendix A of this proposed rule, we set forth an analysis of the impact that the proposed changes would have on affected hospitals. 9. Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services

In Appendix B of this proposed rule, as required by sections 1886(e)(4) and (e)(5) of the Act, we provided our recommendations of the appropriate percentage changes for FY 2008 for the following:

A single average standardized amount for all areas for hospital inpatient services paid under the IPPS for operating costs (and hospital-specific rates applicable to SCHs and MDHs).

Target rate-of-increase limits to the allowable operating costs of hospital inpatient services furnished by hospitals and hospital units excluded from the IPPS. 10. Discussion of Medicare Payment Advisory Commission Recommendations

Under section 1805(b) of the Act, MedPAC is required to submit a report to Congress, no later than March 1 of each year, in which MedPAC reviews and makes recommendations on Medicare payment policies. MedPAC's March 2007 recommendation concerning hospital inpatient payment policies addressed the update factor for inpatient hospital operating costs and capital-related costs under the IPPS and for hospitals and distinct part hospital units excluded from the IPPS. This recommendation is addressed in Appendix B of this proposed rule. For further information relating specifically to the MedPAC March 2007 reports or to obtain a copy of the reports, contact MedPAC at (202) 220-3700 or visit MedPAC's Web site at: http://www.medpac.gov.

II. Proposed Changes to DRG Classifications and Relative Weights

(If you choose to comment on issues in this section, please include the caption ``DRG Reclassifications'' at the beginning of your comment.)

A. Background

Section 1886(d) of the Act specifies that the Secretary shall establish a classification system (referred to as DRGs) for inpatient discharges and adjust payments under the IPPS based on appropriate weighting factors assigned to each DRG. Therefore, under the IPPS, we pay for inpatient hospital services on a rate per discharge basis that varies according to the DRG to

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which a beneficiary's stay is assigned. The formula used to calculate payment for a specific case multiplies an individual hospital's payment rate per case by the weight of the DRG to which the case is assigned. Each DRG weight represents the average resources required to care for cases in that particular DRG, relative to the average resources used to treat cases in all DRGs.

Congress recognized that it would be necessary to recalculate the DRG relative weights periodically to account for changes in resource consumption. Accordingly, section 1886(d)(4)(C) of the Act requires that the Secretary adjust the DRG classifications and relative weights at least 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.

B. DRG Reclassifications

1. General

As discussed in the preamble to the FY 2007 IPPS final rule (71 FR 47881 through 47971), we are focusing our efforts in FY 2008 on making significant reforms to the IPPS consistent with the recommendations made by MedPAC in its ``Report to the Congress, Physician-Owned Specialty Hospitals'' in March 2005. MedPAC recommended that the Secretary refine the entire DRG system by taking into account severity of illness and applying hospital-specific relative value (HSRV) weights to DRGs.\1\ We began this reform process by adopting cost-based weights over a 3-year transition period beginning in FY 2007 and making interim changes to the DRG system for FY 2007 by creating 20 new CMS DRGs and modifying 32 others across 13 different clinical areas involving nearly 1.7 million cases. As described below in more detail, these refinements are intermediate steps towards comprehensive reform of both the relative weights and the DRG system that is occurring as we undertake further study.

\1\ Medicare Payment Advisory Commission: Report to the Congress, Physician-Owned Specialty Hospitals, March 2005, page viii.

Currently, cases are classified into CMS DRGs for payment under the IPPS based on the principal diagnosis, up to eight additional diagnoses, and up to six procedures performed during the stay. In a small number of DRGs, classification is also based on the age, sex, and discharge status of the patient. The diagnosis and procedure information is reported by the hospital using codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).

The process of forming the DRGs was begun by dividing all possible principal diagnoses into mutually exclusive principal diagnosis areas, referred to as Major Diagnostic Categories (MDCs). The MDCs were formed by physician panels as the first step toward ensuring that the DRGs would be clinically coherent. The diagnoses in each MDC correspond to a single organ system or etiology and, in general, are associated with a particular medical specialty. Thus, in order to maintain the requirement of clinical coherence, no final DRG could contain patients in different MDCs. Most MDCs are based on a particular organ system of the body. For example, MDC 6 is Diseases and Disorders of the Digestive System. This approach is used because clinical care is generally organized in accordance with the organ system affected. However, some MDCs are not constructed on this basis because they involve multiple organ systems (for example, MDC 22 (Burns)). For FY 2007, cases are assigned to one of 538 DRGs in 25 MDCs. The table below lists the 25 MDCs.

Major Diagnostic Categories (MDCs)

1................. Diseases and Disorders of the Nervous System. 2................. Diseases and Disorders of the Eye. 3................. Diseases and Disorders of the Ear, Nose, Mouth, and Throat. 4................. Diseases and Disorders of the Respiratory System. 5................. Diseases and Disorders of the Circulatory System. 6................. Diseases and Disorders of the Digestive System. 7................. Diseases and Disorders of the Hepatobiliary System and Pancreas. 8................. Diseases and Disorders of the Musculoskeletal System and Connective Tissue. 9................. Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast. 10................ Endocrine, Nutritional and Metabolic Diseases and Disorders. 11................ Diseases and Disorders of the Kidney and Urinary Tract. 12................ Diseases and Disorders of the Male Reproductive System. 13................ Diseases and Disorders of the Female Reproductive System. 14................ Pregnancy, Childbirth, and the Puerperium. 15................ Newborns and Other Neonates with Conditions Originating in the Perinatal Period. 16................ Diseases and Disorders of the Blood and Blood Forming Organs and Immunological Disorders. 17................ Myeloproliferative Diseases and Disorders and Poorly Differentiated Neoplasms. 18................ Infectious and Parasitic Diseases (Systemic or Unspecified Sites). 19................ Mental Diseases and Disorders. 20................ Alcohol/Drug Use and Alcohol/Drug Induced Organic Mental Disorders. 21................ Injuries, Poisonings, and Toxic Effects of Drugs. 22................ Burns. 23................ Factors Influencing Health Status and Other Contacts with Health Services. 24................ Multiple Significant Trauma. 25................ Human Immunodeficiency Virus Infections.

In general, cases are assigned to an MDC based on the patient's principal diagnosis before assignment to a DRG. However, for FY 2007, there are 9 DRGs to which cases are directly assigned on the basis of ICD-9-CM procedure codes. These DRGs are for heart transplant or implant of heart assist systems, liver and/or intestinal transplants, bone marrow transplants, lung transplants, simultaneous pancreas/kidney transplants, pancreas transplants, and

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for tracheostomies. Cases are assigned to these DRGs before they are classified to an MDC. The table below lists the nine current pre-MDCs.

Pre-Major Diagnostic Categories (Pre-MDCs)

DRG 103.............. Heart Transplant or Implant of Heart Assist System. DRG 480.............. Liver Transplant and/or Intestinal Transplant. DRG 481.............. Bone Marrow Transplant. DRG 482.............. Tracheostomy for Face, Mouth, and Neck Diagnoses. DRG 495.............. Lung Transplant. DRG 512.............. Simultaneous Pancreas/Kidney Transplant. DRG 513.............. Pancreas Transplant. DRG 541.............. ECMO or Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except for Face, Mouth, and Neck Diagnosis with Major O.R. DRG 542.............. Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except for Face, Mouth, and Neck Diagnosis without Major O.R.

Once the MDCs were defined, each MDC was evaluated to identify those additional patient characteristics that would have a consistent effect on the consumption of hospital resources. Because the presence of a surgical procedure that required the use of the operating room would have a significant effect on the type of hospital resources used by a patient, most MDCs were initially divided into surgical DRGs and medical DRGs. Surgical DRGs are based on a hierarchy that orders operating room (O.R.) procedures or groups of O.R. procedures by resource intensity. Medical DRGs generally are differentiated on the basis of diagnosis and age (0 to 17 years of age or greater than 17 years of age). Some surgical and medical DRGs are further differentiated based on the presence or absence of a complication or comorbidity (CC).

Generally, nonsurgical procedures and minor surgical procedures that are not usually performed in an operating room are not treated as O.R. procedures. However, there are a few non-O.R. procedures that do affect DRG assignment for certain principal diagnoses. An example is extracorporeal shock wave lithotripsy for patients with a principal diagnosis of urinary stones.

Once the medical and surgical classes for an MDC were formed, each diagnosis class was evaluated to determine if complications, comorbidities, or the patient's age would consistently affect the consumption of hospital resources. Physician panels classified each diagnosis code based on whether the diagnosis, when present as a secondary condition, would be considered a substantial CC. A substantial CC was defined as a condition which, because of its presence with a specific principal diagnosis, would cause an increase in the length of stay by at least one day in at least 75 percent of the patients. Each medical and surgical class within an MDC was tested to determine if the presence of any substantial CC would consistently affect the consumption of hospital resources.

A patient's diagnosis, procedure, discharge status, and demographic information is entered into the Medicare claims processing systems and subjected to a series of automated screens called the Medicare Code Editor (MCE). The MCE screens are designed to identify cases that require further review before classification into a DRG.

After patient information is screened through the MCE and any further development of the claim is conducted, the cases are classified into the appropriate DRG by the Medicare GROUPER software program. 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, for a limited number of DRGs, demographic information (that is, sex, age, and discharge status).

After cases are screened through the MCE and assigned to a DRG by the GROUPER, the PRICER software calculates a base DRG payment. The PRICER calculates the payment for each case covered by the IPPS based on the DRG relative weight and additional factors associated with each hospital, such as IME and DSH adjustments. These additional factors increase the payment amount to hospitals above the base DRG 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. However, in the FY 2000 IPPS final rule (64 FR 41500), we discussed a process for considering non-MedPAR data in the recalibration process. In order for us to consider using particular non-MedPAR data, we must have sufficient time to evaluate and test the data. The time necessary to do so depends upon the nature and quality of the non-MedPAR data submitted. Generally, however, a significant sample of the non-MedPAR data should be submitted by mid-October for consideration in conjunction with the next year's proposed rule. This date allows us time to test the data and make a preliminary assessment as to the feasibility of using the data. Subsequently, a complete database should be submitted by early December for consideration in conjunction with the next year's proposed rule.

In this IPPS proposed rule for FY 2008, we are proposing to adopt significant changes to the current DRGs. As described in detail below, we are proposing significant improvement in the DRG system to recognize severity of illness and resource usage by proposing to adopt Medicare Severity DRGs (MS-DRGs). The changes we are proposing in this proposed rule would be reflected in the FY 2008 GROUPER, Version 25.0, and would be effective for discharges occurring on or after October 1, 2007. Unless otherwise noted in this proposed rule, our DRG analysis is based on data from the December 2006 update of the FY 2006 MedPAR file, which contains hospital bills received through December 31, 2006, for discharges occurring in FY 2006. 2. Yearly Review for Making DRG Changes

Many of the changes to the DRG classifications we make annually are the result of specific issues brought to our attention by interested parties. We encourage individuals with concerns about DRG classifications to bring those concerns to our attention in a timely manner so they can be carefully considered for possible inclusion in the annual proposed rule and, if included, may be subjected to public review and comment. Therefore, similar to the timetable for interested parties to submit non-MedPAR data for consideration in

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the DRG recalibration process, concerns about DRG classification issues should be brought to our attention no later than early December in order to be considered and possibly included in the next annual proposed rule updating the IPPS.

The actual process of forming the DRGs was, and will likely continue to be, highly iterative, involving a combination of statistical results from test data combined with clinical judgment. We describe in detail below the process we used to develop the proposed MS-DRGs. In addition, in deciding whether to make further modification to the proposed MS-DRGs for particular circumstances brought to our attention, we would consider whether the resource consumption and clinical characteristics of the patients with a given set of conditions are significantly different than the remaining patients in the proposed MS-DRG. We would evaluate patient care costs using average charges and lengths of stay as proxies for costs and rely on the judgment of our medical officers to decide whether patients are clinically distinct or similar to other patients in the MS-DRG. In evaluating resource costs, we would consider both the absolute and percentage differences in average charges between the cases we would select for review and the remainder of cases in the MS-DRG. We also would consider variation in charges within these groups; that is, whether observed average differences were consistent across patients or attributable to cases that were extreme in terms of charges or length of stay, or both. Further, we also would consider the number of patients who will have a given set of characteristics and generally would prefer not to create a new DRG unless it would include a substantial number of cases.

C. MedPAC Recommendations for Revisions to the IPPS DRG System

In the FY 2006 and FY 2007 IPPS final rules, we discussed a number of recommendations made by MedPAC regarding revisions to the DRG system used under the IPPS (70 FR 47473 through 47482 and 71 FR 47881 through 47939).

In Recommendations 1-3 in the 2005 Report to Congress on Physician- Owned Specialty Hospitals, MedPAC recommended that CMS:

Refine the current DRGs to more fully capture differences in severity of illness among patients.

Base the DRG relative weights on the estimated cost of providing care.

Base the weights on the national average of the hospital- specific relative values (HSRVs) for each DRG (using hospital-specific costs to derive the HSRVs).

Adjust the DRG relative weights to account for differences in the prevalence of high-cost outlier cases.

Implement the case-mix measurement and outlier policies over a transitional period.

As we noted in the FY 2006 IPPS final rule, we had insufficient time to complete a thorough evaluation of these recommendations for full implementation in FY 2006. However, we did adopt severity-weighted cardiac DRGs in FY 2006 to address public comments on this issue and the specific concerns of MedPAC regarding cardiac surgery DRGs. We also indicated that we planned to further consider all of MedPAC's recommendations and thoroughly analyze options and their impacts on the various types of hospitals in the FY 2007 IPPS proposed rule.

For FY 2007, we began this process. In the FY 2007 IPPS proposed rule, we proposed to adopt Consolidated Severity DRGs (CS DRGs) for FY 2008 (if not earlier). However, based on public comments received on the FY 2007 IPPS proposed rule, we decided not to adopt the CS DRGs. Rather, we decided to make interim changes to the existing DRGs for FY 2007 by creating 20 new DRGs involving 13 different clinical areas that would significantly improve the CMS DRG system's recognition of severity of illness. We also modified 32 DRGs to better capture differences in severity. The new and revised DRGs were selected from 40 existing CMS DRGs that contain 1,666,476 cases and represent a number of body systems. In creating these 20 new DRGs, we deleted 8 and modified 32 existing DRGs. We indicated that these interim steps for FY 2007 were being taken as a prelude to more comprehensive changes to better account for severity in the DRG system by FY 2008. In the FY 2007 IPPS final rule, we indicated our intent to pursue further DRG reform through two initiatives. First, we announced that we were in the process of engaging a contractor to assist us with evaluating alternative DRG systems that were raised as potential alternatives to the CS DRGs in the public comments. Second, we indicated our intent to review over 13,000 ICD-9-CM diagnosis codes as part of making further refinements to the current CMS DRGs to better recognize severity of illness based on the work that CMS (then HCFA) did in the mid-1990's to adopt severity DRGs. We describe in detail below the progress we have made on these two initiatives, our proposed actions for FY 2008, and our plans for continued analysis of reform of the DRG system for FY 2009. We note that revising the DRGs to better recognize severity of illness has implications for the outlier threshold, the application of the postacute care transfer policy, the measurement of real case-mix versus apparent case-mix, and the IME and the DSH adjustments. We discuss these implications in more detail in the following sections.

In the FY 2007 IPPS proposed rule, we discussed MedPAC's recommendations to move to a cost-based HSRV weighting methodology beginning with the FY 2007 IPPS proposed rule. Although we proposed to adopt HSRV weights for FY 2007, we decided not to adopt the proposed methodology in the final rule after considering the public comments. Instead, in the FY 2007 IPPS final rule, we adopted a cost-based weighting methodology without the hospital-specific portion of the methodology. The cost weights are being adopted over a 3-year transition period in 1/3 increments between FY 2007 and FY 2009. In addition, in the FY 2007 IPPS final rule, we indicated our intent to further study the hospital-specific methodology as well as other issues brought to our attention with respect to the cost weights. There was significant concern in the public comments that we account for charge compression or the practice of applying a higher charge markup over costs to lower cost than higher cost items and services, if we are to develop relative weights based on cost. Further, public commenters expressed concern about potential inconsistencies between how costs and charges are reported on the Medicare cost reports and charges on the Medicare claims. In the FY 2007 IPPS final rule, we used costs and charges from the cost report to determine departmental level cost-to- charge ratios (CCRs) to apply to charges on the Medicare claims to determine the cost weights. The commenters were concerned about potential distortions to the cost weights that would result from inconsistent reporting between the cost reports and the Medicare claims. After publication of the FY 2007 IPPS final rule, we entered into a contract with RTI International to study both charge compression and to what extent our methodology for calculating DRG relative weights is affected by inconsistencies between how hospitals report costs and charges on the cost report and how hospitals report charges on individual claims. Further, as part of its study of alternative DRG systems, the

[[Page 24691]]

RAND Corporation is analyzing the HSRV cost-weighting methodology.

As we present below, we believe that revisions to the DRG system to better recognize severity of illness and changes to the relative weights based on costs rather than charges are improving the accuracy of the payment rates in the IPPS. We agree with MedPAC that these refinements should be pursued. Although we continue to caution that any system that groups cases will always present some opportunities for providers to specialize in cases they believe to have higher margins, we believe that the changes we have adopted and the continuing reforms we are proposing to adopt for FY 2008 will improve payment accuracy and reduce financial incentives to create specialty hospitals.

D. Refinement of DRGs Based on Severity of Illness

(If you choose to comment on issues in this section, please include the caption ``DRG Reform and Proposed MS-DRGs'' at the beginning of your comment.)

For purposes of the following discussions, the term ``CMS DRGs'' means the DRG system we currently use under the IPPS; the term ``Medicare-Severity DRGs (MS-DRGs)'' means the revisions that we are proposing to make to the current CMS DRGs to better recognize severity of illness and resource use based on case complexity. Although we have found the terms ``CMS DRGs'' and ``MS-DRGs'' useful to distinguish the current DRG system from the DRGs that we are proposing to adopt for FY 2008, we are interested in public comments on how to best refer to both the current DRGs and the proposed DRGs to avoid confusion and improve clarity. 1. Evaluation of Alternative Severity-Adjusted DRG Systems

In the FY 2007 IPPS final rule, we stated our intent to engage a contractor to assist us with an evaluation of alternative DRG systems that may better recognize severity than the current CMS DRGs. We noted it was possible that some of the alternative systems would better recognize severity of illness and are based on the current CMS DRGs. We further stated that if we were to develop a clinical severity concept using the current CMS DRGs as the starting point, it was possible that several of the issues raised by commenters (in response to the CS DRGs, which, in the FY 2007 IPPS proposed rule, we proposed to adopt for FY 2008 or earlier) would no longer be a concern. We noted that if we were to propose adoption of severity DRGs for FY 2008, we would consider the issues raised by commenters on last year's proposed rule as we continued to make further refinements to account for complexity as well as severity to better reflect relative resource use. We stated that we believed it was likely that at least one of several alternative severity-adjusted DRG systems suggested for review (or potentially a system we would develop ourselves) would be suitable to achieve our goal of improving payment accuracy beginning in FY 2008.

On September 1, 2006, we awarded a contract to the RAND Corporation to perform an evaluation of alternative severity-adjusted DRG classification systems. RAND is evaluating several alternative DRG systems based on how well they are suited to classifying and making payments for inpatient hospital services provided to Medicare patients. Each system is being assessed on its ability to differentiate among severity of illness. A final report is due on or before September 1, 2007.

RAND's draft interim report focused on the following criteria:

Severity-adjusted DRG classification systems: --How well does each classification system explain variation in resource use? -- How would the classification system affect a hospital's patient mix? -- Are the groupings manageable, administratively feasible and understandable?

Payment accuracy--What are the payment implications of selected models?

In response to our request, several vendors of DRG systems submitted their products for evaluation. The following products are currently being evaluated by RAND:

3M/Health Information Systems (HIS)

CMS DRGs modified for AP-DRG Logic (CMS + AP-DRGs)

Consolidated Severity-Adjusted DRGs (CS DRGs)

Health Systems Consultants (HSC)

Refined DRGs (HSC-DRGs)

HSS/Ingenix

All-Payer Severity DRGs with Medicare modifications (MM- APS-DRGs)

Solucient

Solucient Refined DRGs (Sol-DRGs)

Vendors submitted their commercial (off-the-shelf) software to RAND in late September 2006. The five systems were compared to the CMS DRGs that were in effect as of October 1, 2006 (FY 2007). RAND assigned FY 2004 and FY 2005 Medicare discharges from acute care hospitals to the FY 2007 CMS DRGs and to each of the alternative severity-adjusted DRG systems. RAND's initial analysis provided an overview of each alternative DRG classification system, their comparative performance in explaining variation in resource use, differences in DRG grouping logic, and case-mix change.

A Technical Expert Panel comprised of individuals representing academic institutions, hospital associations, and MedPAC was formed in October 2006. The members received the preliminary draft report of RAND's alternative severity-adjusted DRG systems evaluation in early January 2007. The panel met with RAND and CMS on January 18, 2007, to discuss the preliminary draft report and to provide additional comments. RAND incorporated items raised by the panel into its preliminary draft report and submitted a revised interim report to CMS in mid-March 2007. CMS posted RAND's interim report on the CMS Web site in late March 2007. Interested individuals can view RAND's interim report on the CMS Web site at: http://www.cms.hhs.gov/Reports/downloads/Wynn0307.pdf .

At this time, RAND has not completed its final evaluation. RAND's interim report reflects its preliminary evaluation of the alternative DRG systems using the criteria described above. In the project's second phase, RAND will continue to evaluate alternative DRG systems as well as to compare performance using HSRVs. As RAND has not completed its evaluation of alternative DRG systems, we are not ready at this time to propose use of one of the alternative DRG systems being evaluated for Medicare in FY 2008. Further, even if RAND had completed its evaluation, we would need to explore whether any transition issues would need to be resolved before we are ready to propose adopting an alternative DRG system. Among other issues, we would need to evaluate the legal and contractual issues associated with adopting a proprietary DRG product. Although vendors for four of the five systems have indicated a willingness to make their products available in the public domain, we believe it is likely there would need to be some discussion as to whether there would be any limitations (such as the source code as well as the DRG logic) on the availability of the DRG systems to hospitals or competing vendors. Further, we would need to resolve contractual issues for updates and maintenance of an alternative DRG system and consider how they interact with our current ongoing contract to maintain the CMS DRGs. There may be further system conversion issues that we have not yet considered. The RAND

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contract will be complete by September 1, 2007. Once RAND completes its work, we believe we will be in a better position to evaluate whether it would be appropriate to propose to adopt one of the five alternative DRG systems for purposes of the IPPS.

As discussed later in this proposed rule, we are proposing to adopt MS-DRGs beginning with FY 2008. The MS-DRGs are the result of modifications to the CMS DRGs to better account for severity. While we are proposing to implement the MS-DRGs on October 1, 2007, we believe the MS-DRGs should be evaluated by RAND. We have instructed RAND to evaluate the proposed MS-DRGs using the same criteria that it is applying to the other DRG systems. As described below, we believe the proposed MS-DRGs represent a substantial improvement in the recognition of severity of illness and resource consumption. For this reason, we are proposing to adopt MS-DRGs for FY 2008.

As stated earlier, a final report is expected from RAND by September 1, 2007. This report will include further analysis of the five alternative DRG systems and the additional evaluation of the MS- DRGs. We look forward to reviewing RAND's final report that will provide a comprehensive evaluation of each severity DRG system that has been examined. We anticipate that after this process is completed, we will have the necessary information to decide our next steps in the reform of the IPPS. Meanwhile, we are proposing to adopt the MS-DRGs for FY 2008 and are providing the following update on RAND's progress in evaluating alternative DRG systems.

We invite public comment regarding RAND's preliminary analysis of each vendor-supplied alternative severity-adjusted DRG system described below. a. Overview of Alternative DRG Classification Systems

Analysis of how each of the five severity-adjusted DRG systems performs began by using the current CMS DRGs as a baseline. Two of the five systems (CS DRGs and MM-APS-DRGs) are derivatives of all-patient severity-adjusted DRG systems that have been modified by their developers for the Medicare population and two of the systems (HSC-DRGs and Sol-DRGs) are all-patient systems that incorporate severity levels into the CMS DRGs. The CMS-AP-DRGs are a combination of CMS DRGs and a modification for the Medicare population of the major CC severity groupings used in the AP-DRG system. (The AP-DRG system was developed by 3M/HIS specifically for the State of New York to capture the non- Medicare population.)

Table A below shows how each of the five alternative severity- adjusted systems classifies patients into base DRGs and their corresponding severity levels.

Table A.--Logic of CMS and Alternative DRG Systems

Classification element

CMS DRG

CMS+AP-DRG

HSC-DRG

Sol--DRG

MM-APS-DRG

Con-APR-DRG

Number of MDCs.................. 25................ 25................ 25................ 25................ 25................ 25 Number of Pre-MDC base DRGs..... 9................. 9................. 9................. 9................. 9................. 7 Number of base DRGs............. 379............... 379............... 215 ADRGs......... 248 ADRGs......... 361............... 379 Total number of Pre-MDC DRGs.... 9................. 9................. 30................ 27................ 27................ 9 Total number of DRGs............ 538............... 602............... 1,274............. 1,261............. 915............... 859 Number of CC (severity)

2................. 3................. 3 (medical) or 4 3 (medical) or 4 3................. 4 subclasses.

(surgical).

(surgical). CC subclasses................... With CC without CC Without CC With CC No CC, Class C CC, Minor/no

Without CC, with Minor, moderate, for selected base for selected base Class B CC, Class substantial CCs, CC with MCC with major, severe DRGs.

DRGs and With MCC A CC (surgical moderate CCs, some collapsing with some across DRGs

only).

MCCs,

at base DRG level. collapsing at DRG within MDC.

catastrophic CCs

level. (surgical only). Multiple CCs recognized......... No................ No................ No................ No................ Yes (in

Yes. computation of weights. CC assignment specific to base Mostly no......... Mostly no......... Mostly no......... Mostly no......... No................ Yes. DRG. Logic of CC subdivision......... Presence/absence.. Presence/absence.. Presence/absence.. Presence/absence.. Presence/absence.. 18-step process. Logic of MDC assignment......... Principal

Principal

Principal diagnosis.

diagnosis.

diagnosis with rerouting. Death used in DRG assignment.... Yes (in selected Yes (in selected Yes (includes Yes (includes Yes (in selected No. DRGs).

DRGs).

``early death'' ``early death'' DRGs). DRGs).

DRGs). Complications of care are CCs... Yes............... Yes............... Yes............... Yes............... Yes, when

Few. recognized as a CC No, when CC represents ``poor medical care''.

RAND's preliminary evaluation of the logic for each system demonstrated the following:

Four systems add severity levels to the base CMS DRGs; the CS DRGs add severity levels to base APR-DRGs, which are comparable but not identical to the base CMS DRGs. Both the CS DRGs and MM-APS-DRGs collapse some base DRGs with low Medicare volume.

[[Page 24693]]

The HSC-DRGs and the Sol-DRGs use uniform severity levels for each base DRG (three for medical and four for surgical). The general structure of the MM-APS-DRG logic includes three severity levels for each base DRG, but some severity levels for the same base DRG are consolidated to address Medicare low-volume DRGs and monotonicity issues. Monotonicity is when the average costs for a severity group consistently rise as the severity level of the group increases. For example, in a monotonic system, if within a base DRG there are three severity groups and level 1 severity is less than level 2 severity and level 2 severity is less than level 3 severity, the average costs for a level 3 case would be greater than the average costs for a level 2 case, which would be greater than the average costs for a level 1 case. The general structure of the CS DRGs includes four severity levels for each base DRG. However, severity level consolidations occur to address Medicare low-volume DRGs and monotonicity. The CS DRGs consolidate both adjacent severity levels for the same base DRG and the same severity level across multiple base DRGs (especially for severity level 4).

Under the CMS+AP-DRGs and MM-APS-DRGs, each diagnosis is assigned a uniform CC-severity level across all base DRGs (other than CCs on the exclusion list for specific principal diagnoses). The remaining systems assign diagnoses to CC-severity level classifications by groups of DRGs.

Under the grouping logic used by all systems other than the CS DRGs, each discharge is assigned to the highest severity level of any secondary diagnosis. The CS DRGs adjust the initial severity level assignment based on other factors, including the presence of additional CCs. None of the other systems adjust the severity level classification for additional factors or CCs. However, the MM-APS-DRG system handles additional CCs through an enhanced relative weight.

The HSC-DRGs and the Sol-DRGs have a medical ``early death'' DRG within each MDC.

The CS DRGs do not use death in the grouping logic. In addition, most complications of care do not affect the DRG assignment. b. Comparative Performance in Explaining Variation in Resource Use

In evaluating the comparative performance of each alternative DRG system, RAND used MedPAR data from FY 2004 and FY 2005. RAND excluded data from CAHs, Indian Health Service (IHS) hospitals, and hospitals that have all-inclusive rate charging practices. Consistent with CMS practice, RAND did not exclude data from Maryland hospitals, which operate under an IPPS waiver. Records that failed edits for data consistency or that had missing variables that were needed to determine standardized costs were also excluded.

RAND reported that evaluation of each alternative severity-adjusted DRG system is a complex process due to differences in how each of the severity levels are applied, the number of severity-adjusted DRGs in each system, and the average number of discharges assigned to each DRG. In addition, the manner in which the DRGs for patients 0-17 years of age are assigned in the severity-adjusted systems affects the number of low-volume DRGs using Medicare discharges.

Low-volume, severity-adjusted DRGs can affect the relative performance of a classification system. However, the percentage of Medicare discharges assigned to these DRGs is small--approximately 0.7 percent in the HSC-DRG and Sol-DRG systems compared to 0.1 percent in the CMS DRGs.

In determining how much within-DRG variation exists for each alternative severity-adjusted DRG system, RAND calculated the mean standardized cost, standard deviation, and coefficient of variation for each DRG among the systems. The coefficient of variation (CV) is the standard deviation divided by the mean. The CV allowed RAND to compare the variation of populations that contain significantly different mean values. Preliminary results of the comparison demonstrate that all five severity-adjusted systems reduce the amount of variation within DRGs. The HSC-DRGs and Sol-DRGs have a slightly higher proportion of patients assigned to DRGs with a CV=100 percent. The CS DRGs had a slightly lower percentage of patients assigned to DRGs with a CV=100 percent.

RAND utilized a general linear regression model to evaluate how well each severity-adjusted DRG system explains variation in costs per case. The initial results demonstrate that all five severity-adjusted DRG systems predict cost better than the CMS DRGs. The CS DRGs have higher adjusted R\2\ values (explanatory power) than the other severity-adjusted systems in nearly every MDC. In general, the adjusted R\2\ value for the CS DRGs is 0.4458, a 13-percent improvement over the adjusted R\2\ value for the CMS DRGs. The HSC-DRGs demonstrate an 11- percent improvement, while the adjusted R\2\ values for the MM-APS-DRGs and Sol-DRGs are 10.0 percent and 9.7 percent higher respectively, than the CMS DRG R\2\ value. The CMS+AP-DRGs show the smallest improvement, nearly 8 percent.

Another aspect of RAND's evaluation was to identify the validity of each alternative DRG system as a measurement for resource costs. For a base DRG, the severity levels should be monotonic; that is, the mean cost per discharge should increase simultaneously with an increase in the severity level. A distinction between patient groups and varying treatment costs should be accomplished by the severity levels. RAND studied the percentage differences and absolute differences in cost between the severity levels within the base DRGs for each system under evaluation. For the two systems (CMS+AP-DRGs and CS DRGs) that include several base DRGs, RAND assigned those discharges to the lower severity level base DRG. Following that methodology, RAND was able to calculate how much more costly the discharges assigned to the consolidated or lower severity levels were than the discharges in the base DRG assigned to the next higher severity level. Preliminary results demonstrate that, overall, monotonicity is not a factor across the alternative DRG systems. There are only a small percentage of discharges that are assigned to nonmonotonic DRGs. When a DRG is nonmonotonic, the mean cost in the higher severity level is less than the mean cost in the lower severity level.

Using the data from severity of illness levels 1 through 3 (except for the MM-APS-DRGs, which do not have a severity of illness level 3), RAND calculated the discharge-weighted mean cost difference between severity levels and the mean ratio of the cost per discharge for the higher severity level to the adjacent lower severity level. The greatest cost discrimination was present in the higher severity levels versus the lower severity levels across all the systems. The mean cost difference between severity of illness level 1 and severity of illness level 0 was reported to be less than $2,000 for all the severity- adjusted systems. The CMS+AP DRGs have the least amount of cost discrimination between severity levels ($2,117), while the MM-APS-DRG system has the highest mean cost difference ($2,385). The remaining systems demonstrated equivalent percentage cost differences between the

[[Page 24694]]

severity levels as shown in Table B below. BILLING CODE 4120-01-P

[GRAPHIC] [TIFF OMITTED] TP03MY07.000

BILLING CODE 4120-01-C

In examining whether each of the alternative DRG systems provided stability in the relative weights from year to year, RAND compared the relative weights derived from the MedPAR data in FY 2004 to the relative weights data from FY 2005. RAND's preliminary results demonstrate that generally, across all the systems, only a small percentage of DRGs had greater than a 5 percent change in relative weights. The HSC-DRGs and Sol-DRGs had a higher proportion of DRGs with a greater than 5 percent change in relative weights than the other systems. Fewer than 10 percent of the DRGs in the remaining systems had relative weight changes greater than 10 percent. In addition to differences in the number of DRGs and the methodology of assigning the severity levels, RAND noted additional factors that may affect the comparative performance of each alternative severity-adjusted DRG system. For further details and discussion, we encourage readers to view RAND's full interim report on the CMS Web site at: http://www.cms.hhs.gov/Reports/downloads/Wynn0307.pdf .

c. Payment Accuracy and Case-Mix Impact

Similar to how CMS established the relative weights in the FY 2007 IPPS final rule, RAND used standardized costs as determined by the national CCR and the FY 2005 MedPAR data to construct relative weights for each of the DRG systems being evaluated. RAND analyzed the effect of variations in the

[[Page 24695]]

explanatory power on the distribution of Medicare payments for each system under evaluation. The preliminary findings indicate payment accuracy is improved by each severity-adjusted system by redistributing payment from lower-cost discharges to higher-cost discharges. However, the total payment redistribution across systems differs and reflects the payment impact of improved explanatory power. Although these findings are estimates, the percent of total payment redistributed was the least under the CMS+AP-DRGs (7.1 percent) and the most under the CS DRGs (11.9 percent).

Table C shows changes in case-mix index (CMI) by hospital category across alternative severity-adjusted DRG systems. Preliminary results demonstrate that under the severity-adjusted systems, urban hospitals have a higher average CMI than under the CMS DRGs, and rural hospitals have a lower CMI. The analysis suggests that any system adopted to better recognize severity of illness with a budget neutrality constraint will result in payment redistribution that can be expected to benefit urban hospitals at the expense of rural hospitals. This impact occurs because patients treated in urban hospitals are generally more severely ill than patients in rural hospitals and the CMS DRGs are not currently recognizing the full extent of these differences. For purposes of the study, RAND assumed no behavioral changes in coding practice or the types of patients treated.

The shift in case-mix (CMI) is greatest with the CS DRGs. The CMI for rural hospitals is 2.4 percent lower than under the CMS DRGs. The CMI for large urban (hospitals located in CBSAs with greater than 1 million population) and other urban hospitals is 0.6 percent and 0.1 percent higher, respectively, for the CS DRGs. The CMI generally increases for larger hospitals and decreases for smaller hospitals. Under the CMS+AP-DRG, HSC-DRG, and Sol-DRG systems, greater than 70 percent of hospitals would experience less than a 2.5 percent change in their CMI. Under the MM-APS-DRG and Con-APR-DRG systems, 65 and 45 percent of hospitals, respectively, would experience less than a 2.5 percent change. The percentage of hospitals experiencing less than a 5 percent change is significant across all of the CMS-based DRG systems.

Teaching hospitals commonly treat a higher number of complex cases. However, depending on the severity-adjusted DRG system being analyzed, the impact will vary. In the CMS+AP-DRG, HSC-DRG, and MM-APS-DRG systems, facilities with large teaching programs (100 or more residents) demonstrated a larger increase than those facilities with smaller teaching programs. Under the Sol-DRG system, facilities with large teaching programs would experience a 0.1 percent increase, while facilities with the smaller teaching programs would experience a 0.2 percent increase. The CS DRGs showed similar results for hospitals with large teaching programs, but hospitals with the smaller teaching programs would experience an increase of 0.7 percent, relative to the CMS DRGs. RAND found that CMI would decline for nonteaching hospitals from severity adjusted DRGs, from a 0.2 percent decrease under the HSC- DRGs and Sol-DRGs compared to a 0.5 percent decrease under the CS DRGs.

Table C.--CMI Change in Alternative DRG Systems Relative to the CMS DRG CMI

Percentage change from CMS-DRG-CMI N

CMS DRG --------------------------------------------------------- hospitals discharges CMI CMS + AP- DRG HSC-DRG Sol-DRG MM-APS-DRG Con-APR-DRG

ALL......................................................

3,890 12,165,763 1.00

0.0

0.0 By Geographic Location:

Large urban areas (pop>1 million)....................

1,485 5,715,356 1.02

0.5

0.4

0.3

0.6

Other urban areas (popIntensive monitoring (for example, an intensive care unit (ICU) stay).

Expensive and technically complex services (for example, heart transplant).

Extensive care requiring a greater number of caregivers (for example, nursing care for a quadriplegic). There are 3,326 diagnosis codes on the current CC list. Our 2006 review of the CC list reduced the number of diagnosis codes on the CC list to 2,583. Based on the current CC list, 77.6 percent of patients have at least one CC present. Based on the revised CC list from our 2007 review, the percent of patients having at least one CC present would be reduced to 41.24 percent. b. Chronic Diagnosis Codes

The 1979 data used in the original formation of the CC list often did not have the manifestations of a chronic disease fully coded. As a result, the CC list included many chronic diseases with a broad range of manifestations. Such chronic illness diagnoses usually do not cause a significant increase in hospital resource use unless there is an acute exacerbation present or there is a significant deterioration in the underlying chronic condition. Therefore, in the revised CC list, we removed chronic diseases without a significant acute manifestation. Recognition of the impact of the chronic disease is accomplished by separately coding the acute manifestation. For example, the mitral valve disease codes (codes 396.0 through 396.9) are assigned to the current CC list. However, unless the mitral valve abnormalities are associated with other diagnoses indicating acute deterioration, such as acute congestive heart failure, acute pulmonary edema, or respiratory failure, they would not be expected to significantly increase hospital resource use. Therefore, the revised CC list did not include the mitral valve codes. Recognition of the contribution of mitral valve disease to the complexity of hospital care would be accomplished by separately coding those diseases on the CC list that are associated with an acute exacerbation or deterioration of the mitral valve disease.

The revised CC list applied the criterion that chronic diagnoses having a broad range of manifestations are not assigned to the CC list as long as there are codes available that allow the acute manifestations of the disease to be coded separately. For some diseases, there are ICD-9-CM codes that explicitly include a specification of the acute exacerbation of the underlying disease. For example, for congestive heart failure, the following codes specify an acute exacerbation of the congestive heart failure:

428.21, Acute systolic heart failure 428.41, Acute systolic and diastolic heart failure 428.43, Acute on chronic systolic heart failure 428.31, Acute diastolic heart failure 428.33, Acute on chronic diastolic heart failure

These congestive heart failure codes are included on the revised CC List. However, the following congestive heart failure codes do not indicate an acute exacerbation and are not included in the revised CC list:

428.0, Congestive heart failure not otherwise specified 428.1, Left heart failure 428.20, Systolic heart failure not otherwise specified 428.22, Chronic systolic heart failure 428.32, Chronic diastolic heart failure 428.40, Systolic and diastolic heart failure 428.9, Heart failure not otherwise specified

As a result of this approach, most chronic diseases were not assigned to the revised CC list. In general, a significant acute manifestation of the chronic disease must be present and coded for the patient to be assigned a CC. We made exceptions for diagnosis codes that indicate a chronic disease in which the underlying illness has reached an advanced stage or is associated with systemic physiologic decompensation and debility. The presence of such advanced chronic diseases, even in the absence of a separately coded acute manifestation, significantly adds to the treatment complexity of the patient. Thus, the presence of the advanced chronic disease inherently makes the reason for admission more difficult to treat. For example, under the revised CC list, stage IV, V, or end-stage chronic renal failure (codes 585.4 through 585.6) are designated as a CC, but stage I through III chronic renal failure (codes 585.1 through 585.3) are not. For obesity, a body mass index over 35 (codes V85.35 through V85.4) is a CC, but a body mass index between 19 and 35 is not. End-stage renal failure and extreme obesity are examples of chronic diseases for which the advanced stage of the disease is clearly specified.

However, for most major chronic diseases, the stage of the disease is not clearly specified in the code. These

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codes were evaluated based on the consistency and intensity of the physiologic decompensation and debility associated with the chronic disease. For example, quadriplegia (codes 344.00 through 344.09) requires extensive care with a substantial increase in nursing services and more intensive monitoring. Therefore, quadriplegia is considered a CC in the revised CC list. c. Acute Diagnosis Codes

Examples of acute diseases included on the revised CC list included acute myocardial infarction (AMI), cerebrovascular accident (CVA) or stroke, acute respiratory failure, acute renal failure, pneumonia and septicemia. These six diseases are representative of the types of illnesses we included on the revised CC list. Other acute diseases were designated as a CC if their impact on hospital resource use would be expected to be comparable to these representative acute diseases. For example, acute endocarditis was included on the CC list but urinary tract infection was not.

The revised CC list is essentially comprised of significant acute disease, acute exacerbations of significant chronic diseases, advanced or end stage chronic diseases and chronic diseases associated with extensive debility. Compared to the existing CC list, the revised CC list requires a secondary diagnosis to have a consistently greater impact on hospital resource.

The following Table D compares the current CC list and the revised CC list. There are 3,326 diagnosis codes on the current CC list. The CC revisions reduce the number of diagnosis codes on the CC list to 2,583. Based on the current CC list, 77.6 percent of patients have at least one CC present, using FY 2006 MedPAR data. Based on the revised CC list, the percent of patients having at least one CC present is reduced to 40.34 percent. The revised CC list increases the difference in average charges between patients with and without a CC by 56 percent ($15,236 versus $9,743).

Table D.--Comparison of Current CC List and Revised CC List

Current CC Revised CC list

list

Codes designated as a CC................

3,326

2,583 Percent of patients with one or more CCs

77.66

40.34 Percent of patients with no CC..........

22.34

59.66 Average charge of patients with one or

$24,538

$31,451 more CCs............................... Average charge of patients with no CCs.. $14,795

$16,215

The analysis above suggests that merely reviewing and updating the CC list can lead to significant improvements in the ability of the CMS DRGs to recognize severity of illness. Although we could potentially adopt this one change to better recognize severity of illness in the CMS DRGs, we have undertaken additional analyses that further refine secondary diagnoses into MCCs, CCs and non-CCs as described below. d. Prior Research on Subdivision of CCs into Multiple Categories (1) Refined DRGs

During the mid-1980s, CMS (then HCFA) funded a project at Yale University to revise the use of CCs in the CMS DRGs. The Yale University project mapped all secondary diagnoses that were considered a CC in the CMS DRGs into 136 secondary diagnosis groups, each of which was assigned a CC complexity level. For surgical patients, each of the 136 secondary diagnosis groups was assigned to 1 of 4 CC complexity levels (non-CC, moderate CC, MCC, and catastrophic CC). For medical patients, each of the 136 secondary diagnosis groups was assigned to 1 of 3 CC complexity levels (non-CC, moderate/MCC, and catastrophic CC). All age subdivisions and CC subdivisions in the DRGs were eliminated and replaced by the four CC subgroups for surgical patients, or the three CC subgroups for medical patients. The Yale University project did not reevaluate the categorization of secondary diagnosis as a CC versus a non-CC. Only the diagnoses on the standard CC list were used to create the moderate, major, and catastrophic subgroups. All secondary diagnoses in a secondary diagnosis group were assigned the same level, and a patient was assigned to the subgroup corresponding to the highest level secondary diagnosis. The number of secondary diagnoses had no effect on the subgroup assigned to the patient (that is, multiple secondary diagnoses at one level did not cause a patient to be assigned to a higher subgroup). The DRG system developed by the Yale University project demonstrated that a subdivision of the CCs into multiple subclasses would improve the predictability of hospital costs. (2) 1994 Severity DRGs

We also examined the work we performed in the mid-1990's to revise the CMS DRGs to better capture severity. In 1993, we reevaluated the use of CCs within the CMS DRGs. The reevaluation excluded the CMS DRGs associated with pregnancy, newborn, and pediatric patients (MDCs 14 and 15 and DRGs defined based on age 0-17). The major CC list from the AP- DRGs that are used for Medicaid payment by New York and other States was used to identify an initial list of MCCs. Using Medicare data, we reevaluated the categorization of each secondary diagnosis as a non-CC, CC, or an MCC. The end result was that 111 diagnoses that were non-CCs in the standard CMS DRGs were made a CC, 220 diagnoses that were a CC were made a non-CC, and 395 CCs were considered an MCC.

All CC splits in the CMS DRGs were eliminated, and an additional 24 DRGs were merged together. The resulting base CMS DRGs were then subdivided into three, two, or no subgroups based on an analysis of Medicare data. The result was 84 DRGs with no subgroups, 124 DRGs with two subgroups, and 85 DRGs with three subgroups. An additional 63 pregnancy, newborn, and pediatric DRGs not evaluated resulted in a total of 652 DRGs.

A patient was assigned to the CC subgroup corresponding to the highest level secondary diagnosis. Multiple secondary diagnoses at one level did not cause a patient to be assigned to a higher subgroup. The categorization of a diagnosis as non-CC, CC, or MCC was uniform across the CMS DRGs, and there were no modifications for specific DRGs. As part of the FY 1995 IPPS proposed rule, we made a complete file of the revised DRG descriptions available to the public. However, we never adopted the revised DRGs (55 FR 27756). e. Proposed Medicare Severity DRGs (MS-DRGs)

We had several options in developing a refinement to the current CMS DRGs to better recognize increased resource use due to severity of illness. One

[[Page 24700]]

option would involve simply taking the work performed in 1994 and then updating it with all the code changes that have taken place since then. We were reluctant to do this because of changes in medical practices as well as the substantial change in ICD-9-CM codes since that time. Another option would be to build on current CMS DRGs which include a number of advancements that better identify medical practices and technologies. Many commenters on the FY 2007 IPPS proposed rule urged us to take the latter approach because they believed the current base CMS DRGs clearly differentiate between the complexities of varying surgical procedures and medical devices. Therefore, we chose the option of developing a new severity DRG system based on the current CMS DRGs.

The development of the 1994 Severity DRGs involved three steps:

Consolidation of existing DRGs into base DRGs.

Categorization of each diagnosis as an MCC, CC, or non-CC.

Subdivision of each base DRG into subclasses based on CCs.

We reviewed and revised each of the three steps and applied them to our current CMS DRGs to develop DRGs that better identify severity of illness among Medicare patients. We refer to this proposed system as the Medicare Severity DRGs (MS-DRGs). The purpose of the proposed MS- DRGs is to more accurately stratify groups of Medicare patients with varying levels of severity. (1) Consolidation of Existing CMS DRGs Into Proposed Base MS-DRGs

The first step in our process was the consolidation of existing CMS DRGs into new proposed base MS-DRGs. We combined together the 115 pairs of CMS DRGs that are subdivided based on the presence of a CC. We further consolidated the CMS DRGs that are split on the basis of a major cardiovascular condition, AMI with and without major complication (CMS DRGs 121 and 122), and cardiac catheterization with and without complex diagnoses (CMS DRGs 124 and 125). We also consolidated the three pairs of burn CMS DRGs that were defined based on the presence of a CC or a significant trauma (CMS DRGs 506 and 507; 508 and 509; and 510 and 511). Next, we consolidated the 43 pediatric CMS DRGs that are defined based on age less than or equal to 17. These pediatric CMS DRGs contain a very low volume of Medicare patients. As shown in Table 10 of the FY 2007 IPPS final rule (71 FR 48318), only two of these pediatric CMS DRGs contained more than 100 patients (CMS DRGs 298 and 333). Seventeen of these pediatric DRGs had no patients (CMS DRGs 30, 33, 41, 48, 54, 58, 137, 252, 255, 282, 330, 340, 343, 393, 405, 446, and 448). As we have stated frequently, our primary focus in maintaining the CMS DRGs is to serve the Medicare population. We do not have the data or the expertise to maintain the DRGs in clinical areas that are not relevant to the Medicare population. We continue to encourage users of the CMS DRGs (or MS-DRGs if adopted) to make relevant adaptations if they are being used for a non-Medicare patient population.

In addition to the pediatric CMS DRGs defined by the age of the patient, there are a number of CMS DRGs that relate primarily to the pediatric or adult population that have very low volume in the Medicare population, such as male sterilization, tubal interruptions, circumcisions, tonsillectomies, and myringotomies. These CMS DRGs were consolidated into the most clinically similar proposed MS-DRG.

Over the past two decades, the site of service for some elective procedures such as carpal tunnel release, cataract extraction, and laparoscopy has shifted from the inpatient to the outpatient setting, resulting in the CMS DRGs associated with these procedures having very low volume. These CMS DRGs were also consolidated into the most clinically similar proposed MS-DRG. In addition, there were some clinically related CMS DRGs that had significant Medicare patient volume but had no significant difference in resource use. For example, thyroid (CMS DRG 290) and parathyroid (CMS DRG 289) procedures were virtually identical in terms of hospital resource use and were, therefore, consolidated. In total, 34 of these CMS DRGs were consolidated. The DRG consolidations are summarized in Table E below.

Four pairs of proposed MS-DRGs (223 and 224; 228 and 229; 323 and 324; and 551 and 552) were defined based on the presence of a CC or some other condition. For example, proposed MS-DRG 323 is defined based on the presence of a CC or the performance of extracorporeal shock wave lithotripsy. For these proposed MS-DRGs, the CC condition was removed and the pair of DRGs remains separate but defined based only on the other condition (that is, proposed MS-DRG 323 became urinary stones with extracorporeal shock wave lithotripsy). As was done in the 1994 severity DRG work, we did not consolidate any of the CMS DRGs for maternity or newborn cases.

Before proceeding further, we made one additional change to a base DRG assignment after completing these consolidations. We assigned cranial-facial bone procedures to a proposed new base DRG (Cranial/ Facial Bone Procedures). These cases were previously assigned to DRGs 52 and 55 through 63.

Table E below shows how DRGs in the CMS DRGs (Version 24.0) were consolidated into proposed new base MS-DRGs. We refer readers to section II.D.2. of the preamble of this proposed rule for a detailed discussion of CCs and MCCs under the proposed MS-DRGs.

Table E.--DRG Consolidation

Proposed CMS-DRG Version 24.0

DRG description

2008 MS- Proposed new base MS-DRGs DRG

description

6..................................... Carpal Tunnel Release.........

40 Peripheral & Cranial Nerve & 7,8................................... Peripheral & Cranial Nerve &

41 Other Nervous System Other Nervous System

42 Procedure with MCC, with CC, Procedure.

and without CC/MCC.

36.................................... Retinal Procedures............

116 Intraocular Procedures with 38.................................... Primary Iris Procedures.......

117 and without CC/MCC. 39.................................... Lens Procedures with or 42.................................... without Vitrectomy. Intraocular Procedures Except Retina, Iris & Lens.

43.................................... Hyphema.......................

124 Other Disorders of the Eye 46,47,48.............................. Other Disorders of the Eye....

125 with and without MCC.

[[Page 24701]]

50.................................... Sialoadenectomy...............

139 Salivary Gland Procedures. 51.................................... Salivary Gland Procedures Except Sialoadenectomy.

52.................................... Cleft Lip & Palate Repair.....

133 Other Ear, Nose, Mouth & 55.................................... Miscellaneous Ear, Nose, Mouth

134 Throat O.R. Procedures with & Throat Procedures.

and without CC/MCC.

56.................................... Rhinoplasty...................

131 New DRG--Cranial/Facial Bone 57,58................................. Tonsillectomy & Adenoidectomy

132 Procedures with and without 59,60................................. Procedure, Except

CC/MCC. 61,62................................. Tonsillectomy &/or 63.................................... Adenoidectomy Only. Tonsillectomy &/or Adenoidectomy Only. Myringotomy with Tube Insertion. Other Ear, Nose, Mouth & Throat O.R. Procedures. 67.................................... Epiglottitis..................

152 Otitis Media & Upper 68,69,70.............................. Otitis Media & Upper

153 Respiratory Infection with 71.................................... Respiratory Infection.

and without MCC. Laryngotracheitis.............

72.................................... Nasal, Trauma & Deformity.....

154 Other Ear, Nose, Mouth & 73,74................................. Other Ear, Nose, Mouth &

155 Throat Diagnoses with MCC, Throat Diagnoses.

156 with CC, without CC/MCC.

185,186............................... Dental & Oral Diseases Except

157 Dental & Oral Diseases with 187................................... Extractions & Restorations.

158 MCC, with CC, without CC/ Dental Extractions &

159 MCC. Restorations.

199................................... Hepatobiliary Diagnostic

420 Hepatobiliary Diagnostic 200................................... Procedure for Malignancy.

421 Procedures with MCC, with Hepatobiliary Diagnostic

422 CC, without CC/MCC. Procedure for Non-Malignancy.

244,245............................... Bone diseases & Specific

553 Bone Diseases & Arthropathies 246................................... Arthropathies.

554 with and without MCC. Non-Specific Arthropathies....

259,260............................... Subtotal Mastectomy for

584 Breast Biopsy, Local Excision 261................................... Malignancy *.

585 & Other Breast Procedures 262................................... Breast Procedures for Non-

with and without CC/MCC. Malignancy Except Biopsy & Local Excision. Breast Biopsy & Local Excision for Non-Malignancy.

267................................... Perianal & Pilonidal

579 Other Skin, Subcutaneous 268................................... Procedures.

580 Tissue & Breast Procedures 269,270............................... Skin, Subcutaneous Tissue &

581 with MCC, with CC, without Breast Plastic Procedures.

CC/MCC. Other Skin, Subcutaneous Tissue & Breast Procedure.

289................................... Parathyroid Procedures........

625 Thyroid, Parathyroid & 290................................... Thyroid Procedures............

626 Thyroglossal Procedures with 291................................... Thyroglossal Procedures.......

627 MCC, with CC, without CC/ MCC. 294................................... Diabetes > 35.................

637 Diabetes with MCC, with CC, 295................................... Diabetes 427.41, Ventricular fibrillation

[[Page 24705]]

427.5, Cardiac arrest 785.51, Cardiogenic shock 785.59, Other shock without mention of trauma 799.1, Respiratory arrest

Resource use for patients with these diagnoses who were discharged alive was consistent with an MCC. Resource use for patients with these diagnoses who died was consistent with a non-CC. Further, most patients who died could legitimately have one of these diagnoses coded. As a result, these diagnoses are assigned an MCC subclass for patients who lived and a non-CC subclass for patients who died.

For some secondary diagnoses assigned to the CC subclass, our medical consultants identified specific clinical situations in which the diagnosis should not be considered a CC. In such clinical situations, the CC exclusion list was used to exclude the secondary diagnosis from consideration in determining the CC subgroup essentially making the secondary diagnosis a non-CC. For example, primary cardiomyopathy (code 425.4) is designated as a CC. However, for patients admitted for congestive heart failure, our medical consultants believed that primary cardiomyopathy should be treated as a non-CC. In order to accomplish that, the congestive heart failure principal diagnoses were added to the CC exclusion list for primary cardiomyopathy as a secondary diagnosis.

The list of diagnosis codes that we are proposing to classify as an MCC is included in Table 6J in the Addendum of this proposed rule. The diagnosis codes that we are proposing to classify as a CC are included in Table 6K in the Addendum of this proposed rule. The proposed E- codes, which are diagnosis codes used to classify external causes of injury and poisoning, are not included in this list. All proposed E- codes are designated as non-CCs under the current CMS DRG system and our evaluation supports this non-CC designation as appropriate. 3. Dividing Proposed MS-DRGs on the Basis of the CCs and MCCs

In developing the proposed MS-DRGs, two of our major goals were to create DRGs that would more accurately reflect the severity of the cases assigned to them and to create groups that would have sufficient volume so that meaningful and stable payment weights could be developed. As noted above, we excluded the CMS DRGs in MDCs 14 and 15 from consideration because these DRGs are low volume. As stated previously, we do not have the expertise or data to maintain the CMS DRGs for newborns, pediatric, and maternity patients. We continue to maintain MDCs 14 and 15 without modification in order to have MS-DRGs available for these patients in the rare instance where there is a Medicare beneficiary admitted for maternity or newborn care.

In designating a proposed MS-DRG as one that will be subdivided into subgroups based on the presence of a CC or MCC, we developed a set of criteria to facilitate our decision-making process. In order to warrant creation of a CC or major CC subgroup within a base MS-DRG, the subgroup had to meet all of the following five criteria:

A reduction in variance of charges of at least 3 percent.

At least 5 percent of the patients in the MS-DRG fall within the CC or MCC subgroup.

At least 500 cases are in the CC or MCC subgroup.

There is at least a 20-percent difference in average charges between subgroups.

There is a $4,000 difference in average charge between subgroups.

Our objective in developing these criteria was to create homogeneous subgroups that are significantly different from one another in terms of resource use, that have enough volume to be meaningful, and that improve our ability to explain variance in resource use. These criteria are essentially the same criteria we used in our 1994 severity analysis.

To begin our analysis, we subdivided each of the base MS-DRGs into three subgroups: non-CC, CC, and MCC. Each subgroup was then analyzed in relation to the other two subgroups using the volume, charge, and reduction in variance criteria. The criteria were applied in the following hierarchical manner:

If a three-way subdivision met the criteria, we subdivided the base MS-DRG into three CC subgroups.

If only one type of two-way subdivisions met the criteria, we subdivided the base MS-DRG into two CC subgroups based on the type of two-way subdivision that met the criteria.

If both types of two-way subdivisions met the criteria, we subdivided the base MS-DRG into two CC subgroups based on the type of two-way subdivision with the highest R\2\ (most explanatory power to explain the difference in average charges).

Otherwise, we did not subdivide the base MS-DRG into CC subgroups.

For any given base MS-DRG, our evaluation in some cases showed that a subdivision between a non-CC and a combined CC/MCC subgroup was all that was warranted (that is, there was not a great enough difference between the CC and MCC subgroups to justify separate CC and MCC subgroups). Conversely, in some cases, even though an MCC subgroup was warranted, there was not a sufficient difference between the non-CC and CC subgroups to justify separate non-CC and CC subgroups.

Based on this methodology, a base MS-DRG may be subdivided according to the following three alternatives, rather than the current ``with CC'' and ``without CC'' division.

DRGs with three subgroups (MCC, CC, and non-CC).

DRGs with two subgroups consisting of an MCC subgroup but with the CC and non-CC subgroups combined. We refer to these groups as ``with MCC'' and ``without MCC.''

DRGs with two subgroups consisting of a non-CC subgroup but with the CC and MCC subgroups combined. We refer to these two groups as ``with CC/MCC'' and ``without CC/MCC.''

As a result of the application of these criteria, 745 proposed MS- DRGs were created as shown in the following table.

Table K.--Number of CC Subgroups

Number of Number of Subgroups

proposed base proposed MS- MS-DRGs

DRGs

No Subgroups............................

53 Three subgroups.........................

152

456 Two subgroups: major CC and CC; non-CC..

126 Two subgroups: non-CC and CC; major CC..

86 Subtotal................................

311

721 MDC 14..................................

[[Page 24706]]

Error DRGs..............................

Total...............................

335

745

The 745 proposed MS-DRGs represent an increase over the 652 DRGs created in our 1994 CC revision analysis. The increase in the number of DRGs is primarily the result of an increase in the number of proposed base MS-DRGs that are subdivided into three CC subgroups. The distribution of patients across the different types of CC subdivisions is contained in Table L below. The table shows that 51.7 percent of the patients are assigned to base MS-DRGs with three CC subgroups, and only 11.8 percent of the patients are assigned to base MS-DRGs with no CC subgroups.

Table L.--Distribution of Patients by Type of CC Subdivision

CC subdivision

Count Percent

None.......................................... 1,382,810

11.8 (MCC and CC), Non-CC.......................... 629,639

5.4 MCC, (CC and Non-CC).......................... 3,650,321

31.2 MCC, CC, and Non-CC........................... 6,054,081

51.7

Using Medicare charge data (without applying any criteria to remove statistical outlier cases), the reduction in variance (R\2\) was computed for current CMS DRGs, the MS-DRGs with all 311 base MS-DRGs subdivided into 3 CC subgroups, and the MS-DRGs collapsed into 745 DRGs. Table L below shows that the R\2\ for the proposed MS-DRGs with all 311 base MS-DRGs subdivided into 3 CC subgroups (957 DRGs composed of 311 base MS-DRGs subdivided into 3 CC subgroups plus an additional 22 MDC 14 and MDC 15 DRGs as well as 2 error DRGs) is 10.62 percent higher than the current CMS DRGs. Collapsing the 957 proposed MS-DRGs down to 745 proposed MS-DRGs lowers this increase in R\2\ slightly to 9.41 percent. Although adopting a 3-way split for each base MS-DRG would produce a DRG system with higher explanatory power, the 957 MS- DRGs would not meet the criteria we specified above for subdividing each base DRG. The criteria we specified above would create a monotonic DRG system. We believe that the value of having a monotonic DRG system outweighs the slight decrease in explanatory power. For this reason, we are proposing to adopt the 745 MS-DRGs.

Table M.--Explanatory Power (R\2\) for Proposed MS-DRGs

Percent R\2\ change

Current CMS DRG................................... 36.19 ......... 2007 CMS Severity DRGs with 3 CC Subgroups........ 40.03 10.62 2007 CMS Severity DRGs Collapsed to 714 DRGs...... 39.59 9.41

4. Conclusion

We believe the proposed MS-DRGs represent a substantial improvement over the current CMS DRGs in their ability to differentiate cases based on severity of illness and resource consumption. As developed, the proposed MS-DRGs increase the number of DRGs by 207, while maintaining the reasonable patient volume in each DRG. The proposed MS-DRGs increase the explanation of variance in hospital resource use relative to the current CMS DRGs by 9.41 percent. Further, the data shown below in Table N and Table O illustrate how assignment of cases to different severity of illness subclasses improves in the proposed MS-DRGs relative to the CMS DRGs.

Table N.--Overall Statistics for CMS DRGs

Average CC subclass--Current CMS DRG

Percent charges

One or more CCs................................... 77.66 $24,538 Non-CC............................................ 22.34 14,795

Table O.--Overall Statistics for Proposed MS-DRGs

Number of

Average CC subgroup

cases Percent charges

MCC.................................. 2,607,351 22.2 $44,219 CC................................... 4,298,362 36.6 24,115 Non-CC............................... 4,826,980 41.1 18,416

Under the current CMS DRGs, 78 percent of cases are assigned to the highest severity levels (CC) and the remaining 22 percent are assigned to the lowest severity level (non-CC). Applying the three severity subclasses to FY 2006 data would result in approximately 22 percent of patients being assigned to the severity subgroup with the highest level of severity (MCC), 41 percent being assigned to the lowest severity subclass (non-CC), and the remaining 37 percent being assigned to the middle severity subclass (CC). Adding the new MCC subgroup greatly enhances our ability to identify and reimburse hospitals for treating patients with high levels of severity. As Table N above shows, the

[[Page 24707]]

new subgroups also have significantly different resource requirements. The MCC subgroup contains patients with average charges almost twice as large as for those in the CC group ($44,219 compared to $24,115).

In addition to resulting in improvements in the DRG system's recognition of severity of illness, we believe the proposed MS-DRGs are responsive to the public comments that were made on last year's IPPS proposed rule with respect to how we should undertake further DRG reform. In the FY 2007 IPPS final rule, we identified three major concerns in the public comments about our proposed adoption of CS DRGs:

We received comments after the FY 2007 IPPS final rule suggesting that further adjustments are needed to the proposed DRG system. The commenters believed that the CS DRGs did not incorporate many of the changes to the DRG assignments that have been made over the year to the CMS DRGs. There was significant interest in the public comments in either revising the CS DRGs to reflect these changes or using the CMS DRGs at the starting point to better recognize severity.

We believe that the proposed MS-DRGs discussed in this proposed rule are responsive to these suggestions. The proposed MS-DRGs use the CMS DRGs as the starting point for revising the DRGs to better recognize resource complexity and severity of illness. We are generally retaining all of the refinements and improvements that have been made to the base DRGs over the years that recognize the significant advancements in medical technology and changes to medical practice. At the same time, the proposed MS-DRGs greatly improve our ability to identify groups of patients with varying levels of severity. They retain all of the improvements made to the DRGs over the years, while providing a more equitable basis for hospital payment.

We received many comments about the potential use of a proprietary DRG system. The comments about the CS DRGs raised compelling issues about the potential government use of a proprietary system including concerns about the availability, price, and transparency of the source code, logic and documentation of the DRG system. The commenters noted that CMS makes available these resources in the public domain for purchase through the National Technical Information Service at nominal fees to cover costs. The commenters urged CMS not to adopt a proprietary DRG system that would not be available on the same terms as the current CMS DRGs.

There are no proprietary issues associated with the proposed MS- DRGs in this proposed rule. The proposed MS-DRGs would be available on the same terms as the current CMS DRGs through the National Technical Information Service.

We also received other comments concerning the use of CS DRGs. The commenters stated that no alternatives to CS DRGs had been evaluated. The commenters suggested that alternative DRG systems can better recognize severity than the CS DRGs and should be evaluated before CMS decides which system to adopt.

We currently have a contract with the RAND Corporation to evaluate several alternative DRG systems. We believe it is premature to propose adopting one of the systems as RAND has not yet completed its evaluation. However, we believe the proposed MS-DRGs should be part of this process and have asked RAND to evaluate the proposed MS-DRGs with other DRG products that have been submitted for review. Although we are proposing to adopt the MS-DRGs for FY 2008, this decision would not preclude us from adopting any of the systems being evaluated by RAND for FY 2009.

As indicated above, we believe the proposed MS-DRGs offer significant improvements to the DRG system without many of the liabilities the public commenters identified with the CS DRGs. Thus, we believe the proposed MS-DRGs offer significant improvements in recognition of severity of illness and complexity of resources and are proposing to adopt them for FY 2008. However, we are continuing our evaluation of alternative DRG systems that can better recognize severity of illness and resource consumption and have submitted the proposed MS-DRGs to RAND for further evaluation. 5. Impact of the Proposed MS-DRGs

Unlike the CS DRGs we proposed last year for FY 2008, the payment impacts from the MS-DRGs we are proposing to adopt this year would largely be redistributive within each base MS-DRG. Such a result occurs because we collapse the current CC/non-CC, age and other distinctions that exist in the CMS DRGs and redivide them based on MCCs, CCs, and non-CCs. Thus, within each proposed base MS-DRG, some cases will be paid more and some less, but the base MS-DRGs are retained so there is no redistribution between types of cases as would have occurred under the proposed CS DRGs. We encourage readers to review Table 5 in the Addendum to this proposed rule for a list of the proposed MS-DRGs and the proposed respective relative weight from the revisions we are proposing to better recognize severity of illness to better understand how payment for cases within each base MS-DRG will be affected.

As indicated above, all of the severity DRG systems being evaluated by RAND can be expected to result in similar redistributions in case- mix among hospitals. The payment models used by RAND and CMS (and RTI as well) all assume static utilization. That is, payment impact models simulate the effects of a change in policy, assuming no change to Medicare utilization. Any system adopted to better recognize severity of illness with a budget neutrality constraint will result in case-mix changes that can be expected to benefit urban hospitals at the expense of rural hospitals. This impact occurs because patients treated in urban hospitals are generally more severely ill than patients in rural hospitals and the CMS DRGs are not currently recognizing the full extent of these differences. Similarly, there will be differential impacts among other categories of hospitals (for example, teaching, disproportionate share, large urban, and other urban hospitals) depending on the mix of cases that each hospital treats. The impact of the proposed MS-DRGs can be expected to have similar effects on case- mix as the DRG systems being analyzed by RAND. In addition, we believe that it is important to note that the MS-DRGs are proposed to be adopted for FY 2008 at the same time that we are phasing in cost weights. In the FY 2007 IPPS final rule, we adopted cost weights over a 3-year transition period in \1/3\ increments. Thus, the full impact of adopting cost weights will not be incorporated into IPPS payments until FY 2009. Nevertheless, we believe it is important to consider together the effect on case-mix of the fully phased-in cost weights and proposed MS-DRGs to get a complete understanding of how IPPS payment reforms would affect case-mix for different categories of hospitals from FY 2007 through FY 2009. For instance, using cost weights are estimated to increase payments to rural hospitals (see 71 FR 47917). In FY 2007, we are paying hospitals using a blend of \1/3\ cost and \2/3\ charge relative weights. In FY 2008, we will pay hospitals using a blend of \2/3\ cost and \1/3\ charge relative weights. In FY 2009, we will pay hospitals using 100 percent cost relative weights. Therefore, there will likely be some additional increases in payments to rural hospitals from the final year of the transition to fully implemented cost weights that are not

[[Page 24708]]

illustrated in the table in the impact section of this proposed rule. 6. Changes to Case-Mix Index (CMI) From the Proposed MS-DRGs

After the 1983 implementation of the IPPS DRG classification system, CMS observed unanticipated growth in inpatient hospital case- mix (the average relative weight of all inpatient hospital cases), which we use as a proxy measurement for severity of illness. We had projected the rate of growth in case-mix for the period 1981 to 1984 to be 3.4 percent. The realized rate of growth during this period, which included the introduction of the IPPS, was 8.4 percent, a variance in excess of 1.6 percent per year. The unexpected growth in payments was due to increases in the hospital case-mix index (CMI) beyond the previously projected trend. Hospitals' CMI values measure the expected treatment cost of the mix of patients treated by a particular hospital. There are three factors that determine changes in a hospital's CMI:

(a) Admitting and treating a more resource intensive patient-mix (due, for example, to technical changes that allow treatment of previously untreatable conditions and/or an aging population);

(b) Providing services (such as higher cost surgical treatments, medical devices, and imaging services) on an inpatient basis that previously were more commonly furnished in an outpatient setting; and

(c) Changes in documentation (more complete medical records) and coding practice (more accurate and complete coding of the information contained in the medical record).

We note that changes in patient-mix and medical practice signal real changes in underlying resource utilization and cost of treatment. While these changes may have occurred in response to incentives from IPPS policies, they represent real changes in resource needs. In contrast, changes in CMI as a result of improved documentation and coding do not represent real increases in underlying resource demands. For the implementation of the IPPS in 1983, improved documentation and coding were found to be the primary cause in the underprojection of CMI increases, accounting for as much as 2 percent in the annual rate of CMI growth observed post-PPS.\2\

\2\ Carter, Grace M. and Ginsburg, Paul: The Medicare Case Mix Index Increase, Medical Practice Changes, Aging and DRG Creep, Rand, 1985.

The Medicare Trustees Technical Review Panel \3\ has previously determined the annual measured change in CMI for inpatient hospital services to oscillate around an underlying real trend of 1 percent annual growth. In 1991 the Medicare specific trend in real CMI growth was found in a then-HCFA funded study \4\ to be within a range of 1 to 1.4 percent. In the annual study conducted by CMS, there has been no evidence to support a real case-mix increase in excess of the annually projected 1 percent upper bound in the period. MedPAC findings have echoed this with its recent study of real case-mix change finding growth rates for years 2002, 2003, and 2004 of 1 percent, 0.6 percent, and 0.4 percent, respectively.\5\

\3\ Review of Assumptions and Methods of the Medicare Trustees' Financial Projections; Technical Review Panel on the Medicare Trustees Reports, December 2000.

\4\ ``Has DRG Creep Crept Up? Decomposing the Case Mix Index Change Between 1987 and 1988''; Carter, Newhouse, Relles ; R-4098- HCFA/ProPAC (1991).

\5\ Medicare Payment Advisory Commission: Report to the Congress, March 2006 (p. 52).

We believe that adoption of the MS-RGs proposed in this proposed rule would create a risk of increased aggregate levels of payment as a result of increased documentation and coding. MedPAC notes that ``refinements in DRG definitions have sometimes led to substantial unwarranted increase in payments to hospitals, reflecting more complete reporting of patients' diagnoses and procedures.'' MedPAC further notes that ``refinements to the DRG definitions and weights would substantially strengthen providers' incentives to accurately report patients' comorbidities and complications.'' To address this issue, MedPAC recommended that the Secretary ``project the likely effect of reporting improvements on total payments and make an offsetting adjustment to the national average base payment amounts.'' \6\

\6\ Medicare Payment Advisory Commission: Report to Congress on Physician-Owned Specialty Hospitals, March 2005, p. 42.

The Secretary has broad discretion under section 1886(d)(3)(A)(vi) of the Act to adjust the standardized amount so as to eliminate the effect of changes in coding or classification of discharges that do not reflect real changes in case-mix. While we modeled the changes to the DRG system and relative weights to ensure budget neutrality, we are concerned that the large increase in the number of DRGs will provide opportunities for hospitals to do more accurate documentation and coding of information contained in the medical record. Coding that has no effect on payment under the current CMS DRGs may result in a case being assigned to a higher paid DRG under the proposed MS-DRGs. Thus, more accurate and complete documentation and coding may occur because it will result in higher payments under the proposed MS-DRGs. We believe the potential for more accuate and complete documentation and coding will apply equally under the acute IPPS as well as under the LTCH PPS because the same DRGs are used for both payment systems. Thus, the analysis below will apply to both the IPPS and the LTCH PPS.

CMS in the past has adjusted standardized amounts under the IRF PPS to account for case-mix increases due to improvements in documentation and coding. In 2004, RAND \7\ published a technical report as part of the followup to the implementation of the IRF PPS. The initial weights used within the IRF PPS were based on a mix of CY 1999 and CY 1998 data. The study reviewed the changes between this base data set and the IRF PPS implementation year of 2002. The report found that the weight per discharge for IRFs had grown by 3.4 percent between the CY 1999 data set and the CY 2002 data set. In a detailed analysis of both statistical patterns in acute stay records and directly measured coding behaviors, RAND found that the level of case-mix increase associated with documentation and coding-induced changes in the transition year ranged between 1.9 and 5.8 percent, with the upper end of the estimate associated with real declines in resource use. (We note that RAND revised its report in late 2005 to reflect an upper bound of 5.9 percent, instead of the 5.8 percent that we reported in the FY 2006 IRF PPS proposed and final rules.)

\7\ Carter, Paddock: Preliminary Analyses of Changes in Coding and Case Mix Under the Inpatient Rehabilitation Facility Prospective Payment System, RAND, 2004.

We used the results of this analysis to justify a 1.9 percent adjustment to payment rates for IRFs in FY 2006 (70 FR 47904) and a 2.6 percent adjustment to payment rates for IRFs in FY 2007 (71 FR 48370), for a combined total adjustment of 4.5 percent. The implementation year was marked by the transitioning of hospitals to the IRF PPS payment based on cost reports beginning January 1, 2002, and staggered to October 1, 2002. A combination of increased familiarity with the system by providers and the staggered transition could mean that documentation and coding-induced case-mix change continued as hospitals experienced ongoing changes in the early years of the IRF PPS and as the

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incentives within the system were more widely recognized. We also recognize that significant changes in IRF patient populations may be occurring as a result of recent regulatory changes, such as the phase- in of the 75 percent rule compliance percentage. We intend to continue analyzing changes in coding and case-mix closely, using the most current available data, as part of our ongoing monitoring of the IRF PPS and, based on this analysis, we intend to propose additional payment refinements for IRFs in the future as the analysis indicates such adjustments are warranted.

Furthermore, as part of our analysis of this issue, we considered the recent experience of the State of Maryland with adopting the APR DRG system. Maryland introduced APR DRGs for payment for three teaching hospitals in 2000. Between State fiscal years (SFYs) 2001 and 2005,\8\ the remaining hospitals continued to be paid using modified CMS DRGs. In June 2004, the remaining hospitals were notified that Maryland would expand the use of APR DRGs throughout its all payer charge-per-case system beginning in July 2005. Hospitals in Maryland improved coding and documentation in response to the adoption of APR DRGs. As a result of this improved documentation and coding, reported CMI increased at a greater rate than real CMI. Given the similarity between coding incentives using the APR DRGs in Maryland and the MS-DRGs that are being proposed for Medicare, we analyzed Maryland data to develop an adjustment for improved documentation and coding.

\8\ Maryland uses a July 1 to June 30 State fiscal year. Prior to FY 2003, Maryland had a 6-month lag in the data used to calculate the hospital base case-mix index and case-mix change. Maryland used 12 months data ending December even though the hospitals' rate year was July 1 to June 30. In FY 2003, Maryland moved to what it called ``Real Time Case-Mix'' and started using 12 months data ending June 30 to calculate case-mix index and case-mix change for a rate year beginning July 1.

For the Maryland analysis, we assume that, in SFY 2005, those hospitals not already being paid under the APR DRG system began acting as if the transition to the new DRG logic had already taken place. This assumption is supported by the following facts: (a) Maryland hospitals were reporting to the Health Services and Cost Review Commission (HSCRC), Maryland's governing body of its all-payer ratesetting system) using the APR DRG GROUPER in 2005; (b) hospitals were provided training in coding under the APR DRG GROUPER; (c) hospitals had access to reports based on APR DRG logic; and (d) hospitals were given large amounts of feedback as to their performance under the GROUPER by the HSCRC relative to peer hospitals.

The incentives for Maryland hospitals are to code as completely and accurately as possible because, beginning in July 2005, all Maryland hospitals were paid using APR DRGs. SFY 2005 was an important year in Maryland, as it marked the beginning of the 2-year period of transition after which a hospital's revenues were reduced if coding was not as complete as a peer hospital. Under the current CMS DRGs, each secondary diagnosis code is recognized as either a CC or non-CC. Hospitals in Maryland and nationally for Medicare only needed to code one secondary diagnosis as a CC when paid using CMS DRGs for the patient to be assigned to a higher weighted DRG split based on the presence or absence of a CC. Under the APR DRGs, each secondary diagnosis is designated as minor, moderate, major, or extreme. Under the proposed MS-DRGs, each secondary diagnosis is designated as a non-CC, CC, or MCC. Hospitals in Maryland have incentives under the APR DRGs to code until a case is assigned to the highest of the four severity levels within a base DRG. Under the proposed MS-DRGs, hospitals will have incentives to code until a case is assigned to one of up to three severity levels within a base DRG. Although the APR DRGs and the proposed MS-DRGs may be different, we believe that hospitals have the same incentive under both systems to code as completely as possible. For this reason, we believe that the Maryland experience is a reasonable basis for projecting behavioral changes in the wider national hospital population for the first 2 years of the MS-DRGs.

We believe the analysis presented below provides a reasonable analysis of the potential growth in CMI due to improved documentation and coding. In addition to the similarity between coding incentives under the proposed MS-DRGs and the APR DRGs, we note that Maryland is an all-payer State; therefore, hospitals are paid by all third party payers--not just the State's Medicaid program--using the APR DRGs. Coding has been very important for each hospital's overall revenue for many years, and the incentives are uniform across all third party payers. The transition to APR DRGs was known well in advance of the actual date and, as stated above, hospitals were provided training in coding under the APR DRGs. It is reasonable to expect that hospitals' experience with improved documentation and coding will occur over a period of at least 2 years. Thus, the experience in Maryland may be similar to expectations for case-mix growth for the nation as a whole. Finally, in reviewing the results from Maryland, we note that three large teaching hospitals began using APR DRGs prior to SFY 2005. These facilities generally treat a wider variety of patients with higher acuity that gives them a greater potential for increasing coding under the APR DRG system than other hospitals throughout Maryland. Because these hospitals were paid using the APR DRGs earlier than other Maryland hospitals, we believe data for them need to be analyzed from an earlier time period. However, based on the consultations with the HSCRC, we believe there were special issues with one of these hospitals that may have made its case-mix growth during the early years of the transition to the APR DRGs atypical of the other teaching hospitals.\9\ Therefore, we did not separately analyze the data for this hospital from the earlier time period and, as stated below, included its data with the rest of Maryland hospitals.

\9\ The HSCRC informed us that it began using APR DRGs for this hospital to calculate the CMI and case-mix change to set the hospital's charge per case target (CPC) that is used in Maryland's all-payer ratesetting system for payment. However the HSCRC also compared the reasonableness of hospital rates and costs for this hospital relative to peer institutions using modified CMS DRGs to calculate CMI and case-mix change. This use of dual systems to calculate CMI and case-mix change made it difficult for the hospital to code aggressively in the first few years of using APR DRGs.

As part of its contract with CMS, 3M Health Information Systems reviewed the Maryland data in the context of our proposed changes to adopt MS-DRGs. 3M grouped Medicare cases in Maryland through both the CMS DRGs Version 24.0 and the MS-DRGs that we are proposing to adopt for FY 2008. At our request, 3M deleted two of the three early transition hospitals from the data. It compared the results of the observed growth in case-mix from these data to the same process applied to Medicare data, excluding Maryland hospitals.

The MedPAR data file for Federal fiscal year (FFY) 2006 (October 2005 through September 2006) was used to create relative weights for both CMS DRG Version 24.0 and the proposed MS-DRGs. The MedPAR data file contained 12,794,280 records. In constructing the weights, the following edits were used:

Cases with zero covered charges or length of stay were excluded.

Cases with length of stay greater than 2 years were excluded.

Only hospitals contained in the impact file for the FY 2007 IPPS final rule were included.

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The latter criterion excluded providers reimbursed outside of the IPPS, including Maryland hospitals, from the weight calculation. 3M employed standardized charge-based relative weights developed in accordance with the CMS methodology. Cost-based weights were not used and no adjustment to the charge weights was made for application of CMS transfer and postacute care transfer payment policy.

3M further grouped 2 years of MedPAR data from FY 2004 and FY 2005, using CMS DRG Version 24.0 and the proposed MS-DRGs for hospitals nationally. Using 2 years of MedPAR data with one version of each DRG system further required 3M to make adjustments to the data to reflect revisions to ICD-9-CM codes that are made each year. MedPAR data for Maryland IPPS acute care providers within the IPPS data set were similarly assigned to the proposed MS-DRGs and CMS DRGs for FYs 2004 through 2006.

Each Maryland record, exclusive of the two early transition teaching hospitals for the 3 observed years (SFY 2004 to SFY 2006), was assigned to a proposed MS-DRG based on the ICD-9-CM codes the hospital submitted. The same results were obtained from data at the national level using the proposed MS-DRGs. Further, we obtained data from the HSCRC showing the weighted average increase in case-mix for calendar years 2001 to 2003 for the two large academic medical centers that began an early transition to the APR DRGs. In addition, we also obtained case-mix increases under the CMS DRGs for FYs 2004 through 2006. The Medicare Actuary examined the data below:

Table Q.--Maryland and National Data Used for Case-Mix Adjustment Analysis

FY 2004 to FY 2005 to FY 2004 to 2005

2006

Rest of Maryland MS-DRG CMI [Delta] 2.30% 2.57%

4.93% .......... .......... CY 2000 to FY 2003 Early Transition Hospitals.........

4.4

6.7

11.4 National MS-DRG CMI [Delta]........

0.47

2.65

3.13 National CMS DRG CMI [Delta]....... -0.04

1.20

1.16 Blend of MS-DRG & CMS DRG [Delta] .......... ..........

1.68 using 0.47 Percent for 2005 and 1.2 Percent for 2006.............. Difference between Maryland Early .......... ..........

9.58 Transition Hospitals and National Data.............................. Difference between Rest of Maryland .......... ..........

3.20 and National Data................. Medicare Actuary Estimate (75%/25%) .......... ..........

4.8 between Early Transition and Rest of Maryland.......................

The data above show that case-mix for hospitals increased by 4.93 percent from SFYs 2004 to 2006, during which Maryland adopted the APR DRGs for most hospitals. Case-mix for the two large teaching hospitals that were paid using the APR DRGs earlier than other hospitals in the State increased by 11.4 percent from SFYs 2001 to 2003. The weighted average increase in Maryland from these two categories of hospitals is 5.58 percent. Case-mix using the proposed MS-DRGs would have increased 0.47 percent in FY 2005 and 2.65 percent in FY 2006. Nationally, Medicare case-mix using the CMS DRGs decreased by 0.04 percent in FY 2005 and increased by 1.2 percent in FY 2006. The Actuary calculated a Medicare case-mix increase nationally over 2 years using a blend of these data from proposed MS-DRGs for FY 2005 and national Medicare data for FY 2006 from the CMS DRGs. The Actuary did not use either the -0.04 percent for the CMS DRGs or the 2.65 percent for the proposed MS-DRGs to create this blended case-mix because these figures appeared atypical to national trends. Therefore, the Actuary dropped one atypically high and low number from each of the 2 years of data and calculated an average increase of 1.68 percent from FY 2004 to FY 2006. These data demonstrate that the measure of average CMI for Medicare cases is growing more rapidly within Maryland than nationally. Case-mix for the Maryland teaching hospitals and the rest of Maryland increased 9.58 percent and 3.20 percent more, respectively, than the national average over 2 years, suggesting that improved documentation and coding lead to perceived, but not real, changes in case-mix.

The Actuary noted that the case-mix increase in Maryland for two large teaching hospitals over a 2-year period was much higher in the early years of the APR DRGs than other Maryland hospitals (11.4 percent compared to 4.93 percent for the rest of Maryland). Further, teaching hospitals generally treat cases with higher acuity than other hospitals and have more opportunity to improve coding and documentation to increase case-mix than other hospitals. Teaching hospitals also represent a higher proportion of national Medicare data than they do of the data in Maryland. The two early transition teaching hospitals in Maryland account for approximately 10 percent of the Medicare discharges in Maryland. Nationally, teaching hospitals account for approximately 50 percent of Medicare discharges. Therefore, the Actuary believes that the teaching hospitals should be given a higher weight in the national data than they represent in Maryland. However, like other hospitals, teaching hospitals vary in size and patient-mix and not all have the same opportunity to improve documentation and coding. Therefore, we believe the weight given to teaching hospitals should be higher than the 10 percent for the two early transition hospitals in Maryland but lower than the 50 percent of discharges that they account for in Maryland. The Actuary gave a weight of 25 percent for teaching hospitals and 75 percent for the rest of Maryland to the excess growth in case-mix over the national average and estimates that an adjustment of 4.8 percent will be necessary to maintain budget neutrality for the transition to the MS-DRGs. This analyis reflects our current estimate of the necessary adjustment needed to maintain budget neutrality for improvements in documentation and coding that lead to increases in case-mix. Consistent with the statute, we will compare the actual increase in case-mix due to documentation and coding to our projection once we have actual data to revise the Actuary's estimate and the adjustment we make to the standardized amounts.

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standardized amounts by 2.4 percent each year for FY 2008 and FY 2009. We are considering proposing a 4.8 percent adjustment for FY 2008. However, we believe it would be appropriate to provide a transition because we would be making a significant adjustment to the standardized amounts. We are interested in public comments on whether we should apply the proposed adjustment in a single year, over 2 years, or in different increments than \1/2\ of the adjustment each year. Section 1886(d)(3)(A)(vi) of the Act further gives the Secretary authority to revisit adjustments to the standardized amounts for changes in coding or classification of discharges that were based on estimates in a future year. Consistent with the statute, we will compare the actual increase in case-mix due to documentation and coding to our projection once we have actual data for FY 2008 and FY 2009 for the FY 2010 and FY 2011 IPPS rules. At that time, if necessary, we may make a further adjustment to the standardized amounts to account for the difference between our projection and actual data.

Under section 123(a)(1) of Pub. L. 105-33, as amended by section 307(b) of Pub. L. 106-554, we are also proposing to adjust the DRG relative weights that are used for the LTCH PPS by -2.4 percent (0.976) in FYs 2008 and 2009 to account for the anticipated increase in case mix from improved documentation and coding. This proposed budget neutrality adjustment is necessary to ensure that estimated aggregate LTCH PPS payments would be neither greater than nor less than the estimated aggregate LTCH PPS payments that would have been made without the proposed LTC-DRG reclassification and update of the relative weights. As discussed earlier with regards to the IPPS, we have estimated that a 2.4 percent adjustment is needed to maintain budget neutrality. We believe an adjustment of at least 2.4 percent for both FYs 2008 and 2009 is appropriate under the LTCH PPS because LTCHs have an average inpatient length of stay greater than 25 days and due to the comorbidities of these patients, LTCHs will have a significantly increased opportunity to better code for these paitents under the proposed MS-LTC-DRG system. In the LTCH proposed rule (72 FR 4793) for rate year (RY) 2008, we proposed to update the LTCH standardized amounts by 0.71 percent. The proposed changes to the LTCH standardized amounts will be effective on July 1. However, the proposed changes to adopt MS-LTC-DRGs for LTCHs would not be effective until October 1 if finalized. Because changes to the LTCH standardized amounts for RY 2008 are already being set through a separate rulemaking process and are effective on July 1 instead of October 1, we decided that the adjustment for increases in case mix due to improvements and documentation and coding should be applied to the LTCH relative weights rather than the standardized amounts. 7. Effect of the Proposed MS-DRGs on the Outlier Threshold

To qualify for outlier payments, a case must have costs greater than Medicare's payment rate for the case plus a ``fixed loss'' or cost threshold. The statute requires that the Secretary set the cost threshold so that outlier payments for any year are projected to be not less than 5 percent or more than 6 percent of total operating DRG payments plus outlier payments. The Secretary is required by statute to reduce the average standardized amount by a factor to account for the estimated proportion of total DRG payments made to outlier cases. Historically, the Secretary has set the cost threshold so that 5.1 percent of estimated IPPS payments are paid as outliers. The FY 2007 cost outlier threshold is $24,485. Therefore, for any given case, a hospital's charge adjusted to cost by its hospital-specific CCR must exceed Medicare's DRG payment by $24,485 for the case to receive cost outlier payments.

Adoption of the proposed MS-DRGs will have an effect on calculation of the outlier threshold. For this proposed rule, we analyzed how the outlier threshold would be affected by adopting the proposed MS-DRGs. Using FY 2005 MedPAR data, we have simulated the effect of the proposed MS-DRGs on the outlier threshold. By increasing the number of DRGs from 538 to 745 to better recognize severity of illness, the proposed MS- DRGs would be providing increased payment that better recognizes complexity and severity of illness for cases that are currently paid as outliers. That is, many cases that are high-cost outlier cases under the current CMS DRG system would be paid using an MCC DRG under the proposed MS-DRGs and could potentially be paid as nonoutlier cases. For this reason, we expected the proposed FY 2008 outlier threshold to decline from its FY 2007 level of $24,485. We are proposing an FY 2008 outlier threshold of $23,015. In section II.A.4. of the Addendum to this proposed rule, we provide a more detailed explanation of how we determined the proposed FY 2008 cost outlier threshold. 8. Effect of the Proposed MS-DRGs on the Postacute Care Transfer Policy

Existing regulations at Sec. 412.4(a) define discharges under the IPPS as situations in which a patient is formally released from an acute care hospital or dies in the hospital. Section 412.4(b) defines transfers from one acute care hospital to another. Section 412.4(c) establishes the conditions under which we consider a discharge to be a transfer for purposes of our postacute care transfer policy. In transfer situations, each transferring hospital is paid a per diem rate for each day of the stay, not to exceed the full DRG payment that would have been made if the patient had been discharged without being transferred.

The per diem rate paid to a transferring hospital is calculated by dividing the full DRG payment by the geometric mean length of stay for the DRG. Based on an analysis that showed that the first day of hospitalization is the most expensive (60 FR 45804), our policy provides for payment that is double the per diem amount for the first day (Sec. 412.4(f)(1)). Transfer cases are also eligible for outlier payments. The outlier threshold for transfer cases is equal to the fixed-loss outlier threshold for nontransfer cases, divided by the geometric mean length of stay for the DRG, multiplied by the length of stay for the case, plus one day. The purpose of the IPPS postacute care transfer payment policy is to avoid providing an incentive for a hospital to transfer patients to another hospital early in the patients' stay in order to minimize costs while still receiving the full DRG payment. The transfer policy adjusts the payments to approximate the reduced costs of transfer cases.

Beginning with FY 2006 IPPS, the regulations at Sec. 412.4 specified that, effective October 1, 2005, we make a DRG subject to the postacute care transfer policy if, based on Version 23.0 of the DRG Definitions Manual (FY 2006), using data from the March 2005 update of FY 2004 MedPAR file, the DRG meets the following criteria:

The DRG had a geometric mean length of stay of at least 3 days;

The DRG had at least 2,050 postacute care transfer cases; and

At least 5.5 percent of the cases in the DRG were discharged to postacute care prior to the geometric mean length of stay for the DRG.

In addition, if the DRG was one of a paired set of DRGs based on the presence or absence of a CC or major cardiovascular condition (MCV), both paired DRGs would be included if either one met the three criteria above.

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If a DRG met the above criteria based on the Version 23.0 DRG Definitions Manual and FY 2004 MedPAR data, we made the DRG subject to the postacute care transfer policy. We noted in the FY 2006 final rule that we would not revise the list of DRGs subject to the postacute care transfer policy annually unless we make a change to a specific CMS DRG. We established this policy to promote certainty and stability in the postacute care transfer payment policy. Annual reviews of the list of CMS DRGs subject to the policy would likely lead to great volatility in the payment methodology with certain DRGs qualifying for the policy in one year, deleted the next year, only to be reinstated the following year. However, we noted that, over time, as treatment practices change, it was possible that some CMS DRGs that qualified for the policy will no longer be discharged with great frequency to postacute care. Similarly, we explained that there may be other CMS DRGs that at that time had a low rate of discharges to postacute care, but which might have very high rates in the future.

The regulations at Sec. 412.4 further specify that if a DRG did not exist in Version 23.0 of the DRG Definitions Manual or a DRG included in Version 23.0 of the DRG Definitions Manual is revised, the DRG will be a qualifying DRG if it meets the following criteria based on the version of the DRG Definitions Manual in use when the new or revised DRG first became effective, using the most recent complete year of MedPAR data:

The total number of discharges to postacute care in the DRG must equal or exceed the 55th percentile for all DRGs; and

The proportion of short-stay discharges to postacute care to total discharges in the DRG exceeds the 55th percentile for all DRGs. A short-stay discharge is a discharge before the geometric mean length of stay for the DRG.

A DRG also is a qualifying DRG if it is paired with another DRG based on the presence or absence of a CC or MCV that meets either of the above two criteria.

The MS-DRGs that we are proposing to adopt for FY 2008 are a significant revision to the current CMS DRG system. Because the proposed new MS-DRGs are not reflected in Version 23.0 of the DRG Definitions Manual, consistent with Sec. 412.4, we will need to recalculate the 55th percentile thresholds in order to determine which proposed MS-DRGs, if adopted, would be subject to the postacute care transfer policy. Further, under the proposed MS-DRGs, the subdivisions within the base DRGs will be different than those under the current CMS DRGs. Unlike the current CMS DRGs, the proposed MS-DRGs are not divided based on the presence or absence of a CC or MCV. Rather, the proposed MS-DRGs have up to three subdivisions based on: (1) The presence of a MCC; (2) the presence a CC; or (3) the absence of either an MCC or CC. Consistent with our existing policy under which both DRGs in a CC/non- CC pair are qualifying DRGs if one of the pair qualifies, we are proposing that each MS-DRG that shares a base MS-DRG would be a qualifying DRG if one of the MS-DRGs that shares the base DRG qualifies. We are proposing to revise Sec. 412.4(d)(3)(ii) to codify this proposed policy.

Similarly, we believe that the proposed changes to adopt MS-DRGs also necessitate a revision to one of the criteria used in Sec. 412.4(f)(5) of the regulations to determine whether a DRG meets the criteria for payment under the ``special payment methodology.'' Under the special payment methodology, a case subject to the special payment methodology that is transferred early to a postacute care setting will be paid 50 percent of the total IPPS payment plus the average per diem for the first day of the stay. Fifty percent of the per diem amount will be paid for each subsequent day of the stay, up to the full MS-DRG payment amount. A CMS DRG is currently subject to the special payment methodology if it meets the criteria of Sec. 412.4(f)(5). Section 412.4(f)(5)(iv) specifies that if a DRG meets the criteria specified under Sec. 412.4(f)(5)(i) through (f)(5)(iii), any DRG that is paired with it based on the presence or absence of a CC or MCV is also subject to the special payment methodology. Given that this criterion would no longer be applicable under the proposed MS-DRGs, we are proposing to add a new Sec. 412.4(f)(6) that includes a DRG in the special payment methodology if it is part of a CC/non-CC MCV/non-MCV pair. We are proposing to update this criterion so that it conforms to the proposed changes to adopt MS-DRGs for FY 2008. The proposed revision would make an MS-DRG subject to the special payment methodology if it shares a base MS-DRG with an MS-DRG that meets the criteria for receiving the special payment methodology.

Section 412.4(f)(3) states that the postacute care transfer policy does not apply to CMS DRG 385 for newborns who die or are transferred. We are proposing to make a conforming change to this paragraph to reflect that this CMS DRG would become MS-DRG 789 (Neonates, Died or Transferred to Another Acute Care Facility) under our proposed DRG changes for FY 2008.

These revisions do not constitute a change to the application of the postacute care transfer policy. Therefore, any savings attributed to the postacute care transfer policy would be unchanged as a result of adopting the MS-DRGs. Consistent with section 1886(d)(4)(C)(iii) of the Act, aggregate payments from adoption of the proposed MS-DRGs cannot be greater or less than those that would have been made had we not proposed to make any DRG changes.

We are also proposing technical changes to Sec. Sec. 412.4(f)(5)(i) and (f)(5)(iv) to correct a cross-reference and a typographical error, respectively.

E. Refinement of the Relative Weight Calculation

(If you choose to comment on issues in this section, please include the caption ``DRGs: Relative Weight Calculations'' at the beginning of your comment.)

In the FY 2007 IPPS final rule (71 FR 47882), effective for FY 2007, we began to implement significant revisions to Medicare's inpatient hospital rates by basing the relative weights on hospitals' estimated costs rather than on charges. This reform was one of several measured steps to improve the accuracy of Medicare's payment for inpatient stays that include using costs rather than charges to set the relative weights and making refinements to the current DRGs so they better account for the severity of the patient's condition. Prior to FY 2007, we used hospital charges as a proxy for hospital resource use in setting the relative weights. Both MedPAC and CMS have found that the limitations of charges as a measure of resource use include the fact that hospitals cross-subsidize departmental services in many different ways that bear little relation to cost, frequently applying a lower charge markup to routine and special care services than to ancillary services. In MedPAC's 2005 Report to the Congress on Physician-Owned Specialty Hospitals, MedPAC found that hospitals charge much more than their costs for some types of services (such as operating room time, imaging services and supplies) than others (such as room and board and routine nursing care).\10\ Our analysis of the MedPAC report in the FY 2007 IPPS proposed rule (71 FR 24006) produced consistent findings.

\10\ Medicare Payment Advisory Commission: Report to the Congress: Physician-Owned Specialty Hospitals, March 2005, p. 26.

In the FY 2007 IPPS proposed rule, we proposed to implement cost- based weights incorporating aspects of a

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methodology recommended by MedPAC, which we called the hospital- specific relative value cost center (HSRVcc) methodology. MedPAC indicated that an HSRVcc methodology would reduce the effect of cost differences among hospitals that may be present in the national relative weights due to differences in case-mix adjusted costs. After studying Medicare cost report data, we proposed to establish 10 national cost center categories from which to compute 10 national CCRs based upon broad hospital accounting definitions. We made several important changes to the HSRVcc methodology that MedPAC recommended using in its March 2005 Report to the Congress on Physician-Owned Specialty Hospitals. We refer readers to the FY 2007 IPPS proposed rule (71 FR 24007 through 24011) for an explanation and our reasons for the modification to MedPAC's methodology. In its public comments on the FY 2007 IPPS proposed rule, MedPAC generally agreed with the adaptations we made to its methodology, with the exception of expanding the number of distinct hospital department CCRs being used from 10 to 13 and basing the CCRs on Medicare-specific costs and charges.\11\

\11\ Hackbarth, Glenn: MedPAC Comments on the IPPS Rule, June 12, 2006, page 2.

We did not finalize the HSRVcc methodology for FY 2007 because of concerns raised in the public comments on the FY 2007 IPPS proposed rule (71 FR 47882 through 47898). Rather, we adopted a cost-weighting methodology without the hospital-specific relative weight feature. We also expanded the number of distinct hospital departments with CCRs from 10 to 13. We indicated our intent to study whether to adopt the HSRVcc methodology after we had the opportunity to further consider some of the issues raised in the public comments. In the interim, we adopted a cost-weighting methodology over a 3-year transition period, substantially mitigating the redistributive payment impacts illustrated in the proposed rule, while we engaged a contractor to assist us with evaluating the HSRVcc methodology.

Some public commenters raised concerns about potential bias in cost weights due to ``charge compression,'' which is the practice of applying a lower percentage markup to higher cost services and a higher percentage markup to lower cost services. These commenters were concerned that our proposed weighting methodology may undervalue high cost items and overvalue low cost items if a single CCR is applied to items of widely varying costs in the same cost center. The commenters suggested that the HSRVcc methodology would exacerbate the effect of charge compression on the final relative weights. One of the commenters suggested an analytic technique of using regression analysis to identify adjustments that could be made to the CCRs to better account for charge compression. We indicated our interest in researching whether a rigorous model should allow an adjustment for charge compression to the extent that it exists. We engaged a contractor, RTI International (RTI), to study several issues with respect to the cost weights, including charge compression, and to review the statistical model provided to us by the commenter for adjusting the weights to account for it. We discuss RTI's findings in detail below.

Commenters also suggested that the cost report data used in the cost methodology are outdated, not consistent across hospitals, and do not account for the costs of newer technologies such as medical devices. However, the relationship between costs and charges (not costs alone) is the important variable in setting the relative weights under this new system. Older cost reports also do not include the hospital's higher charges for these same medical devices. Therefore, it cannot be known whether the CCR for the more recent technologies will differ from those we are using to set the relative weights. The use of national average cost center CCRs rather than hospital-specific CCRs may mitigate potential inconsistencies in hospital cost reporting. Nevertheless, we agree that it is important to review how hospitals report costs and charges on the cost reports and on the Medicare claims and asked RTI to further study this issue as well.

In summary, we proposed to adopt HSRVcc relative weights for FY 2007 using national average CCRs for 10 hospital departments. Based on public comments concerned about charge compression and the accuracy of cost reporting, we decided not to finalize the HSRVcc methodology, but adopted costs weights without the hospital-specific feature. In response to comments from MedPAC, we expanded the number of hospital cost centers used in calculating the national CCRs from 10 to 13. Finally, we decided to implement the cost-based weighting methodology gradually, by blending the cost and charge weights over a 3-year transition period beginning with FY 2007, while we further studied many of the issues raised in the public comments. We refer readers to the FY 2007 IPPS final rule (71 FR 47882) for more details on our final policy for calculating the cost-based DRG relative weights. 1. Summary of RTI's Report on Charge Compression

In August 2006, we awarded a contract to RTI to study the effects of charge compression in calculating DRG relative weights. The purpose of the study was to develop more accurate estimates of the costs of Medicare inpatient hospital stays that can be used in calculating the relative weights per DRG. RTI was asked to assess the potential for bias in relative weights due to CCR differences within the 13 CCR groups used in calculating the cost-based DRG relative weights and to develop an analysis plan that explored alternative methods of estimating costs, with the objective of better aligning the charges and costs used in those calculations. RTI was asked to consider methods of reducing the variation in CCRs across services within cost centers by:

Modifying existing cost centers and/or creating new costs centers.

Using statistical methods, such as the regression adjustment for charge compression. Some commenters on the FY 2007 IPPS proposed rule suggested that we use a regression adjustment to account for charge compression.

As part of its contract, RTI convened a Technical Expert Panel composed of individuals representing academic institutions, hospital associations, medical device manufacturers, and MedPAC. The members of the panel met on October 27, 2006, to evaluate RTI's analytic plan, to identify other areas that are likely to be affected by compression or aggregation problems, and to propose suggestions for adjustments for charge compression. We posted RTI's draft interim report on the CMS Web site in March 2007. For more information, interested individuals can view RTI's report at the following Web site: http://cms.hhs.gov/reports/downloads/Dalton.pdf .

As the first step in its analysis, RTI compared the reported Medicare program charge amounts from the cost reports to the total Medicare charges summed across all claims filed by providers. Using cost and charge data from the most recent available Medicare cost reports and inpatient claims from IPPS hospitals, RTI was charged with performing an analysis to determine how well the MedPAR charges matched the cost report charges used to compute CCRs. The accuracy of the DRG cost estimates is directly affected by this match because MedPAR charges are multiplied by CCRs to estimate cost. RTI found consistent matching of charges

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from the Medicare cost report to charges grouped in the MedPAR claims for some cost centers but there appeared to be problems with others. For example, RTI found that the data between the cost report and the claims matched well for total discharges, days, covered charges, nursing unit charges, pharmacy, and laboratory. However, there appeared to be inconsistent reporting between the cost reports and the claims data for charges in several ancillary departments (medical supplies, operating room, cardiology, and radiology). For example, the data suggested that hospitals often include costs and charges for devices and other medical supplies within the Medicare cost report cost centers for Operating Room, Radiology or Cardiology instead of the Medical Supplies cost center.

RTI found that some charge mismatching results from the way in which charges are grouped in the MedPAR file. Examples include the intermediate care nursing charges being grouped with intensive care nursing charges, and electroencephalography (EEG) charges being grouped with laboratory charges. RTI suggested that reclassifying intermediate care charges from the intensive care unit to the routine cost center could address the former problem.

As the second step in its analysis, RTI reviewed the existing cost centers that are combined into the 13 groups used in calculating the national average CCRs. RTI identified CCRs with potential aggregation problems and considered whether separating the charge groups could result in more accurate cost conversion at the DRG level. The analysis led RTI to calculate separate CCRs for Emergency Room and Blood and Blood Administration, both of which had been included in ``Other Services'' in FY 2007.

During this second step, RTI noted that a variation of charge compression is also present in inpatient nursing services because most patients are charged a single type of accommodation rate per day that is linked to the type of nursing unit (routine, intermediate, or intensive), but not to the hours of nursing services given to individual patients. Unlike the situation with charge compression in ancillary service areas, there are virtually no detailed charge codes that can distinguish patient nursing care use. Therefore, any potential bias cannot be empirically evaluated or adjustments made without additional data.

Next, RTI examined individual revenue codes within the cost centers and used regression analysis to determine whether certain revenue codes in the same cost center had significantly different markup rates. Those revenue codes include devices, prosthetics, implants within the Medical Supplies cost center, IV Solutions within the Drugs cost center, CT scanning and MRI within the Radiology cost center, Cardiac Catheterization within the Cardiology cost center, and Intermediate Care Units within the Routine Nursing Care cost center. Devices, prosthetics, and implants within the Medical Supplies cost center have a lower markup and, as a result, a higher CCR than the remainder of the medical supplies group according to RTI's analysis. Within the Drugs CCR, IV Solutions have a much higher markup and much lower CCR than the other drugs included in the category. Within the Radiology CCR, CT scanning and MRI have higher markups and lower CCRs than the remaining radiology services. RTI's results for Cardiac Catheterization and Intermediate Care Units were ambiguous due to data problems.

RTI's analysis also determined the impact of the disaggregated CCRs on the relative weights. Differences in CCRs alone do not necessarily alter the DRG relative weights. The impact on the relative weights is the result of the interaction of CCR differences and DRG differences in the proportions of the services with different CCRs. In FY 2007, we calculated relative weights using CCRs for 13 hospital departments. The RTI analysis suggests expanding the number of distinct hospital department CCRs from 13 to 19. Of the additional six CCRs, two would result from separating the Emergency Department and Blood (Products and Administration) from the residual ``Other Services'' category. Four additional CCRs would result from applying a regression method similar to a method suggested in last year's public comments to three existing categories: supplies, radiology, and drugs. This method, as adapted by RTI, used detailed coding of charges to disaggregate hospital cost centers and derive separate, predicted alternative CCRs for the disaggregated services. RTI's analysis suggests splitting Medical Supplies into one CCR for devices, implants, and prosthetics and one CCR for Other Supplies; splitting Radiology into one CCR for MRIs, one CCR for CT scans, and one CCR for Other Radiology; and splitting Drugs into one CCR for IV Solutions and one CCR for Other Drugs.

RTI's draft report provides the potential impacts of adopting these changes to the CCRs. We note that RTI's analysis was based on Version 24.0 of the CMS DRGs. Because the proposed MS-DRGs were under development for the FY 2008 IPPS proposed rule, they were unavailable to RTI for their analysis. The results of RTI's analysis may be different if applied to the proposed MS-DRGs. However, it seems reasonable to believe that the impact of RTI's suggestions will be consistent using Version 24.0 of the CMS DRGs and the proposed MS-DRGs, as both systems generally use the same base DRGs while applying different subdivisions to recognize severity of illness. Of all the adjusted CCRs, the largest impact on weights came from accounting for charge compression in medical supplies for devices and implants. The impact on weights from accounting for CCR differences among drugs was modest. The impact of splitting MRI and CT scanning from the radiology CCR was greater than the impact of modifying the Drugs CCRs, but less than the impact of splitting the medical supplies group. Separating Emergency Department and Blood Products and Administration from the ``Other Services'' category would raise the CCR for other services in the group.

RTI found that disaggregating cost centers may have a mitigating effect on the impact of transitioning from charge-based weights to cost-based weights. That is, the changes being suggested by RTI will generally offset (fully or more than fully in some cases or in part in other cases) the impacts of fully implemented cost weights that we are adopting over the FY 2007-FY 2009 transition period. Thus, RTI's analysis suggests that expanding the number of distinct hospital department CCRs used to calculate cost weights from 13 to 19 will generally increase the relative weights for surgical DRGs and decrease them for the medical DRGs compared to the fully implemented cost-based weights to which we began transitioning in FY 2007. 2. RTI Recommendations

In its report, RTI provides recommendations for the short term, medium term, and long term, to mitigate aggregation bias in the calculation of relative weights. We summarize RTI's recommendations below and respond to each of them. a. Short-Term Recommendations

Most of RTI's short-term recommendations have already been described above. The most immediate changes that RTI recommends implementing include expanding from 13 distinct hospital department CCRs to 19 by:

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Disaggregating ``Emergency Room'' and ``Blood and Blood Products'' from the ``Other Services'' cost center;

Establishing regression-based estimates as a temporary or permanent method for disaggregating the Medical Supplies, Drugs, and Radiology cost centers; and

Reclassifying intermediate care charges from the intensive care unit cost center to the routine cost center.

We believe these recommendations have significant potential to address issues of charge compression and potential mismatches between how costs and charges are reported in the cost reports and on the Medicare claims.

RTI's recommendations show significant promise in the short term for addressing issues raised in the public comments on the cost weights in the FY 2007 IPPS proposed rule. However, in the time available for the development of this proposed rule, we have been unable to investigate how RTI's recommended changes may interact with other potential changes to the DRGs and to the method of calculating the DRG relative weights. As we noted above, RTI's analysis was done on the Version 24.0 of the CMS DRGs and not the MS-DRGs we are proposing for FY 2008. For this proposed rule, we were not able to examine the combined impacts of the proposed MS-DRGs and RTI's recommendations. In addition, we believe it is also important to consider that, in the FY 2007 IPPS final rule (71 FR 47897), we anticipated undertaking further analysis of the HSRVcc methodology over the next year in conjunction with the research we were to do on charge compression. Analysis of the HSRVcc methodology will be part of the second phase of the RAND study of alternative DRG systems to be completed by September 1, 2007, that has not been completed in time for this proposed rule. As a result, we have also been unable to consider the effects of the HSRVcc methodology together with the proposed MS-DRGs and RTI's recommendations. Finally, we note that in order to complete the analysis in time for this proposed rule, RTI's study used only inpatient hospital claims. However, hospital ancillary departments typically include both inpatient and outpatient services within the same department and only a single CCR covering both inpatient and outpatient services can be calculated from Medicare cost reports. Although we believe that applying the regression method used by RTI to only inpatient services is unlikely to have had much impact for the adjustments recommended by RTI, the preferred approach would be to apply the regression method to the combined inpatient and outpatient services. The latter approach would ensure that any potential CCR adjustments in the IPPS would be consistent with potential CCR adjustments in the OPPS. We hope to expand their analysis to incorporate outpatient services during the coming year. For all of these reasons, we are not proposing to adopt RTI's recommendations for FY 2008.

Although we are not proposing to adopt RTI's recommendations for FY 2008, we are interested in public comments on expanding from 13 CCRs to 19 CCRs. Again, we note that RTI's analysis suggests significant improvements that could result in the cost weights from adopting its recommendations to adjust for charge compression. Therefore, we are also interested in public comments on whether we should proceed to adopt the RTI recommended changes for FY 2008 in the absence of a detailed analysis of how the relative weights would change if we were to address charge compression while simultaneously adopting an HSRVcc methodology together with the proposed MS-DRGs. Given the change in the impacts that were illustrated in last year's FY 2007 IPPS final rule (71 FR 47915-47916), going from a hospital-specific to a nonhospital- specific cost-weighting methodology, we believe that sequentially adjusting for charge compression and later adopting an HSRVcc methodology could create the potential for instability in IPPS payments over the next 2 years (that is, payments for surgical DRGs would increase and payment for medical DRGs would decrease if we were adopt the RTI recommended changes for FY 2008, but could potentially reverse direction if we were to adopt an HSRVcc methodology for FY 2009). Again, we are interested in public comments on all of these issues before we make a final decision as to whether to proceed with the RTI's short-term recommendations in the final rule for FY 2008.

Among its other short-term recommendations, RTI also suggested that we incorporate edits to reject or require more intensive review of cost reports from hospitals with extreme CCRs. This action would reduce the number of hospitals with excluded data in the national CCR computations, and would also improve the accuracy of all departmental CCRs within problem cost reports by forcing hospitals to review and correct the assignment of costs and charges before the cost report is filed. Although we do not have a substantive disagreement with the recommendation, we generally focus our audit resources on areas in which cost report information directly affects payments to individual providers.

RTI further suggested revising cost report instructions to reduce cost and charge mismatching and program charge misalignment in its short-term recommendations. Although RTI suggests such an action could be immediately effective for correcting the reporting of costs and charges for medical supply items that are now distributed across multiple cost centers, we note that changes to improve cost reporting now will not become part of the relative weights for several years because of lags between the submission of hospital reports and our ability to use them in setting the relative weights. Currently, we expect there will continue to be a 3-year lag between a hospital's cost report fiscal year and the year it is used to set the relative weights. Thus, even if it were possible to issue instructions immediately beginning for FY 2008, revised reporting would not affect the relative weights until at least FY 2011. Nevertheless, we agree with this recommendation, and we welcome public input on potential changes to cost reporting instructions to improve consistency between how charges are reported on cost reports and in the Medicare claims. We will consider these changes to the cost reporting instructions as we consider further changes to the cost report described below. b. Medium-Term Recommendations

RTI recommended that we expand the MedPAR file to include separate fields that disaggregate several existing charge departments. For compatibility with prior years' data, the new fields should partition the existing ones rather than recombine charges. RTI recommended including additional fields in the MedPAR file for the hospital departments that it statistically disaggregated in its report, as well as intermediate care, observation beds, other special nursing codes, therapeutic radiation and EEG, and possibly others. As with some of RTI's earlier recommendations with respect to cost reports, we will examine this suggestion in conjunction with other competing priorities CMS has been given for our information systems. We have limited information systems resources, and we will need to consider whether the time constraints we have to develop the IPPS final rule, in conjunction with the inconvenience of using the SAF and accounting for charge compression through regression, will justify the infrastructure cost to our information

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systems of incorporating these variables into the MedPAR.

Finally, RTI's medium-term recommendations include encouraging providers to use existing standard cost centers, particularly those for Blood and Blood Administration and for Therapeutic Radiology, in the current Medicare cost report. We believe this recommendation is closely related to the one for improved cost reporting instructions. Therefore, we will consider this recommendation as part of any further effort we may undertake to revise cost reporting instructions or change the cost report. c. Long-Term Recommendations

RTI's long-term recommendations include adding new cost centers to the Medicare cost report and/or undertaking the following activities:

Add ``Devices, Implants and Prosthetics'' under the line for ``Medical Supplies Charged to Patients.'' Consider also adding a similar line for IV Solutions as a subscripted line under the line for ``Drugs Charged to Patients.''

Add CT Scanning and MRI as subscripted lines under the line for ``Radiology-Diagnostic.'' About one-third of hospitals that offer CT Scanning and/or MRI services are already reporting these services on nonstandard line numbers. More consistent reporting for both cost centers would eliminate the need for statistical estimation on the radiology CCRs.

In consultation with hospital industry representatives, determine the best way to separate cardiology cost centers and add a new standard cost center for cardiac catheterization and/or for all other cardiac diagnostic laboratory services. About 20 percent of hospitals already include a nonstandard line on their cost reports for catheterization. Creating a new standard cost center could improve consistency in reporting and substantially improve the program charge mismatching that now occurs.

In consultation with hospital industry representatives, consider establishing a new cost center to capture intermediate care units as distinct from routine or intensive care.

Establish expert study groups or other research vehicles to study options for improving patient-level charging within nursing units. Nursing accounts for one-fourth of IPPS charges and 41 percent of the computed costs from our claims analysis file. Historically, nursing charges and costs have been assigned to patients without relying on individual measures of service use. Consideration should be given to finding ways to improve precision in nursing cost-finding that will improve relative resource weights without adding substantial administrative costs to either the Medicare program or to hospitals.

We agree with RTI that attention should be paid to these issues as we consider changes to the Medicare cost report. The cost report has not been revised in nearly 10 years. During this time, there have been significant changes to the Medicare statute and regulations that have affected the Medicare payment policies. Necessary incremental changes have been made to the Medicare cost report over the years to accommodate the Medicare wage index, disproportionate share payments, indirect and direct graduate medical education payments, reporting of uncompensated care costs, among others. The adoption of cost-based weights for the IPPS beginning in FY 2007 has brought further attention to the importance of the Medicare cost report and how hospitals report costs and charges. We recently began doing a comprehensive review of the Medicare cost report and plan to make updates that will consider its many uses. As we update the cost report, we will give strong consideration to RTI's recommendations and potential long-term improvements that could be made to the IPPS cost-based relative weighting methodology.

F. Hospital-Acquired Conditions, Including Infections

(If you choose to comment on issues in this section, please include the caption ``DRGs: Hospital-Acquired Conditions'' at the beginning of your comment.) 1. General

Medicare's IPPS encourages hospitals to treat patients efficiently. Hospitals receive the same DRG payment for stays that vary in length. In many cases, complications acquired in the hospital do not generate higher payments than the hospital would otherwise receive for other cases in the same DRG. To this extent, the IPPS does encourage hospitals to manage their patients well and to avoid complications, when possible. However, complications, such as infections, acquired in the hospital can trigger higher payments in two ways. First, the treatment of complications can increase the cost of hospital stays enough to generate outlier payments. However, the outlier payment methodology requires that hospitals experience large losses on outlier cases (for example, in FY 2007, the fixed-loss amount was $24,485 before a case qualified for outlier payments, and the hospital then only received 80 percent of its costs above the fixed-loss cost threshold). Second, there are about 121 sets of DRGs that split based on the presence or absence of a complication or comorbidity (CC). The CC DRG in each pair would generate a higher Medicare payment. If a condition acquired during the beneficiary's hospital stay is one of the conditions on the CC list, the result may be a higher payment to the hospital under a CC DRG. Under the proposed MS-DRGs, there will be 258 sets of DRGs that are split into 2 or 3 subgroups based on the presence or absence of a major CC (MCC) or CC. If a condition acquired during the beneficiary's hospital stay is one of the conditions on the MCC or CC list, the result may be a higher payment to the hospital under the MS-DRGs. (See section II.C. of the FY 2007 IPPS final rule (71 FR 47881) for a detailed discussion of proposed DRG reforms.) 2. Legislative Requirement

Section 5001(c) of Pub. L. 109-171 requires the Secretary to select, by October 1, 2007, at least two conditions that are (a) high cost or high volume or both, (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case will be paid as though the secondary diagnosis was not present. Section 5001(c) provides that we can revise the list of conditions from time to time, as long as the list contains at least two conditions. Section 5001(c) also requires hospitals to submit the secondary diagnoses that are present at admission when reporting payment information for discharges on or after October 1, 2007. 3. Public Input

In the FY 2007 IPPS proposed rule (71 FR 24100), we sought input from the public about which conditions and which evidence-based guidelines should be selected in order to implement section 5001(c) of Public Law 109-171. The comments that we received were summarized in the FY 2007 IPPS final rule (71 FR 48051 through 48053). In that final rule, we indicated that the next opportunity for formal public comment would be this FY 2008 proposed rule and encouraged the public to comment on our proposal at that time.

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In summary, the majority of the comments that we received in response to the FY 2007 IPPS proposed rule addressed conceptual issues concerning the selection, measurement, and prevention of hospital- acquired infections. Many commenters encouraged CMS to engage in a collaborative discussion with relevant experts in designing, evaluating, and implementing this section. The commenters urged CMS to include individuals with expertise in infection control and prevention, as well as representatives from the provider community, in the discussions.

Many commenters supported the statutory requirement for hospitals to submit information regarding secondary diagnoses present on admission beginning in FY 2008, and suggested that it would better enable CMS and health care providers to more accurately differentiate between comorbidities and hospital-acquired complications. MedPAC, in particular, noted that this requirement was recommended in its March 2005 Report to Congress and indicated that this information is important to Medicare's value-based purchasing efforts. Other commenters cautioned us about potential problems with relying on secondary diagnosis codes to identify hospital-acquired complications, and indicated that secondary diagnosis codes may be an inaccurate method for identifying true hospital-acquired complications.

A number of commenters expressed concerns about the data coding requirement for this payment change and asked for detailed guidance from CMS to help them identify and document hospital-acquired complications. Other commenters expressed concern that not all hospital-acquired infections are preventable and noted that sicker and more complex patients are at greater risk for hospital-acquired infections and complications. Commenters suggested that CMS include standardized infection-prevention process measures, in addition to outcome measures of hospital-acquired infections.

Some commenters proposed that CMS expand the scope of the payment changes beyond the statutory minimum of two conditions. They noted that the death, injury, and cost of hospital-acquired infections are too high to limit this provision to only two conditions. Commenters also recommended that CMS annually select additional hospital-acquired complications for the payment change. Conversely, a number of commenters proposed that CMS initially begin with limited demonstrations to test CMS' methodology before nationwide implementation. One commenter recommended that CMS include appropriate consumer protections to prevent providers from billing patients for the nonreimbursed costs of the hospital-acquired complications and to prevent hospitals from selectively avoiding patients perceived at risk of complications.

In addition to the broad conceptual suggestions, some commenters recommended specific conditions for possible inclusion in the payment changes, which we discuss in detail in section II.D.4. of this preamble. We also discuss throughout section II.D. of this preamble other comments that we have considered in developing hospital-acquired conditions that would be subject to reporting. 4. Collaborative Effort

CMS worked with public health and infectious disease experts from the Centers for Disease Control and Prevention (CDC) to identify a list of hospital-acquired conditions, including infections, as required by section 5001(c) of Public Law 109-171. As previously stated, the selected conditions must meet the following three criteria: (a) High cost or high volume or both; (b) result in the assignment of the case to a DRG that has a higher payment when present as a secondary diagnosis; and (c) could reasonably have been prevented through the application of evidence-based guidelines. CMS and CDC staff also collaborated on developing a process for hospitals to submit a Present on Admission (POA) indicator with each secondary condition. The statute requires the Secretary to begin collecting this information as of October 1, 2007. The POA indicator is required in order for us to determine which of the selected conditions developed during a hospital stay. The current electronic format used by hospitals to obtain this information (ASC X12N 837, Version 4010) does not provide a field to obtain the POA information. We are in the process of issuing instructions to require acute care IPPS hospitals to submit the POA indicator for all diagnosis codes effective October 1, 2007. The instructions will specify how hospitals under the IPPS will submit this information in segment K3 in the 2300 loop, data element K301 on the ASC X12N 837, Version 4010 claim. Specific instructions on how to select the correct POA indicator for a diagnosis code are included in the ICD-9-CM Official Guidelines for Coding and Reporting. These guidelines can be found at the following Web site: http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm

CMS and CDC staff also received input from a number of groups and

organizations on hospital-acquired conditions, including infections. Many of these groups and organizations recommended the selection of conditions mentioned in the FY 2007 IPPS final rule, including the following because of the high cost or high volume (frequency) of the condition, or both, and because in some cases preventable guidelines already exist:

Surgical site infections. The groups and organizations stated that there were evidence-based measures to prevent the occurrence of these infections which are currently measured and reported as part of the Surgical Care Improvement Program (SCIP).

Ventilator-associated pneumonias. The groups and organizations pointed out that these conditions are currently measured and reported through SCIP. However, other organizations counseled against selecting these conditions because they believed it was difficult to obtain good definitions and that it was not always clear which ones are hospital-acquired.

Catheter associated bloodstream infections.

Pressure ulcers, as an alternative to hospital-acquired infections. The groups and organizations pointed out that the specific language in section 5001(c) of Public Law 109-171 mentions hospital- acquired conditions; therefore, the language does not restrict the Secretary to the selection of infections.

Hospital falls, as an alternative to hospital-acquired infections. The injury prevention groups included this condition among a group referred to as ``serious preventable events,'' also commonly referred to as ``never events'' or ``serious reportable events.'' A serious preventable event is defined as a condition which should not occur during an inpatient stay.

In addition to the aforementioned conditions, we received other recommendations for the selection of hospital-acquired conditions. These recommendations were also based on the high cost and the high volume of the condition, or both, or the fact that preventable guidelines exist. The recommendations include--

Bloodstream infections/septicemia. Some commenters suggested that we focus on one specific organism, such as staph aureus septicemia.

Pneumonia. Some commenters recommended the inclusion of a broader group of pneumonia patients, instead of restricting cases to ventilator-associated pneumonias. Some commenters

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mentioned that while prevention guidelines exist for pneumonia, it is not clear how effective these guidelines may be in preventing pneumonia.

Vascular catheter associated infections. Commenters pointed out that there are CDC guidelines for these infections. Other commenters pointed out that while this condition certainly deserves focused attention by health care providers, there is not a clear one unique ICD-9-CM code that identifies vascular catheter-associated infections. Therefore, these commenters suggested that there would be difficulty separately identifying these conditions.

Clostridium difficile-associated disease (CDAD). Several commenters identified this condition as a significant public health issue. Other commenters pointed out that while prevalence of this condition is emerging as a public health problem, there is not currently a strategy for reasonably preventing these infections.

Methicillin-resistant staphylococcus aureus (MRSA). Several commenters pointed out that MRSA has become a very common bacteria occurring both in and outside the hospital environment. However, other organizations pointed out that the code for MRSA (V09.0, Infection with microorganism resistant to penicillins Methicillin- resistant staphylococcus aureus) is not currently classified as a CC. Therefore, the commenters stated that MRSA does not lead to a higher reimbursement when the code is reported.

Serious preventable events. As stated earlier, some commenters representing injury prevention groups suggested including a broader group of conditions than hospital falls which should not be expected to occur during a hospital admission. Hey notes that these conditions are referred to as ``serious preventable events,'' and include events such as the following: (a) Leaving an object in during surgery; (b) operating on the wrong body part or patient, or performing the wrong surgery; (c) air embolism as a result of surgery; and (d) providing incompatible blood or blood products. Other commenters indicated that serious preventable events are so rare that they should not be selected as a hospital condition that cannot result in a case being assigned to a higher paying DRG. 5. Criteria for Selection of the Hospital-Acquired Conditions

CMS and CDC staff greatly appreciate the many comments and suggestions offered by organizations and groups that were interested in providing input into the selection of the initial hospital-acquired conditions.

CMS and CDC staff evaluated each recommended condition under the three criteria established by section 1886(d)(4)(D)(iv) of the Act. In order to meet the higher payment criterion, the condition selected must have an ICD-9-CM diagnosis code that clearly identifies the condition and is classified as a CC, or as an MCC as proposed for the MS-DRGs in this proposed rule. Some conditions recommended for inclusion among the initial hospital-acquired conditions did not have codes that clearly identified the conditions. Because there has not been national reporting of a POA indicator for each diagnosis, there is no Medicare data to determine the incidence of the reported secondary diagnoses occurring after admission. To the extent possible, we used information from the CDC on the incidence of these conditions. CDC's data reflect the incidence of hospital-acquired conditions in 2002. We also examined FY 2006 Medicare data on the frequency that these conditions were reported as secondary diagnoses. We developed the following criteria to assist in our analysis of the conditions. The conditions described were those recommended for inclusion in the initial hospital-acquired infection provision.

Coding--Under section 1886(d)(4)(D)(ii)(I) of the Act, a discharge is subject to the payment adjustment if ``the discharge includes a condition identified by a diagnosis code'' selected by the Secretary under section 1886(d)(4)(D)(iv) of the Act. We only selected conditions that have (or could have) a unique ICD-9-CM code that clearly describes the condition. Some conditions recommended by the commenters would require the use of two or more ICD-9-CM codes to clearly identify the conditions. Although we did not exclude these conditions from further consideration, the need to utilize multiple ICD-9-CM codes to identify them may present operational issues. For instance, below we describe in detail the complexities associated with selecting septicemia as a hospital-acquired condition that would be subject to section 5001(c) of the DRA. In some cases, septicemia may be a reasonably preventable condition with proper hospital care. However, in other cases, clinicians may argue that the condition arose from further development of another infection the patient did have upon admission and the septicemia was not preventable. As we indicate in detail below, there could be a significant variety of clinical scenarios and potential coding vignettes to describe situations where septicemia occurs. Although we could select septicemia, we would also have to identify many exclusions for situations where the septicemia is not preventable. The vast number of clinical scenarios that we would have to account for could complicate implementation of the provision.

Burden (High Cost/High Volume)--Under section 1886(d)(4)(D)(iv)(I) of the act, we must select cases that have conditions that are high cost or high volume, or both.

Prevention guidelines--Under section 1886(d)(4)(D)(iv)(II) of the Act, we must select codes that describe conditions that could reasonably have been prevented through application of evidence-based guidelines. We evaluated whether there is information available for hospitals to follow to prevent the condition from occurring.

CC--Under section 1886(d)(4)(D)(iv)(III) of the Act, we must select codes that result in assignment of the case to a DRG that has a higher payment when the code it present as a secondary diagnosis. The condition must be an MCC or a CC that would, in the absence of this provision, result in assignment to a higher paying DRG.

Considerations--We evaluate each condition above according to how it meets the statutory criteria in light of the potential difficulties that we would face if the condition were selected. 6. Proposed Selection of Hospital-Acquired Conditions

We discuss below our analysis of each of the conditions that were raised as possible candidates for selection under section 5001(c) of Pub. L. 109-171 according to the criteria described above in section II.D.5. of this preamble. We also discuss any considerations, which would include any administrative issues surrounding the selection of a proposed condition. For example, the condition may only be able to be identified by multiple codes, thereby requiring the development of special GROUPER logic to also exclude similar or related ICD-9-CM codes from being classified as a CC. Similarly, a condition acquired during a hospital stay may arise from another condition that the patient had prior to admission, making it difficult to determine whether the condition was reasonably preventable. Following a discussion of each condition, we provide a summary table that describes the extent to which each condition meets each of the above criteria. We present 13 conditions in rank order. In our view, the conditions listed at the top of the table best meet the statutory selection criteria, while the conditions

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listed lower may meet the selection criteria but could present a particular challenge (that is, they may be preventable only in some circumstances but not in others). Therefore, we would submit that the first conditions listed should receive the highest consideration of selection among our initial group of hospital-acquired conditions. We encourage comments on whether or not we have ranked these conditions appropriately. We also encourage additional comments on clinical, coding, and prevention issues that may affect the conditions selected. While we have ranked these conditions, there may be compelling public health reasons for including conditions that are not at the top of our list. We ask commenters to recommend how many and which conditions should be selected for implementation on October 1, 2008, along with justifications for these selections. (a) Catheter-Associated Urinary Tract Infections

Coding--ICD-9-CM code 996.64 (Infection and inflammatory reaction due to indwelling urinary catheter) clearly identifies this condition. The hospital would also report the code for the specific type of urinary infection. For instance, when a patient develops a catheter associated urinary tract infection during the inpatient stay, the hospital would report code 996.64 and 599.0 (Urinary tract infection, site not specified) to clearly identify the condition. There are also a number of other more specific urinary tract infection codes that could also be coded with code 996.64. These codes are classified as CCs. If we were to select catheter-associated urinary tract infections, we would implement the decision by not counting code 996.64 and any of the urinary tract infection codes listed below when both codes are present and the condition was acquired after admission. If only code 996.64 were coded on the claim as a secondary diagnosis, we would not count it as a CC.

Burden (High Cost/High Volume)--CDC reports that there are 561,667 catheter-associated urinary tract infections per year. For FY 2006, there were 11,780 reported cases of Medicare patients who had a catheter associated urinary tract infection as a secondary diagnosis. The cases had average charges of $40,347 for the entire hospital stay. According to a study in the American Journal of Medicine, catheter- associated urinary tract infection is the most common nosocomial infection, accounting for more than 1 million cases in hospitals and nursing homes nationwide.\12\ Approximately 11.3 million women in the United States had at least one presumed acute community-acquired urinary tract infection resulting in antimicrobial therapy in 1995, with direct costs estimated at $659 million and indirect costs totaling $936 million. Nosocomial urinary tract infection necessitates one extra hospital day per patient, or nearly 1 million extra hospital days per year. It is estimated that each episode of symptomatic urinary tract infection adds $676 to a hospital bill. In total, according to the study, the estimated annual cost of nosocomial urinary tract infection in the United States ranges between $424 and $451 million.

\12\ Foxman, B.: ``Epidemiology of urinary tract infections: incidence, morbidity, and economic costs,'' The American Journal of Medicine, 113 Suppl. 1A, pp. 5s-13s, 2002.

Prevention guidelines--There are widely recognized guidelines for the prevention of catheter-associated urinary tract infections. Guidelines can be found at the following Web site: http://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html .

CC--Codes 996.64 and 599.0 are classified as CCs in the current CMS DRGs as well as in the proposed MS-DRGs.

Considerations--The primary prevention intervention would be not using catheters or removing catheters as soon as possible, both of which are worthy goals because once catheters are in place for 3 to 4 days, most clinicians and infectious disease/infection control experts do not believe urinary tract infections are preventable. While there may be some concern about the selection of catheter associated urinary tract infections, it is an important public health goal to encourage practices that will reduce urinary tract infections. Approximately 40 percent of Medicare beneficiaries have a urinary catheter during hospitalization based on Medicare Patient Safety Monitoring System (MPSMS) data.

As stated above in the Coding section, this condition is clearly identified through ICD-9-CM code 996.64. Code 996.64 is classified as a CC. The hospital would also report the code for the specific type of urinary infection. For instance, when a patient develops a catheter associated urinary tract infection during the inpatient stay, the hospital would report codes 996.64 and 599.0 or another more specific code that clearly identifies the condition. These codes are classified as CCs under the current CMS DRGs as well as the proposed MS-DRGs. To select catheter-associated urinary tract infections as one of the hospital-acquired conditions that would not be counted as a CC, we would not classify code 996.64 as a CC if the condition occurred after admission. Furthermore, we would also not classify any of the codes listed below as CCs if present on the claim with code 996.64 because these additional codes identify the same condition. The following codes represent specific types of urinary infections. We did not include codes for conditions that could be considered chronic urinary infections, such as code 590.00 (Chronic pyelonephritis, without lesion or renal medullary necrosis). Chronic conditions may indicate that the condition was not acquired during the current stay. We would not count code 996.64 or any of the following codes representing acute urinary infections if they developed after admission and were coded together on the same claim.

112.2 (Candidiasis of other urogenital sites)

590.10 (Acute pyelonephritis, without lesion of renal medullary necrosis)

590.11 (Acute pyelonephritis, with lesion of renal medullary necrosis)

590.2 (Renal and perinephric abscess)

590.3 (Pyeloureteritis cystica)

590.80 (Pyelonephritis, unspecified)

590.81 (Pyelitis or pyelonephritis in diseases classified elsewhere)

590.9 (Infection of kidney, unspecified)

595.0 (Acute cystitis)

595.3 (Trigonitis)

595.4 (Cystitis in diseases classified elsewhere)

595.81 (Cystitis cystica)

595.89 (Other specified type of cystitis, other)

595.9 (Cystitis, unspecified)

597.0 (Urethral abscess)

597.80 (Urethritis, unspecified)

599.0 (Urinary tract infection, site not specified)

We believe the condition of catheter-associated urinary tract infection meets all of our criteria for selection as one of the initial hospital-acquired conditions. We can easily identify the cases with ICD-9-CM codes. The condition is a CC under both the current CMS DRGs and the proposed MS-DRGs that are discussed earlier in this proposed rule. The condition meets our burden criterion with its high cost and high frequency. There are prevention guidelines on which the medical community agrees. Of all 13 conditions discussed in this proposed rule, we believe this condition best meets the

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criteria discussed. Therefore, we are proposing the selection of catheter-associated urinary tract infections as one of the initial hospital-acquired conditions.

We encourage comments on both the selection of this condition and the related conditions that we are proposing to exclude from being counted as CCs. (b) Pressure Ulcers

Coding--Pressure ulcers are also referred to as decubitus ulcers. The following codes clearly identify pressure ulcers.

707.00 (Decubitus ulcer, unspecified site)

707.01 (Decubitus ulcer, elbow)

707.02 (Decubitus ulcer, upper back)

707.03 (Decubitus ulcer, lower back)

707.04 (Decubitus ulcer, hip)

707.05 (Decubitus ulcer, buttock)

707.06 (Decubitus ulcer, ankle)

707.07 (Decubitus ulcer, heel)

707.09 (Decubitus ulcer, other site)

Burden (High Cost/High Volume)--This is both a high-cost and high- volume condition. For FY 2006, there were 322,946 reported cases of Medicare patients who had a pressure ulcer as a secondary diagnosis. These cases had average charges for the hospital stay of $40,381.

Prevention guidelines--Prevention guidelines can be found at the following Web sites: http://www.npuap.org/positn1.html http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.4409.

CC--Decubitus ulcer codes are classified as CCs under the current stat2.chapter.4409.

CC--Decubitus ulcer codes are classified as CCs under the current MS-DRGs. Codes 707.02 through 707.07 are considered MCCs under the proposed MS-DRGs. As discussed earlier, MCCs result in even larger payments than CCs.

Considerations--Pressure ulcers are an important hospital-acquired complication. Prevention guidelines exist (non-CDC) and can be implemented by hospitals. Clinicians may state that some pressure ulcers present on admission cannot be identified (skin is not yet broken (Stage I) but damage to tissue is already done and skin will eventually break down. However, by selecting this condition, we would provide hospitals the incentive to perform careful examination of the skin of patients on admission to identify decubitus ulcers. If the condition is present on admission, the provision will not apply. We are proposing to include pressure ulcers as one of our initial hospital- acquired conditions. This condition can be clearly identified through ICD-9-CM codes. These codes are classified as a CC under the current CMS DRGs and as a CC or MCC under the proposed MS-DRGs. Pressure ulcers meet the burden criteria because they are both high cost and high frequency cases. There are clear prevention guidelines. While there is some question as to whether all cases with developing pressure ulcers can be identified on admission, we believe the selection of this condition will result in a closer examination of the patient's skin on admission. This will result in better quality of care. We welcome comments on the proposed inclusion of this condition. Serious Preventable Events

Serious preventable events are events that should not occur in health care. The injury prevention community has developed information on serious preventable events. CMS reviewed the list of serious preventable events and identified those events for which there was an ICD-9-CM code that would assist in identifying them. We identified four types of serious preventable events to include in our evaluation. These include leaving an object in a patient; performing the wrong surgery (surgery on the wrong body part, wrong patient, or the wrong surgery); air embolism following surgery; and providing incompatible blood or blood products. Three of these serious preventable events have unique ICD-9-CM codes to identify them. There is not a clear and unique code for surgery performed on the wrong body part, wrong patient, or the wrong surgery. Each of these events is discussed separately. (c) Serious Preventable Event--Object Left in During Surgery

Coding--Retention of a foreign object in a patient after surgery is identified through ICD-9-CM code 998.4 (Foreign body accidentally left during a procedure).

Burden (High Cost/High Volume)--For FY 2006, there were 764 cases reported of Medicare patients who had an object left in during surgery reported as a secondary diagnosis. The average charges for the hospital stay were $61,962. This is a rare event. Therefore, it is not high volume. However, an individual case will likely have high costs, given that the patient will need additional surgery to remove the foreign body. Potential adverse events stemming from foreign body could further raise costs for an individual case.

Prevention guidelines--There are widely accepted and clear guidelines for the prevention of this event. Prevention guidelines for avoiding leaving objects in during surgery are located at the following Web site: http://www.qualityindicators.ahrq.gov/psi_download.htm.e classified as CCs under the current This

event should not occur.

CC--This code is a CC under the current CMS DRGs as well as under the proposed MS-DRGs.

Considerations--There are no significant considerations for this condition. There is a unique ICD-9-CM code and wide agreement on the prevention guidelines. We are proposing to include this condition as one of our initial hospital-acquired conditions. The cases can be clearly identified through an ICD-9-CM. This code is a CC under both the current CMS DRGs and the proposed MS-DRGs. There are clear prevention guidelines. While the cases may not meet the high frequency criterion, they do meet the high-cost criterion. Individual cases can be high cost. We welcome comments on including this condition as one of our initial hospital-acquired conditions. (d) Serious Preventable Event--Air Embolism

Coding--An air embolism is identified through ICD-9-CM code 999.1 (Complications of medical care, NOS, air embolism).

Burden (High Cost/High Volume)--This event is rare. For FY 2006, there were 45 reported cases of air embolism for Medicare patients. The average charges for the hospital stay were $66,007.

Prevention guidelines--There are clear prevention guidelines for air embolisms. This event should not occur. Serious preventable event guidelines can be found at the following Web site: http://www.qualityindicators.ahrq.gov/psi_download.htm .

CC--This code is a CC under the current CMS DRGs and is an MCC under the proposed MS-DRGs.

Considerations--There are no significant considerations for this condition. There is a unique ICD-9-CM code and wide agreement on the prevention guidelines. In addition, as stated earlier, the condition is a CC under the current CMS DRGs and an MCC under the proposed MS-DRGs. While the condition is rare, it does meet the cost burden criterion because individual cases can be expensive. Therefore, air embolism is a high-cost condition because average charges per case are high. We welcome comments on the proposal to include this condition.

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(e) Serious Preventable Event--Blood Incompatibility Coding--Delivering ABO-incompatible blood or blood products is identified by ICM-9-CM code 999.6 (Complications of medical care, NOS, ABO incompatibility reaction).

Burden (High Cost/High Volume)--This event is rare. Therefore, it is not high volume. For FY 2006, there were 33 reported cases of blood incompatibility among Medicare patients, with average charges of $46,492 for the hospital stay. Therefore, individual cases have high costs.

Prevention guidelines--There are prevention guidelines for avoiding the delivery of incompatible blood or blood products. The event should not occur. Serious preventable event guidelines can be found at the following Web site: http://www.qualityindicators.ahrq.gov/psi_download.htm

CC--This code is a CC under the current CMS DRGs as well as the

proposed MS-DRGs.

Considerations--There are no significant considerations for this condition. There is a unique ICD-9-CM code which is classified as a CC under the CMS DRGs as well as the proposed MS-DRGs. There is wide agreement on the prevention guidelines. While this may not be a high- volume condition, average charges per case are high. Therefore, we believe this condition is a high-cost condition and, therefore, meets our burden criterion. We are proposing to include this condition as one of our initial hospital-acquired conditions. (f) Staphylococcus Aureus Bloodstream Infection/Septicemia

Coding--ICD-9-CM Code 038.11 (Staphylococcus aureus septicemia) identifies this condition. However, the codes selected to identify septicemia are somewhat complex. The following ICD-9-CM codes may also be reported to identify septicemia:

995.91 (Sepsis) and 995.92 ( Severe sepsis). These codes are reported as secondary codes and further define cases with septicemia.

998.59 (Other postoperative infections). This code includes septicemia that develops postoperatively.

999.3 (Other infection). This code includes but is not limited to sepsis/septicemia resulting from infusion, injection, transfusion, vaccination (ventilator-associated pneumonia also included here).

Burden (High Cost/High Volume)--CDC reports that there are 290,000 cases of staphylococcus aureus infection annually in hospitalized patients of which approximately 25 percent are bloodstream infections or sepsis. For FY 2006, there were 29,500 cases of Medicare patients who had staphylococcus aureus infection reported as a secondary diagnosis. The average charges for the hospital stay were $82,678. Inpatient staphylococcus aureus result in an estimated 2.7 million days in excess length of stay, $9.5 billion in excess charges, and approximately 12,000 inpatient deaths per year.

Prevention guidelines--CDC guidelines are located at the following Web site: http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html.

CC--Codes 038.11, 995.91, 998.59, and 999.3 are classified as CCs under the current CMS DRGs and as MCCs under the proposed MS-DRGs.

Considerations--Preventive health care associated bloodstream infections/septicemia that are preventable are primarily those that are related to a central venous/vascular catheter, a surgical procedure (postoperative sepsis) or those that are secondary to another preventable infection (for example, sepsis due to catheter-associated urinary tract infection). Otherwise, physicians and other public health experts may argue whether septicemia is reasonably preventable. The septicemia may not be simply a hospital-acquired infection. It may simply be a progression of an infection that occurred prior to admission. Furthermore, physicians cannot always tell whether the condition was hospital-acquired. We examined whether it might be better to limit the septicemia cases to a specific organism (for example, code 038.11 (Staphylococcus aureus septicemia)). CDC staff recommended that we focus on staphylococcus aureus septicemia because this condition is a significant public health issue. As stated earlier, there is a specific code for staphylococcus aureus septicemia, code 038.11. Therefore, the cases would be easy to identify. However, as stated earlier, while this type of septicemia is identified through code 038.11, coders may also provide sepsis code 995.91 or 995.92 to more fully describe the staphylococcus aureus septicemia. Codes 995.91 and 995.92 are reported as secondary codes and further define cases with septicemia. Codes 995.91 and 995.92 are CCs under the current CMS DRGs and MCCs under the proposed MS-DRGs.

998.59 (Other postoperative infections). This code includes septicemia that develops postoperatively.

999.3 (Other infection). This code includes but is not limited to sepsis/septicemia resulting from infusion, injection, transfusion, vaccination (ventilator-associated pneumonia also indexed here).

To implement this condition as one of our initial ones, we would have to exclude the specific code for staphylococcus aureus septicemia, 038.11, and the additional septicemia codes, 995.91, 995.92, 998.59, and 999.3.

We acknowledge that there are additional issues involved with the selection of this condition that may involve developing an exclusion list of conditions present on admission for which we would not apply a CC exclusion to staphylococcus aureus septicemia. For example, a patient may come into the hospital with a staphylococcus aureus infection such as pneumonia. The pneumonia might develop into staphylococcus aureus septicemia during the admission. It may be appropriate to consider excluding cases such as those of patients admitted with staphylococcus aureus pneumonia that subsequently develop staphylococcus aureus septicemia from the provision. In order to exclude cases that did not have a staphylococcus aureus infection prior to admission, we would have to develop a list of specific codes that identified all types of staphylococcus aureus infections such as code 482.41 (Pneumonia due to staphylococcus aureus). We likely would not apply the new provision to cases of staphylococcus aureus septicemia if a patient were admitted with staphylococcus aureus pneumonia. However, if the patient had other types of infections, not classified as being staphylococcus aureus, and then developed staphylococcus aureus septicemia during the admission, we would apply the provision and exclude the staphylococcus aureus septicemia as a CC. We were not able to identify any other specific ICD-9-CM codes that identify specific infections as being due to staphylococcus aureus.

Other types of infections, such as urinary tract infections, would require the reporting of an additional code, 041.11 (Staphylococcus aureus), to identify the staphylococcus aureus infection. This additional coding presents administrative issues, because it will not always be clear which condition code 041.11 (Staphylococcus aureus) is describing. We do not believe it would be appropriate to make code 041.11, in combination with other codes, subject to the hospital- acquired conditions provision until we better understand how to address the

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administrative issues that would be associated with their selection. Therefore, we would exclude staphylococcus aureus septicemia cases with code 482.41 reported as being subject to the hospital-acquired conditions provision. Stated conversely, we would allow staphylococcus aureus septicemia to count as a CC if the patient was admitted with staphylococcus aureus pneumonia.

We recognize that there may be other conditions which we should consider for this type of exclusion. We are proposing to include staphylococcus aureus bloodstream infection/septicemia (code 038.11) as one of our initial hospital-acquired conditions. We would also exclude codes 995.91, 998.59, and 999.3 from counting as an MCC/CC when they are reported with code 038.11. The condition can be clearly identified through ICD-9-CM codes that are classified as CC under the current CMS DRGs and MCCs under the proposed MS-DRGs. The condition meets our burden criterion by being both high cost and high volume. There are prevention guidelines which we acknowledge are subject to some debate among the medical community. We also acknowledge that we would have to exclude this condition if a patient were admitted with a staphylococcus aureus infection of a more limited location, such as pneumonia. We encourage commenters to make suggestions on this issue and to recommend any other appropriate exclusion for staphylococcus aureus septicemia. We encourage comments on the appropriateness of selecting staphylococcus aureus septicemia as one of our proposed initial hospital-acquired conditions. (g) Ventilator Associated Pneumonia (VAP) and Other Types of Pneumonia Coding `` Pneumonia is identified through the following codes:

073.0 (Ornithosis with pneumonia)

112.4 (Candidiasis of lung)

136.3 (Pneumocystosis)

480.0 (Pneumonia due to adenovirus)

480.1 (Pneumonia due to respiratory syncytial virus)

480.2 (Pneumonia due to parainfluenza virus)

480.3 (Pneumonia due to SARS-associated coronavirus)

480.8 (Pneumonia due to other virus not elsewhere classified)

480.9 (Viral pneumonia, unspecified)

481 (Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia])

482.0 (Pneumonia due to Klebsiella pneumoniae)

482.1 (Pneumonia due to Pseudomonas)

482.2 (Pneumonia due to Hemophilus influenzae [H. influenzae])

482.30 (Pneumonia due to Streptococcus, unspecified)

482.31 (Pneumonia due to Streptococcus, Group A)

482.32 (Pneumonia due to Streptococcus, Group B)

482.39 (Pneumonia due to other Streptococcus)

482.40 (Pneumonia due to Staphylococcus, unspecified)

482.41 (Pneumonia due to Staphylococcus aureus)

482.49 (Other Staphylococcus pneumonia)

482.81 (Pneumonia due to Anaerobes)

482.82 (Pneumonia due to Escherichia coli [E. coli])

482.83 (Pneumonia due to other gram-negative bacteria)

482.84 (Pneumonia due to Legionnaires' disease)

482.89 (Pneumonia due to other specified bacteria)

482.9 (Bacterial pneumonia unspecified)

483.0 (Pneumonia due to Mycoplasma pneumoniae)

There is not a unique code that identifies ventilator associated pneumonia. The creation of a code for ventilator associated pneumonia was discussed at the September 29, 2006 meeting of the ICD-9-CM Coordination and Maintenance Committee meeting. Many issues and concerns were raised at the meeting concerning the creation of this proposed new code. It has been difficult to define ventilator- associated pneumonia. We plan to continue working closely with the CDC to develop a code that can accurately describe this condition for implementation in FY 2009. CDC will address the creation of a unique code for this condition at the September 28-29, 2007 ICD-9-CM Coordination and Maintenance Committee meeting.

While we list 27 pneumonia codes above, our clinical advisors do not believe that all of the codes mentioned could possibly be associated with ventilator-associated pneumonia. Our clinical advisors specifically question whether the following codes would ever represent cases of ventilator-associated pneumonia: 073.0, 480.0, 480.1, 480.2, 480.3, 480.8, 480.9, and 483.0. Therefore, we have a range of pneumonia codes, all of which may not represent cases that could involve ventilator-associated pneumonia. In addition, we do not have a specific code that uniquely identifies cases of ventilator-associated pneumonia.

Burden (High Cost/High Volume)--CDC reports that there are 250,205 ventilator-associated pneumonias per year. Because there is not a unique ICD-9-CM code for ventilator-associated pneumonia, there is not accurate data for FY 2006 on the number of Medicare patients who had this condition as a secondary diagnosis. However, we did examine data for FY 2006 on the number of Medicare patients who listed pneumonia as a secondary diagnosis. There were 92,586 cases with a secondary diagnosis of pneumonia, with average charges of $88,781. According to the journal Critical Care Medicine, patients with ventilator-associated pneumonia have statistically significantly longer intensive care lengths of stay (mean = 6.10 days) than those who do not (mean = 5.32- 6.87 days). In addition, patients who develop ventilator-associated pneumonia incur, on average, greater than or equal to $10,019 in additional hospital costs compared to those who do not.\13\ Therefore, we believe that this is a high-volume condition.

\13\ Safdar N.: Clinical and Economic Consequences of Ventilator-Associated Pneumonia: A Systematic Review, Critical Care Medicine, 2005, 33(10), pp. 2184-2193.

Prevention guidelines--Prevention guidelines are located at the following Web site: http://www.cdc.gov/ncidod/dhqp/ gl--

hcpneumonia.html. However, it is not clear how effective these guidelines are in preventing pneumonia. Ventilator-associated pneumonia may be particularly difficult to prevent.

CC--All of the pneumonia codes listed above are CCs under the current CMS DRGs and under the proposed MS-DRGs, except for the following pneumonia codes which are non-CCs: 073.0, 480.0, 480.1, 480.2, 480.3, 480.8, 480.9, 483.0. However, as mentioned earlier, there is not a unique ICD-9-CM code for ventilator-associated pneumonia. Therefore, this condition does not currently meet the statutory criteria for being selected.

Considerations--Hospital-acquired pneumonias, and specifically ventilator associated pneumonias, are an important problem. However, based on our work with the medical community to develop specific codes for this condition, we have learned that it is difficult to define what constitutes ventilator associated pneumonia. Although prevention guidelines exist, it is not clear how effective these are in preventing pneumonia. Clinicians cannot always tell which pneumonias are acquired in a hospital. In addition,

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as mentioned above, there is not a unique code that identifies ventilator-associated pneumonia. There are a number of codes that capture a range of pneumonia cases. It is not possible to specifically identify if these pneumonia cases are ventilator-associated or arose from other sources. Because we cannot identify cases with ventilator- associated pneumonia and there are questions about its preventability, we are not proposing to select this condition as one of our initial hospital-acquired conditions. However, we welcome public comments on how to create an ICD-9-CM code that identifies ventilator-associated pneumonia, and we encourage participation in our September 28-29, 2007 ICD-9-CM Coordination and Maintenance Committee meeting where this issue will be discussed. We will reevaluate the selection of this condition in FY 2009. (h) Vascular Catheter-Associated Infections

Coding--The code used to identify vascular catheter associated infections is ICD-9-CM code 996.62 (Infection due to other vascular device, implant, and graft). This code includes infections associated with all vascular devices, implants, and grafts. It does not uniquely identify a vascular catheter associated infections. Therefore, there is not a unique ICD-9-CM code for this infection. CDC and CMS staff requested that the ICD-9-CM Coordination and Maintenance Committee discuss the creation of a unique ICD-9-CM code for vascular catheter associated infections because the issue is important for public health. The proposal to create a new ICD-9-CM was discussed at the March 22-23, 2007 meeting of the ICD-9-CM Coordination and Maintenance Committee. A summary of this meeting can be found at: http://www.cdc.gov/nchs/icd9.htm. Coders would also assign an additional code for the infection

such as septicemia. Therefore, a list of specific infection codes would have to be developed to go along with code 996.62. If the vascular catheter associated infection was hospital-acquired, the DRG logic would have to be modified so that neither the code for the vascular catheter associated infection along with the specific infection code would count as a CC.

Burden (High Cost/High Volume)--CDC reports that there are 248,678 central line associated bloodstream infections per year. It appears to be both high cost and high volume. However, we were not able to identify Medicare data on these cases because there is no existing unique ICD-9-CM code.

Prevention guidelines--CDC guidelines are located at the following Web site: http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html.

CC--Code 996.62 is a CC under the current CMS DRGs and the proposed MS-DRGs. However, as stated earlier, this code is broader than vascular catheter-associated infections. Therefore, there is not a unique ICD-9- CM code to identify the condition at this time, and it does not currently meet the statutory criteria to be selected. However, as indicated above, we will be creating a code(s) to identify this condition and may select it as a condition under the provision beginning in FY 2009.

Considerations--There is not yet a unique ICD-9-CM code to capture this condition. If one is implemented on October 1, 2007, we would be able to specifically identify these cases. Some patients require long- term indwelling catheters, which are more prone to infections. Ideally catheters should be changed at certain time intervals. However, circumstances might prevent such practice (for example, the patient has a bleeding diathesis). In addition, a patient may acquire an infection from another source which can colonize the catheter. As mentioned earlier, coders would also assign an additional code for the infection, such as septicemia. Therefore, a list of specific infection codes would have to be developed to go along with code 996.62. If the vascular catheter-associated infection was hospital-acquired, the DRG logic would have to be modified so that neither the code for the vascular catheter-associated infection along with the specific infection code would count as a CC. Without a specific code for infections due to a catheter, it would be difficult to identify these patients. Given the current lack of an ICD-9-CM code for this condition, we are not proposing to include it as one of our initial hospital-acquired conditions at this time. However, we believe it shows merit for inclusion in future lists of hospital-acquired conditions once we have resolved the coding issues and are able to better identify the condition in the Medicare data. We will reevaluate the selection of this condition in FY 2009.

We encourage comments on this condition which was identified as an important public health issue by several organizations that provided recommendations on hospital-acquired conditions. We are particularly interested in receiving comments on how we should handle additional associated infections that might develop along with the vascular catheter-associated infection. (i) Clostridium Difficile-Associated Disease (CDAD)

Coding--This condition is identified by ICD-9-CM code 008.45 (Clostridium difficile).

Burden (High Cost/High Volume)--CDC reports that there are 178,000 cases per year in U.S. hospitals. For FY 2006, there were 110,761 reported cases of Medicare patients with CDAD as a secondary diagnosis, with average charges for the hospital stay of $52,464. Therefore, this is a high-volume condition.

Prevention guidelines--Prevention guidelines are not available. Therefore, we do not believe this condition can reasonably be prevented through the application of evidence-based guidelines.

CC--Code 008.45 is a CC under the current CMS DRGs and the proposed MS-DRGs.

Considerations--CDAD is an emerging problem with significant public health importance. If found early CDAD cases can easily be treated. However, cases not diagnosed early can be expensive and difficult to treat. CDAD occurs in patients on a variety of antibiotic regiments, many of which are unavoidable, and therefore preventability is an issue. We are not proposing to include CDAD as one of our initial hospital-acquired conditions at this time, given the lack of prevention guidelines. We welcome public comments on CDAD, specifically on its preventability and whether there is potential to develop guidelines to identify it early in the disease process and/or diminish its incidence. We will reevaluate the selection of this condition in FY 2009. (j) Methicillin-Resistant Staphylococcus Aureus (MRSA)

Coding--MRSA is identified by ICD-9-CM code V09.0 (Infection with microorganisms resistant to penicillins). One would also assign a code(s) to describe the exact nature of the infection.

Burden (High Cost/High Volume)--For FY 2006, there were 95,103 reported cases of Medicare patients who had MRSA as a secondary diagnosis. The average charges for these cases were $31,088. This condition is a high-cost and high-volume infection. MRSA has become a very common bacteria occurring both in and outside of the hospital environment.

Prevention guidelines--CDC guidelines are located at the following Web site: http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf.

CC--Code V09.0 is not a CC under the current CMS DRGs and the proposed

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MS-DRGs. The specific infection would be identified in a code describing the exact nature of the infection, which may be a CC.

Considerations--As stated earlier, preventability may be hard to ascertain since the bacteria has become so common both inside and outside the hospital. There are also considerations in identifying MRSA infections because hospitals would report the code for MRSA along with additional codes that would describe the exact nature of the infection. We would have to develop a list of specific infections that could be the result of MRSA. We are not proposing to include MRSA as one of our initial hospital-acquired conditions because the condition is not a CC. We recognize that associated conditions may be a CC. We welcome comments on the proposal not to include this condition. Should there be support for including this condition, we request recommendations on what codes might be selected to identify the specific types of infections associated with MRSA. (k) Surgical Site Infections

Coding--Surgical site infections are identified by ICD-9-CM code 998.59 (Other postoperative infection). The code does not tell the exact location or nature of the postoperative wound infection. The code includes wound infections and additional types of postoperative infections such as septicemia. The coding guidelines instruct the coder to add an additional code to identify the type of infection. To implement this condition we would have to remove both code 998.59 and the specific infection from counting as a CC if they occurred after the admission. We would have to develop an extensive list of possible infections that would be subject to the provision. We may also need to recommend the creation of a series of new ICD-9-CM codes to identify various types of surgical site infections, should this condition merit inclusion among those that are subject to the proposed hospital- acquired conditions provision.

Burden (High Cost/High Volume)--CDC reports that there are 290,485 surgical sites infections each year. As stated earlier, there is not a unique code for surgical site infection. Therefore, we examined Medicare data on patients with any type of postoperative infection. For FY 2006, there were 38,763 reported cases of Medicare patients who had a postoperative infection. These patients had average charges for the hospital stay of $79,504. We are unable to determine how many of these patients had surgical site infections.

Prevention guidelines--CDC guidelines are available at the following Web site: http://www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html

CC--Code 998.59 is a CC under the current CMS DRGs and the proposed

MS-DRGs.

Considerations--As mentioned earlier, code 998.59 is not exclusive to surgical site infections. It includes other types of postoperative infections. Therefore, code 998.59 does not currently meet the statutory criteria for being subject to the provision because it does not uniquely identify surgical site infections. To identify surgical site infections, we would need new codes that provide more detail about the type of postoperative infection as well as the site of the infection. In addition, one would report both code 998.59 as well a more specific code for the specific type of infection, making implementation difficult. While there are prevention guidelines, it is not always possible to identify the specific types of surgical infections that are preventable. Therefore, we are not proposing to select surgical site infections as one of our proposed hospital- acquired conditions at this time. However, we welcome public comments on whether we can develop criteria and codes to identify preventable surgical site infections that would assist us in reducing their incidence. We are exploring ways to identify surgical site infections and will reevaluate this condition in FY 2009. (l) Serious Preventable Event--Surgery on Wrong Body Part, Patient, or Wrong Surgery

Coding--Surgery performed on the wrong body part, wrong patient, or the wrong surgery would be identified by ICD-9-CM code E876.5 (Performance of inappropriate operation). This diagnosis code does not specifically identify which of these events has occurred.

Burden (High Cost/High Volume)--As stated earlier, there are not unique ICD-9-CM codes which capture surgery performed on the wrong body part or the wrong patient, or the wrong surgery. Therefore, we examined Medicare data on the code for performance of an inappropriate operation. For FY 2006, there was one Medicare case reported with this code, and the patient had average charges for the hospital stay of $24,962. This event is rare. Therefore, it is not high volume. Individual cases could have high costs. However, we were unable to determine the impact with our limited data.

Prevention guidelines--There are prevention guidelines for performing the correct surgery on the correct patient or correct patient's body part. This event should not occur.

CC--This code is not a CC under the current CMS DRGs and the proposed MS-DRGs. Therefore, it does not meet the criteria for selection under section 1886(d)(4)(D)(iv) of the Act. However, Medicare does not pay for performing surgery on the wrong body part or patient, or performing the wrong surgery. These services are not considered to be reasonable and necessary and are excluded from Medicare coverage.

Considerations--There are significant considerations for the selection of this condition. There is not a unique ICD-9-CM code that would describe the nature of the inappropriate operation. All types of inappropriate operations are included in code E876.5. Unlike other conditions, performance of an inappropriate operation is not a complication of a prior medical event that was medically necessary. Rather, in this case, there was a needed intervention but it was done to either the wrong body part or the wrong patient, or was not the correct operation. Thus, a service was completed that was not reasonable and necessary and Medicare does not pay for any inpatient service associated with the wrong surgery. It is not necessary for us to select this condition because Medicare does not pay for it under any circumstances. (m) Falls

Coding--There is no single code that shows that a patient has suffered a fall in the hospital. Codes would be assigned to identify the nature of any resulting injury from the fall such as a fracture, contusion, concussion, etc. There is a code to indicate that a patient fell from bed, code E884.4 (Fall from bed). One would then assign a code that identifies the external cause of the injury (the fall from the bed) and an additional code(s) for any resulting injury (a fractured bone).

Burden (High Cost/High Volume)--As stated earlier, there is not a code to capture all types of falls. Therefore, we examined Medicare data on the number of Medicare beneficiaries who fell out of bed. For FY 2006, there were 2,591 cases reported of Medicare patients who fell out of bed. These patients had average charges of the hospital stay of $24,962. However, depending on the nature of the injury, costs may vary in specific cases.

Prevention guidelines--Falls may or may not be preventable. Serious preventable event guidelines can be found at the following Web site: http://www.qualityindicators.ahrq.gov/psi_download.htm

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CC--Code E884.4 is not a CC under the current CMS DRGs or the proposed MS-DRGs.

Considerations--There are not clear codes that identify all types of falls. Hospitals would also have to use additional codes for fractures and other injuries that result from the fall. In addition, depending on the circumstances, the falls may or may not be preventable. We are not proposing the inclusion of falls as one of our initial hospital-acquired conditions at this time because we can only identify a limited number of these cases, and they are not classified as a CC. However, we welcome public comments on how to develop codes or coding logic that would allow us to identify injuries that result from falls in the hospital so that Medicare would not recognize the higher costs associated with treating patients who acquire these conditions in the hospital. We will reevaluate this condition in FY 2009.

The following table summarizes whether or not the potential conditions meet our criteria and if there are significant considerations with selecting the particular condition. As mentioned earlier, we have listed these conditions in the priority order according to how well they meet the statutory criteria. As discussed earlier, we are proposing to select the first six conditions (catheter associated urinary tract infections through Staphylococcus aureus septicemia) as our initial hospital-acquired conditions. We would not include the last seven conditions (ventilator-associated pneumonia through falls) as initial hospital-acquired conditions. We welcome comments on how appropriately we have evaluated and proposed the selection of the first six conditions. We also encourage specific comments on any additional conditions we should select for October 1, 2008 implementation. We request commenters to include a rationale for selecting any suggested additional conditions, as well as an analysis of why each suggested additional condition meets the criteria under section 1886(d)(4)(D)(iv) of the Act and whether there would be coding issues or other considerations associated with selecting each condition.

Proposed Hospital-Acquired Conditions and Criteria

Proposed hospital-acquired

Burden--high cost

Prevention condition

Coding--unique code? and/or high volume? guidelines?

CC?

Considerations?

1. Catheter associated urinary Yes................. Yes................. Yes................. Yes................. Minimal--additional infection tract infections.

codes. 2. Pressure ulcers (Decubitus Yes................. Yes................. Yes................. Yes................. No. ulcers). 3. Serious preventable event-- Yes................. Yes--high cost in Yes................. Yes................. No. Object left in surgery.

specific circumstances. 4. Serious preventable event--air Yes................. Yes--high cost in Yes................. Yes................. No . embolism.

specific circumstances. 5. Serious preventable event-- Yes................. Yes--high cost in Yes................. Yes................. No. Blood incompatibility.

specific circumstances. 6. Staphylococcus aureus

Yes--multiple codes Yes................. Yes................. Yes................. Multiple codes. septicemia.

reported. 7. Ventilator associated

No VAP code,

Yes................. Yes................. No--no unique codes. Preventability issues. VAPs-- pneumonia (VAP)/Pneumonia/.

multiple pneumonia

identification issues. codes. 8. Vascular catheter associated No.................. Yes................. Yes................. Yes--but code is too Preventability issues. infections.

broad. 9. Clostridium difficile-

Yes................. Yes................. No.................. Yes................. Preventability issues. associated disease (CDAD). 10. Methicillin-resistant

Yes................. Yes................. Yes................. No.................. Preventability issues. staphylococcus aureus (MRSA). 11. Surgical site infections..... No.................. Yes................. Yes................. Yes--but code is too Cannot identify. broad. 12. Serious preventable event-- Yes................. Yes--high cost in Yes................. No.................. Not a CC. Wrong surgery.

specific circumstances. 13. Falls........................ No--not for all Yes--high cost in No--for all types of No.................. Cannot identify. types of falls. specific

falls. circumstances.

As stated earlier, we are soliciting comments on the six conditions we proposed to include among the initial hospital-acquired conditions. We welcome any comments on the clinical aspects of the conditions and on which conditions should be selected for implementation on October 1, 2008. We also solicit comments on any problematic issues for specific conditions that may support not selecting them as one of the initial conditions. We encourage comments on how some of the administrative problems can be overcome if there is support for a particular condition. 7. Other Issues

Under section 1886(d)(4)(D)(vi) of the Act, ``[a]ny change resulting from the application of this subparagraph shall not be taken into account in adjusting the weighting factors under subparagraph (C)(i) or in applying budget neutrality under subparagraph (C)(iii).'' Subparagraph (C)(i) refers to DRG classifications and relative weights. Therefore, the statute requires the Secretary to continue counting the conditions selected under section 5001(c) of the DRA as MCCs or CCs when updating the relative weights annually. Thus, the higher costs

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associated with a case with a hospital-acquired MCC or CC will continue to be assigned to the MCC or CC DRG when calculating the relative weight but payment will not be made to the hospital at one of these higher-paying DRGs. Further, subparagraph (C)(iii) refers to the budget neutrality calculations that are done so aggregate payments do not increase as a result of changes to DRG classifications and relative weights. Again, the higher costs associated with the cases that have a hospital-acquired MCC or CC will be included in the budget neutrality calculation but Medicare will make a lower payment to the hospital for the specific case that include an MCC or CC. Thus, to the extent that the provision applies and cases with an MCC or CC are assigned to a lower-paying DRG, section 5001(c) of the DRA will result in cost savings to the Medicare program. We note that the provision will only apply when the selected conditions are the only MCCs and CCs present on the claim. Therefore, if a nonselected MCC or CC is on the claim, the case will continue to be assigned to the higher paying MCC or CC DRG, and there will be no savings to Medicare from the case. We believe the provision will apply in a small minority of cases because it is rare that one of the selected conditions will be the only MCC or CC present on the claim. We provide our estimate of the savings associated with this provision in the impact section of this proposed rule.

G. Proposed Changes to Specific DRG Classifications

1. Pre-MDC: Intestinal Transplantation

(If you choose to comment on issues in this section, please include the caption ``DRGs: Intestinal Transplantation'' at the beginning of your comment.)

In the FY 2005 IPPS final rule (69 FR 48976), we reassigned intestinal transplant cases from CMS DRG 148 (Major Small and Large Bowel Procedures with CC) and CMS DRG 149 (Major Small and Large Bowel Procedures without CC) to CMS DRG 480 (Liver Transplant and/or Intestinal Transplantation). In the FY 2006 IPPS final rule (70 FR 47286), we continued to evaluate these cases to see if a further DRG change was warranted. While we found that intestinal only transplants and combination liver-intestine transplants have higher average charges than other cases in CMS DRG 480, these cases are extremely rare (there were only 4 cases in FY 2004) and the insufficient number of cases does not warrant creating a separate DRG.

For FY 2008, we examined the September 2006 update of the FY 2006 MedPAR file and found 1,208 cases assigned to CMS DRG 480. In the proposed MS-DRGs described in section II.C. of the preamble of this proposed rule, we are proposing to split CMS DRG 480 into two severity levels: proposed MS-DRG 005 (Liver Transplant and/or Intestinal Transplant with MCC) and proposed MS-DRG 006 (Liver Transplant and/or Intestinal Transplant without MCC). The following table displays our results:

Average Proposed MS-DRG

Number of length of Average cases stay charges

MS-DRG 006--All cases...............

446 10.05 $129,519 MS-DRG 006--Intestinal transplant

34 354,793 cases only......................... MS-DRG 005--All cases...............

762 22.25 243,271 MS-DRG 005--Intestinal transplant

9 40.22 460,089 cases only......................... MS-DRG 005--Intestinal and liver

56 1,179,425 transplant.........................

Under the proposed MS-DRGs, 10 of 13 intestinal transplant cases are assigned to proposed MS-DRG 005 based on the secondary diagnosis of the patient. The three remaining intestinal transplant cases do not have an MCC and would have been assigned to proposed MS-DRG 006, absent further changes to the DRG logic. These three intestinal transplants have average charges of approximately $354,793 and an average length of stay of 34 days. Average charges and length of stay for these three cases are more comparable to the average charges of approximately $243,271 and average length of stay of 40.22 days for all cases assigned to proposed MS-DRG 005. For this reason, we are proposing to move all intestinal transplant cases to proposed MS-DRG 005. As part of this proposal, we would redefine proposed MS-DRG 005 as ``Liver Transplant with MCC or Intestinal Transplant.'' The presence of a liver transplant with MCC or an intestinal transplant would assign a case to the higher severity level. Proposed MS-DRG would also be redefined as ``Liver Transplant without MCC.'' 2. MDC 1 (Diseases and Disorders of the Nervous System) a. Implantable Neurostimulators

(If you choose to comment on issues in this section, please include the caption ``DRGs: Neurostimulators'' at the beginning of your comment.)

We received a joint request from three manufacturers to review the DRG assignment for cases involving neurostimulators. The commenters are concerned that:

Neurostimulator cases may be assigned to 30 different DRGs in 12 different MDCs depending upon the patient's principal diagnosis.

Neurostimulator cases represent a small proportion of the total cases in their assigned DRG and have higher costs.

The 11 new ICD-9-CM codes created beginning in FY 2007 that identify pain are assigned to MDC 23 (Factors Influencing Health Status and Other Contacts With Health Services) rather than MDC 1 (Diseases and Disorders of the Nervous System). The commenters are concerned that these pain codes will be a common principal diagnosis for patients who receive a neurostimulator and will be assigned to MDC 23, which contains a wide variety of dissimilar diagnoses. The new ICD- 9-CM codes are: 338.0 (Central pain syndrome), 338.11 (Acute pain due to trauma), 338.12 (Acute post-thoracotomy pain), 338.18 (Other acute postoperative pain), 338.19 (Other acute pain), 338.21 (Chronic pain due to trauma), 338.22 (Chronic post-thoracotomy pain), 338.28 (Other chronic postoperative pain), 338.29 (Other chronic pain), 338.3 (Neoplasm related pain (acute)(chronic)), and 338.4 (Chronic pain syndrome)

The commenters recommended that we:

Reroute all spinal and peripheral neurostimulator cases into a common set of base DRGs.

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Reclassify ICD-9-CM pain codes 338.0 through 338.4 currently assigned to MDC 23 into MDC 1 when reported as principal diagnosis.

Revise surgical CMS DRGs in MDC 1 based on whether the patient received a major device.

Split the single surgical CMS DRG in MDC 19 (Mental Diseases and Disorders) and MDC 23 into two CMS DRGs: one CMS DRG for minor procedures as defined by CMS DRGs 477 (Non-Extensive O.R. Procedure Unrelated to Principal Diagnosis) and CMS DRG 468 (Extensive O.R. Procedure Unrelated to Principal Diagnosis) and one CMS DRG for major procedures.

Create a new CMS DRG in MDC 1 for major devices.

The commenters recognize that implementing a re-routing feature in the CMS DRG system would be a major undertaking and, alternatively, suggested reassigning the pain codes to MDC 1 as an interim step. We agree with this suggestion as described further below. With respect to the suggestion to split the single surgical CMS DRG in MDCs 19 and 23 into two CMS DRGs and create a major device CMS DRG within MDC 1, we encourage the commenters to examine the assignment of neurostimulator cases under the MS-DRGs to determine whether the changes we are proposing to adopt to better recognize severity in the CMS DRG system would address these concerns.

The implantation of a neurostimulator requires two types of procedures. First, the surgeons implant leads containing electrodes into the targeted section of the brain, spine, or peripheral nervous system. Second, a neurostimulator pulse generator is implanted into the pectoral region and extensions from the neurostimulator pulse generator are tunneled under the skin and connected with the proximal ends of the leads. Hospitals stage the two procedures required for a full system neurostimulator implant.

There are separate ICD-9-CM procedure codes that identify the implant of the leads and the insertion of the pulse generator. The three codes for the leads insertion are: 02.93 (Implantation or replacement of intracranial neurostimulator lead(s)); 03.93 (Implantation or replacement of spinal neurostimulator lead(s)); and code 04.92 (Implantation or replacement of peripheral neurostimulator lead(s). The five codes for the insertion of the pulse generator are: 86.94 (Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable); 86.95 (Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable); 86.96 (Insertion or replacement of other neurostimulator pulse generator); 86.97 (Insertion or replacement of single array rechargeable neurostimulator pulse generator); and 86.98 (Insertion or replacement of dual array rechargeable neurostimulator pulse generator).

The patient's principal diagnosis determines the MDC assignment. Implant of a cranial, spinal or peripheral neurostimulator will result in assignment of the case to a surgical DRG within that MDC. Although the commenters are correct that neurostimulator cases can potentially be assigned to many different CMS DRGs based on the patient's principal diagnosis, they also provided data that showed that nearly 90 percent are assigned to 6 different CMS DRGs that cross two MDCs. In MDC 1, neurostimulator cases are assigned to four CMS DRGs: CMS DRG 7 (Peripheral and Cranial Nerve and Other Nervous System Procedures With CC); CMS DRG 8 (Peripheral and Cranial Nerve and Other Nervous System Procedures Without CC); CMS DRG 531 (Spinal Procedures With CC); and CMS DRG 532 (Spinal Procedures Without CC). In MDC 8 (Disease and Disorders of the Musculoskeletal System and Connective Tissue), neurostimulator cases are assigned to two CMS DRGs: CMS DRG 499 (Back and Neck Procedures Except Spinal Fusion With CC); and CMS DRG 500 (Back and Neck Procedures Except Spinal Fusion Without CC).

With very limited exceptions, such as tracheostomies and certain types of transplants, the principal diagnosis is fundamental to the assignment of a case to an MDC within the DRG system. By relying on the patient's principal diagnosis, the DRG system will group together patients who are clinically similar. For this reason, we are concerned about adopting the suggestion that all neurostimulator cases be rerouted to a common DRG irrespective of the patient's principal diagnosis. We believe such a step would be fundamentally inconsistent with the idea of creating common groups of patients who are clinically similar based on diagnosis and procedures. For this reason, we do not believe that a rerouting step should be adopted that would group together all neurostimulator cases.

However, we do agree with the commenters' suggestion that the new ICD-9-CM codes created in FY 2007 for central and chronic pain syndrome and chronic pain (codes 338.0, 338.21 through 338.29, and 338.4) should be assigned to MDC 1 when present as the principal diagnosis. The commenters requested that we reclassify the pain codes (338.0 through 338.4) from MDC 23 to MDC 1. Our medical consultants advised that the acute pain codes (codes 338.11 through 338.19) should remain in MDC 23 because the acute pain is not a neurological condition. According to the commenters, the National Center for Health Statistics' (NCHS) choice in locating the pain codes within ICD-9-CM's Nervous System chapter has much clinical validity, particularly for chronic pain. The commenters further noted that acute pain is typically self-limited, a symptomatic response to an immediate insult that serves the body as a warning sign. However, chronic pain is unrelenting and serves no warning or protective function. It is a disease process of its own accord, according to the commenters.

The commenters described pain as follows. Broadly, there are two main categories of pain: nociceptive and neuropathic. Nociceptive pain is caused by sensory neurons, called nociceptors, responding to tissue damage. This type of pain is the body's normal response to injury. The pain is usually localized and time-limited. That is, when the tissue damage heals, the pain typically resolves. Acute pain is typically nociceptive. In general, nociceptive pain is typically treated with anti-inflammatories and, in more severe cases, with opioids via a morphine pump for example.

In contrast, neuropathic pain is caused by malfunctioning or pathologically altered nervous pathways stemming from injury to the nervous system, either as a direct result of trauma to a nerve (phantom limb syndrome, reflex sympathetic dystrophy/complex regional pain syndrome after injury) or due to other medical conditions that cause damage to the nerve such as herpes (postherpetic neuralgia), diabetes (diabetic neuropathy), and peripheral vascular disease (critical limb ischemia). Failed back surgery syndrome (FBSS) is another common source of neuropathic pain. Typically, neuropathic pain is chronic and may persist for months or years beyond the healing of damaged tissue. Because the nerves themselves have been damaged, neuropathic pain can be considered its own disease process. Neuropathic pain may be more difficult to treat than nociceptive pain and has been shown to be more responsive to neurostimulation.

The pain codes, created effective October 1, 2006, are currently assigned to MDC 23. The neurostimulator cases with a principal diagnosis using the pain codes were assigned to CMS DRG

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461 (O.R. Procedure With Diagnoses of Other Contact With Health Services) for the first time in FY 2007. As explained above, prior to our adoption of the new pain codes in FY 2007, these cases had historically been assigned to CMS DRGs 7 and 8 (Peripheral and Cranial Nerve and Other Nervous System Procedure With and Without CC, respectively) tin MDC 1. Adopting the commenters' recommendation would result in the neurostimulator cases being assigned to their historic CMS DRGs.

Our medical officers agree that cases that use the new pain diagnosis codes for central and chronic pain syndrome and chronic pain (codes 338.0, 338.21 through 338.29, and 338.4) as a principal diagnosis should be assigned to MDC 1. For this reason, we are proposing to assign cases with a principal diagnosis of central pain syndrome (code 338.0), chronic pain due to trauma (code 338.21), chronic post-thoracotomy pain (code 338.22), other chronic postoperative pain (code 338.28), other chronic pain (code 338.29), or chronic pain syndrome (code 338.4) to MDC 1, although we plan to monitor their use and may reassign them if needed. b. Intracranial Stents

(If you choose to comment on issues in this section, please include the caption ``DRGs: Intracranial Stents'' at the beginning of your comment.)

Effective October 1, 2004, the ICD-9-CM Coordination and Maintenance Committee created procedure code 00.62 (Percutaneous angioplasty or atherectomy of intracranial vessel(s)). At the same time, we created code 00.65 (Percutaneous insertion of intracranial vascular stent(s)). It is our customary practice to assign new codes to the same DRG as their predecessor codes. Code 00.62 was removed from code 39.50 (Angioplasty or atherectomy of other noncoronary vessel(s)), which is assigned to CMS DRG 533 (Extracranial Procedures with CC) and CMS DRG 534 (Extracranial Procedures Without CC) (proposed MS-DRGs 37, 38, and 39 (Extracranial Procedures With MCC, With CC, and Without CC/ MCC, respectively)) when the patient has principal diagnosis in MDC 1. Therefore, we assigned code 00.62 to CMS DRGs 533 and 534 in MDC 1 beginning in FY 2005. In addition, we made code 00.65 a non-O.R. procedure for DRG assignment. We also assigned code 00.62 to the Non- Covered Procedure edit of the MCE, as Medicare had a national noncoverage determination for intracranial angioplasty and atherectomy with stenting.

Effective November 7, 2006, Medicare covers percutaneous transluminal angioplasty (PTA) and stenting of intracranial arteries for the treatment of cerebral artery stenosis in cases in which stenosis is 50 percent or greater in patients with intracranial atherosclerotic disease when furnished in accordance with FDA-approved protocols governing Category B Investigational Device Exemption (IDE) clinical trials. CMS determined that coverage of intracranial PTA and stenting is reasonable and necessary under these circumstances. All other indications for PTA without stenting to treat obstructive lesions of the vertebral and cerebral arteries remain noncovered. This decision can be found online in the CMS Coverage Manual: http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp at section 20.7.B.5.

A manufacturer recently met with CMS to request that code 00.62 be reassigned to CMS DRGs 1 and 2 (Craniotomy Age > 17 With and Without CC, respectively) (proposed MS-DRGs 37 (Extracranial Procedures With MCC), 38 (Extracranial Procedures With CC), and 39 (Extracranial Procedures Without CC/MCC)) and CMS DRG 543 (Craniotomy with Major Device Implant or Acute Complex Central Nervous System Principal Diagnosis) (proposed MS-DRGs 23 and 24 (Craniotomy With Major Device Implant or Acute Complex Central Nervous System Principal Diagnosis With MCC and Without MCC, respectively). The manufacturer noted that other similar endovascular intracranial procedures that treat a cerebrovascular blockage are currently assigned to the craniotomy CMS DRGs. These endovascular-approach cases already assigned to the craniotomy CMS DRGs are identified by procedure codes 39.72 (Endovascular repair or occlusion of head and neck vessels), 39.74 (Endovascular removal of obstruction from head and neck vessel(s)), and 39.79 (Other endovascular repair (of aneurysm) of other vessels). Under the proposed MS-DRGs, we are proposing to assign procedure codes 39.72, 39.74, and 39.79 to MS-DRGs 011 through 013 and MS-DRG 543. Although we are concerned about the assignment of additional endovascular procedures to an open surgical DRG, we agree that there is clinical consistency between procedure codes 39.72, 39.74, and 39.79 and procedure code 00.62. For this reason, we agree that procedure code 00.62 should be assigned to CMS DRGs 1, 2, and 543 (proposed MS-DRGs 37, 38, and 39 and 243 and 24, respectively, that are divided by the presence or absence of specific CCs).

For FY 2008, we are proposing to remove code 00.62 from CMS DRGs 533 and 534 and assign them to proposed MS-DRGs 37, 38, and 39, as well as to proposed MS-DRGs 23 and 24.

In order to assure appropriate DRG assignment as described above, we are proposing to make conforming changes to the MCE by removing code 00.62 from the Non-Covered Procedure edit. However, as intracranial PTA is only covered when performed in conjunction with insertion of a stent, we are proposing to redefine the edit by specifying that code 00.62 must be accompanied by code 00.65 (Percutaneous insertion of intracranial vascular stent(s)). Should code 00.65 not be reported on the claim, the case would fail the MCE edit. For a full discussion of this proposed change, we refer readers to the MCE discussion in section II.F.6. of the preamble of this proposed rule.

Although we are proposing to assign endovascular intracranial procedures to the same DRG as craniotomy, we remain concerned that endovascular intracranial procedures are clinically different than open craniotomy surgical procedures and may have very different resource requirements. At the current time, there are an insufficient number of cases to warrant creation of a separate base DRG for endovascular intracranial procedures. However, we intend to revisit the assignment of intracranial endovascular procedures at a later date when more data are available to analyze these cases. 3. MDC 3 (Diseases and Disorders of the Ear, Nose, Mouth, and Throat)-- Cochlear Implants

(If you choose to comment on issues in this section, please include the caption ``DRGs: Cochlear Implants'' at the beginning of your comment.)

Cochlear implants were first covered by Medicare in 1986 and were assigned to CMS DRG 49 (Major Head and Neck Procedures) in MDC 3 (Diseases and Disorders of the Ear, Nose, Mouth, and Throat). CMS DRG 49 is the highest weighted DRG in that MDC. However, two manufacturers of cochlear implants contend that this DRG assignment is clinically and economically inappropriate and have requested that cochlear implant cases be reassigned from CMS DRG 49 to CMS DRG 543 (Craniotomy With Major Device Implant or Acute Complex Central Nervous System Principal Diagnosis).

The manufacturers stated that procedures assigned to CMS DRG 49 are performed mostly for diseases such as head and neck cancers, while procedures in CMS DRG 543 include

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operations on and inside the skull and implantation of complex devices, including intracranial neurostimulators. The manufacturers described the cochlear implant procedure as requiring incisions behind the ear to remove a section of the temporal bone, followed by microscopic neurotologic surgery under general anesthesia, and is typically completed in 2 to 4 hours to restore hearing to the profoundly deaf. For these reasons, these manufacturers believe cochlear implant procedures are similar to open craniotomies.

Based on their analysis of the FY 2005 MedPAR data, the manufacturers identified a total of 139 cochlear implant cases using ICD-9-CM procedure codes 20.96 (Implantation or replacement of cochlear prosthetic device NOS), 20.97 (Implantation or replacement of cochlear prosthetic device, single channel), and 20.98 (Implantation or replacement of cochlear prosthetic device, multiple channel). The manufacturers reported 121 out of 139 cochlear implant cases were assigned to CMS DRG 49 with average standardized charges of approximately $58,078.

When we reviewed the FY 2006 MedPAR data, we identified 104 cochlear implant cases assigned to CMS DRG 49. In the proposed MS-DRGs, CMS DRG 49 is subdivided into two severity levels: Proposed MS-DRG 129 (Major Head and Neck Procedures With CC or MCC) and proposed MS-DRG 130 (Major Head and Neck Procedures Without CC). The following table displays our results:

Average Proposed MS-DRG

Number of length of Average cases

stay charges

MS-DRG 130--All cases............

1,095

3.04 $23,928 MS-DRG 130--Code 20.96 cases only

1.63 51,740 MS-DRG 130--Code 20.97 only......

1.50 38,855 MS-DRG 130--Code 20.98 only......

1.24 50,219 MS-DRG 129--All cases............

1,244

5.35 34,169 MS-DRG 129--Code 20.96 only......

2.70 81,351 MS-DRG 129--Code 20.97 only......

5.00 95,441 MS-DRG 129--Code 20.98 only......

3.13 53.510

Under the proposed MS-DRGs, 19 out of 104 cochlear implant cases are assigned to proposed MS-DRG 129 based on the secondary diagnosis of the patient. The 85 remaining cochlear implant cases do not have a CC or MCC and would be assigned to proposed MS-DRG 130, absent further changes to the DRG logic.

The average charges of approximately $54,238 for cochlear implant cases are higher than the average charges of approximately $29,375 for the other cases in CMS DRG 49. However, the average charges are not as high as the average charges of approximately $78,118 for cases assigned to CMS DRG 543. Further, our medical advisors do not believe that surgery to implant a cochlear implant is clinically similar to an open craniotomy in MDC 1 because typically a craniotomy involves removing and then replacing a section of the skull in order to perform a procedure on or within the brain, whereas a cochlear implant involves drilling a hole in the mastoid bone in order to insert the implant into the inner ear.

We have been unable to address this issue under the current DRGs because there are not enough inpatient cochlear implant cases to warrant creation of a separate DRG. Although these cases will continue to have higher charges than other cases in their assigned DRG, we are proposing to move the cochlear implant cases to the higher DRG severity level within CMS DRG 49. As part of this proposal, we would redefine proposed MS-DRG 129 as ``Major Head and Neck Procedures With CC or MCC or Major Device''. The presence of a major head and neck procedure with a CC or MCC or major device would assign the case to the higher severity level within CMS DRG 49. 4. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue) a. Hip and Knee Replacements

(If you choose to comment on issues in this section, please include the caption ``DRGs: Hip and Knee Replacements'' at the beginning of your comment.)

In the FY 2006 IPPS final rule (70 FR 47303), we deleted DRG 209 (Major Joint and Limb Reattachment Procedures of Lower Extremity) and created two new DRGs: 544 (Major Joint Replacement or Reattachment of Lower Extremity) and 545 (Revision of Hip or Knee Replacement). The two new DRGs were created to identify that revisions of joint replacement procedures are significantly more resource intensive than original hip and knee replacements procedures. DRG 544 includes the following procedure code assignments:

81.51, Total hip replacement

81.52, Partial hip replacement

81.54, Total knee replacement

81.56, Total ankle replacement

84.26, Foot reattachment

84.27, Lower leg or ankle reattachment

84.28, Thigh reattachment

DRG 545 includes the following procedure code assignments:

00.70, Revision of hip replacement, both acetabular and femoral components

00.71, Revision of hip replacement, acetabular component

00.72, Revision of hip replacement, femoral component

00.73, Revision of hip replacement, acetabular liner and/ or femoral head only

00.80, Revision of knee replacement, total (all components)

00.81, Revision of knee replacement, tibial component

00.82, Revision of knee replacement, femoral component

00.83, Revision of knee replacement, patellar component

00.84, Revision of knee replacement, tibial insert (liner)

81.53, Revision of hip replacement, not otherwise specified

81.55, Revision of knee replacement, not otherwise specified

Further, we created a number of new ICD-9-CM procedure codes effective October 1, 2005, that better distinguish the many different types of joint replacement procedures that are currently being performed. In the FY 2006 IPPS final rule (70 FR 47305), we indicated that a commenter had requested that, once we receive claims data using the new procedure codes, we closely examine data from the use of the codes under the two new DRGs to determine if future additional DRG modifications are needed.

Further, the American Association of Hip & Knee Surgeons (AAHKS) recommended that we make further

[[Page 24730]]

refinements to the DRGs for knee and hip arthroplasty procedures. AAHKS previously presented data to CMS on the important differences in clinical characteristics and resource utilization between primary and revision total joint arthroplasty procedures. AAHKS stated that CMS' decision to create a separate DRG for revision of total joint arthroplasty (TJA) in October 2005 resulted in more equitable reimbursement for hospitals that perform a disproportionate share of complex revision of TJA procedures, recognizing the higher resource utilization associated with these cases. AAHKS stated that this important payment policy change led to increased access to care for patients with failed total joint arthroplasties, and ensured that high volume TJA centers could continue to provide a high standard of care for these challenging patients.

AAHKS further stated that the addition of new, more descriptive ICD-9-CM diagnosis and procedure codes for TJA in October 2005 gave it the opportunity to further analyze differences in clinical characteristics and resource intensity among TJA patients and procedures. Inclusive of the preparatory work to submit its recommendations, the AAHKS compiled, analyzed, and reviewed detailed clinical and resource utilization data from over 6,000 primary and revision TJA procedure codes from 4 high volume joint arthroplasty centers located within different geographic regions of the United States: University of California, San Francisco, CA; Mayo Clinic, Rochester, MN; Massachusetts General Hospital, Boston, MA; and the Hospital for Special Surgery, New York, NY. Based on its analysis, AAHKS recommended that CMS examine Medicare claims data and consider the creation of separate DRGs for total hip and total knee arthroplasty procedures. DRG 545 currently contains revisions of both hip and knee replacement procedures. AAHKS stated that based on the differences between patient characteristics, procedure characteristics, resource utilization, and procedure code payment rates between total hip and total knee replacements, separate DRGs were warranted. Furthermore, AAHKS recommended that CMS create separate base DRGs for routine versus complex joint revision or replacement procedures as shown below.

Routine Hip Replacements

00.73, Revision of hip replacement, acetabular liner and/ or femoral heal only

00.85, Resurfacing hip, total, acetabulum and femoral head

00.86, Resurfacing hip, partial, femoral head

00.87, Resurfacing hip, partial, acetabulum

81.51, Total hip replacement

81.52, Partial hip replacement

81.53, Revision of hip replacement, not otherwise specified

Complex Hip Replacements

00.70, Revision of hip replacement, both acetabular and femoral components

00.71, Revision of hip replacement, acetabular component

00.72, Revision of hip replacement, femoral component

Routine Knee Replacements and Ankle Procedures

00.83, Revision of knee replacement, patellar component

00.84, Revision of knee replacement, tibial insert (liner)

81.54, Revision of knee replacement, not otherwise specified

81.55, Revision of knee replacement, not otherwise specified

81.56, Total ankle replacement

Complex Knee Replacements and other reattachments

00.80, Revision of knee replacement, total (all components)

00.81, Revision of knee replacement, tibial component

00.82, Revision of knee replacement, femoral component

84.26, Foot reattachment

84.27, Lower leg or ankle reattachment

84.28, Thigh reattachment

AAHKS also recommended the continuation of DRG 471 (Bilateral or Multiple Major Joint Procedures of Lower Extremity) without modifications. DRG 471 includes any combination of two or more of the following procedure codes:

00.70, Revision of hip replacement, both acetabular and femoral components

00.80, Revision of knee replacement, total (all components)

00.85, Resurfacing hip, total, acetabulum and femoral head

00.86, Resurfacing hip, partial, femoral head

00.87, Resurfacing hip, partial, acetabulum

81.51, Total hip replacement

81.52, Partial hip replacement

81.54, Total knee replacement

81.56, Total ankle replacement

As discussed in section II.C. of the preamble of this proposed rule, we are proposing to adopt MS-DRGs to better recognize severity of illness for FY 2008. The proposed MS-DRGs include two new severity of illness levels under the current base DRG 544. We are also proposing to add three new severity of illness levels to the base DRG for Revision of Hip or Knee Replacement (currently DRG 545). The new MS-DRGs are as follows:

Proposed MS-DRG 466 (Revision of Hip or Knee Replacement with MCC)

Proposed MS-DRG 467 (Revision of Hip or Knee Replacement with CC)

Proposed MS-DRG 468 (Revision of Hip or Knee Replacement without CC)

Proposed MS-DRG 483 (Major Joint Replacement or Reattachment of Lower Extremity with CC/MCC)

Proposed MS-DRG 484 (Major Joint Replacement or Reattachment of Lower Extremity without CC/MCC)

We found that the proposed MS-DRGs greatly improved our ability to identify joint procedures with higher resource costs. The following table indicates the average charges for each new proposed MS-DRG for the joint procedures.

Proposed MS-DRGs That Replace DRGs 544 and 535 With New Severity Levels

Number of Average length Average Proposed MS-DRG

cases

of stay

charges

MS-DRG 466......................................................

390,344

4.03 $33,465.85 MS-DRG 467......................................................

28,211

8.46 53,676.09 MS-DRG 468......................................................

26,718

4.06 38,720.28 MS-DRG 483......................................................

10,078

6.06 48,575.01 MS-DRG 484......................................................

3,886

9.55 69,649.08

[[Page 24731]]

AAHKS analyzed Medicare data under the current DRG system and was unaware of how its analysis would change under the proposed MS-DRGs. Under the current DRGs, the AAHKS recommendation would replace 2 DRGs with 4 new ones. However, under the proposed MS-DRGs, the AAHKS recommendation would result in 5 DRGs becoming 12. Because AAHKS is recommending four new joint replacement DRGs (two for knees and two for hips), each would need to be subdivided into severity levels under our proposed MS-DRG system. Therefore, the four new joint DRGs could be subdivided into three levels each, leading to 12 new DRGs. At this time, we believe that the changes we are proposing to make to adopt the proposed MS-DRGs are sufficiently better for recognizing severity of illness among the hip and knee replacement cases. We do not believe that there would be significant improvements in the proposed MS-DRGs recognition of severity of illness from creating an additional 7 DRGs. However, we acknowledge the valuable assistance the AAHKS has provided to CMS in creating the new joint replacement procedure codes and modifying the joint replacement DRGs beginning in FY 2006. These efforts greatly improved our ability to categorize significantly different groups of patients according to severity of illness. We welcome comments from AAHKS on whether the proposed MS-DRGs recognize patient complexity and severity of illness in the hip and knee replacement DRGs consistent with the concerns it expressed to us in previous comments. We also welcome public comments from others as well on whether the proposed changes to the hip and knee replacement DRGs better recognize severity of illness and complexity of these operations in the Medicare patient population. b. Spinal Fusions

(If you choose to comment on issues in this section, please include the caption ``DRGs: Spinal Procedures'' at the beginning of your comment.)

In the FY 2007 final rule (71 FR 47947), we discussed a request that urged CMS to consider applying a severity concept to all of the back and spine surgical cases, similar to the approach that was used in the FY 2006 final rule in refining the cardiac DRGs with an MCV. Specifically, the commenter recommended that the use of spinal devices be uniquely identified within the spine DRGs. The commenter's suggestion involved the development of 10 new spine DRGs as well as additional modifications. One of these modifications included revising DRG 546 (Spinal Fusions Except Cervical with Curvature of the Spine or Malignancy). The commenter stated DRG 546 did not adequately recognize clinical severity or the resource differences among spinal fusion patients whose surgeries include fusing multiple levels of their spinal vertebrae.

We agreed with the commenter that it was important to recognize severity when classifying groups of patients into specific DRGs. In addition, in response to recommendations from MedPAC's March 2005 Report to Congress, we stated that we were conducting a comprehensive analysis of the entire DRG system to determine if we could better identify severity of illness. We further stated that until results from our analysis were available, it would be premature to implement a severity concept for the spine DRGs. Therefore, we did not make any adjustments to those DRGs at that time.

Under the proposed MS-DRGs described in section II.D. of the preamble of this proposed rule, we are proposing a number of refinements that would better recognize severity for FY 2008. The proposed MS-DRGs include several refinements to the spine DRGs. These refinements are described in detail below.

In the FY 2006 IPPS final rule, we noted that there are numerous innovations occurring in spinal surgery such as artificial spinal disc prostheses, kyphoplasty, vertebroplasty and the use of spine decompression devices. As part of our analysis of the DRG system for this proposed rule, we did a comprehensive review of the DRGs for spinal fusion and other back and neck procedures to determine whether additional refinements beyond the proposed MS-DRGs were necessary. We studied data from the FY 2006 MedPAR file for the entire group of spine DRGs. This group included DRG 496 (Combined Anterior/Posterior Spinal Fusion), DRGs 497 and 498 (Spinal Fusion Except Cervical With and Without CC, respectively), DRGs 499 and 500 (Back and Neck Procedures Except Spinal Fusion With and Without CC, respectively), DRGs 519 and 520 (Cervical Spinal Fusion With and Without CC, respectively), and DRG 546 (Spinal Fusion Except Cervical with Curvature of the Spine or Malignancy).

As indicated earlier, we are proposing a two or three-way split for each of these spine DRGs to better recognize severity of illness, complexity of service, and resource utilization. In addition, we examined the procedure codes that identify multiple fusion or refusion of the vertebrae (codes 81.62 through 81.64) to determine if the data supported further refinement when a greater number of vertebrae are fused.

In applying the proposed MS-DRG logic, CMS DRG 497 and 498 were collapsed and the result is a split with two severity levels: proposed MS-DRG 459 (Spinal Fusion Except Cervical With MCC) and proposed MS-DRG 460 (Spinal Fusion Except Cervical Without MCC). There were a total of 51,667 cases in proposed MS-DRGs 459 and 460. We identified 288 cases where nine or more noncervical vertebrae were fused (code 81.64) that currently are assigned to proposed MS-DRGs 459 and 460. The average charges and length of stay for cases in these MS-DRGs are closer to the average charges and length of stay for cases in proposed MS-DRGs 456 through 458 (Spinal Fusion Except Cervical With Curvature of the Spine or Malignancy With MCC, With CC, and Without CC, respectively). For example, in proposed MS-DRG 460, there were 238 cases with an average length of stay of 6.20 days and average charges of $110,908 when nine or more noncervical vertebrae are fused. There are an additional 50 cases where nine or more vertebrae were fused in proposed MS-DRG 459 with average charges of $171,839. Without any further modification to the proposed MS-DRGs, these cases would be assigned to proposed MS-DRGs 459 and 460 that have average charges of $59,698, and $99,298, respectively. The average charges for these cases are more comparable to $142,871, $95,489, and $77,528, respectively, for proposed MS-DRGs 456 through 458. We believe these data support assigning cases where nine or more noncervical vertebrae are fused from proposed MS-DRG 459 and 460 into proposed MS-DRG 456 through 458. The table below represents our findings.

Average Proposed MS-DRG

Number of length of Average cases

stay charges

MS-DRG 459 (Spinal Fusion Except

3,186

10.10 $99,298 Cervical With MCC)--All Cases...

[[Page 24732]]

MS-DRG 459 (Spinal Fusion Except

13.00 171.839 Cervical With MCC)--Cases with Procedure Code 81.64 (Fusion or refusion of 9 or more vertebrae) MS-DRG 460 (Spinal Fusion Except

48,481

4.36 59,698 Cervical Without MCC)--All Cases MS-DRG 460 (Spinal Fusion Except

238

6.20 110,908 Cervical Without MCC)--Cases with Procedure Code 81.64 (Fusion or refusion of 9 or more vertebrae)...................... MS-DRG 456 (Spinal Fusion Except

548

14.79 142,871 Cervical With Curvature of the Spine or Malignancy With MCC)-- All Cases....................... MS-DRG 456 (Spinal Fusion Except

13.34 170,655 Cervical With Curvature of the Spine or Malignancy With MCC)-- Cases With Procedure Code 81.64 (Fusion or refusion of 9 or more vertebrae)...................... MS-DRG 457 (Spinal Fusion Except

1,500

8.14 95,489 Cervical With Curvature of the Spine or Malignancy With CC)-- All Cases....................... MS-DRG 457 (Spinal Fusion Except

146

8.88 125,722 Cervical With Curvature of the Spine or Malignancy With CC)-- Cases With Procedure Code 81.64 (Fusion or refusion of 9 or more vertebrae)...................... MS-DRG 458 (Spinal Fusion Except

1,340

4.58 77,528 Cervical With Curvature of the Spine or Malignancy Without CC-- All Cases....................... MS-DRG 458 (Spinal Fusion Except

6.21 123,823 Cervical With Curvature of the Spine or Malignancy Without CC)-- Cases With Procedure Code 81.64 (Fusion or refusion of 9 or more vertebrae)......................

Therefore, we are proposing to move those cases that include fusing or refusing nine or more vertebrae from proposed MS-DRGs 459 and 460 into proposed MS-DRGs 456 through 458. This proposed modification would include revising the MS-DRG title to reflect the fusion of nine or more vertebrae. The revised titles for proposed MS-DRGs 456 through 458 would be as follows:

Proposed MS-DRG 456 (Spinal Fusion Except Cervical with Spinal Curvature or Malignancy or 9+ Fusions With MCC)

Proposed MS-DRG 457 (Spinal Fusion Except Cervical with Spinal Curvature or Malignancy or 9+ Fusions With CC)

Proposed MS-DRG 458 (Spinal Fusion Except Cervical with Spinal Curvature or Malignancy or 9+ Fusions Without CC/MCC)

We invite public comment on this topic as well as on the additional changes we are proposing to the spine MS-DRGs discussed below.

Further analysis demonstrates that spinal fusion cases with a principal diagnosis of tuberculosis or osteomyelitis also have higher average charges than other cases in CMS DRG 497 (proposed MS-DRGs 459 and 460) that are more similar to the cases assigned to CMS DRG 546 (proposed MS-DRGs 456 through 458). Although the volume of cases is relatively low, the data show very high average charges for these patients. The following tables display our results:

Average Proposed MS-DRG

Number of length of Average cases

stay charges

MS-DRG 459 (Spinal Fusion Except

3,186

10.10 $99,298 Cervical With MCC).............. MS-DRG 460 (Spinal Fusion Except

48,481

4.36 59,698 Cervical Without MCC)...........

Average Proposed MS-DRG

Number of length of Average cases

stay charges

MS-DRG 456 (Spinal Fusion Except

548

14.79 $142,870 Cervical with Spinal Curvature or Malignancy or 9+ Fusions With MCC)............................ MS-DRG 457 (Spinal Fusion Except

1,500

8.14 95,489 Cervical with Spinal Curvature or Malignancy or 9+ Fusions With CC)............................. MS-DRG 458 (Spinal Fusion Except

1,340

4.58 77,528 Cervical With Spinal Curvature or Malignancy or 9+ Fusions Without CC/MCC).................

Tuberculosis and Osteomyelitis

Average Principal diagnosis

Number of length of Average cases

stay charges

Codes 015.02, 015.04, 015.05,

194

24.8 $128,073 730.08, 730.18 and 730.28.......

For this reason, we are proposing to add the following diagnoses to the principal diagnosis list for proposed MS-DRGs 456 through 458:

015.02, Tuberculosis of bones and joints, vertebral column, bacteriological or histological examination unknown (at present)

015.04, Tuberculosis of bones and joints, vertebral column, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture

015.05, Tuberculosis of bones and joints, vertebral column, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically

730.08, Acute osteomyelitis of other specified sites

[[Page 24733]]

730.18, Chronic osteomyelitis of other specified sites

730.28, Unspecified osteomyelitis of other specified sites

For the complete list of principal diagnosis codes that lead to assignment of CMS DRG 546 (proposed MS-DRGs 496 through 498), we refer readers to section II.D.4.b. of the preamble of the FY 2007 IPPS final rule (71 FR 47947). c. Spinal Disc Devices

Over the past several years, manufacturers of spinal disc devices have requested reassignment of DRGs for their products and applied for new technology add-on payments. CHARITETMis one of these devices. CHARITETMis a prosthetic intervertebral disc. On October 26, 2004, the FDA approved the CHARITETMArtificial Disc for single level spinal arthroplasty in skeletally mature patients with degenerative disc disease between L4 and S1. On October 1, 2004, we created new procedure codes for the insertion of spinal disc prostheses (codes 84.60 through 84.69). We provided the CMS DRG assignments for these new codes in Table 6B of the FY 2005 IPPS proposed rule (69 FR 28673). We received comments on the FY 2005 proposed rule recommending that we change the assignments for these codes from CMS DRG 499 (Back and Neck Procedures Except Spinal Fusion With CC) and CMS DRG 500 (Back and Neck Procedures Except Spinal Fusion Without CC) to the CMS DRGs for spinal fusion, CMS DRG 497 (Spinal Fusion Except Cervical With CC) and CMS DRG 498 (Spinal Fusion Except Cervical Without CC) for procedures on the lumbar spine and to CMS DRGs 519 and 520 for procedures on the cervical spine. In the FY 2005 IPPS final rule (69 FR 48938), we indicated that CMS DRGs 497 and 498 are limited to spinal fusion procedures. Because the surgery involving the CHARITETMArtificial Disc is not a spinal fusion, we decided not to include this procedure in these CMS DRGs. However, we stated that we would continue to analyze this issue and solicited further public comments on the DRG assignment for spinal disc prostheses.

In the FY 2006 final rule (70 FR 47353), we noted that, if a product meets all of the criteria for Medicare to pay for the product as a new technology under section 1886(d)(5)(K) of the Act, there is a clear preference expressed in the statute for us to assign the technology to a DRG based on similar clinical or anatomical characteristics or costs. However, for FY 2006, we did not find that the CHARITETMArtificial Disc met the substantial clinical improvement criterion and, thus, did not qualify as a new technology. Consequently, we did not address the DRG classification request made under the authority of this provision of the Act.

We did evaluate whether to reassign the CHARITETM Artificial Disc to different CMS DRGs using the Secretary's authority under section 1886(d)(4) of the Act (70 FR 47308). We indicated that we did not have Medicare charge information to evaluate CMS DRG changes for cases involving an implant of a prosthetic intervertebral disc like the CHARITETMand did not make a change in its CMS DRG assignments. We stated that we would consider whether changes to the CMS DRG assignments for the CHARITETMArtificial Disc were warranted for FY 2007, once we had information from Medicare's data system that would assist us in evaluating the costs of these patients.

As we discussed in the FY 2007 IPPS proposed rule (71 FR 24036), we received correspondence regarding the CMS DRG assignments for the CHARITETMArtificial Disc, code 84.65 (Insertion of total spinal disc prosthesis, lumbosacral). The commenter had previously submitted an application for the CHARITETMArtificial Disc for new technology add-on payments for FY 2006 and had requested a reassignment of cases involving CHARITETMimplantation to CMS DRGs 497 and 498. The commenter asked that we examine claims data for FY 2005 and reassign procedure code 84.65 from CMS DRGs 499 and 500 into CMS DRGs 497 and 498. The commenter again stated the view that cases with the CHARITETMArtificial Disc reflect comparable resource use and similar clinical indications as do those in CMS DRGs 497 and 498. If CMS were to reject reassignment of the CHARITETMArtificial Disc to CMS DRGs 497 and 498, the commenter suggested creating two separate DRGs for lumbar disc replacements.

On February 15, 2006, we posted a proposed national coverage determination (NCD) on the CMS Web site seeking public comment on our proposed finding that the evidence is not adequate to conclude that lumbar artificial disc replacement with the CHARITETM Artificial Disc is reasonable and necessary. The proposed NCD stated that lumbar artificial disc replacement with the CHARITETM Artificial Disc is generally not indicated in patients over 60 years old. Further, it stated that there is insufficient evidence among either the aged or disabled Medicare population to make a reasonable and necessary determination for coverage. With an NCD pending to make spinal arthroplasty with the CHARITETMArtificial Disc noncovered, we indicated in the FY 2007 IPPS proposed rule that we did not believe it was appropriate at that time to reassign procedure code 84.65 from CMS DRGs 499 and 500 to CMS DRGs 497 and 498.

After considering the public comments and additional evidence received, we made a final NCD on May 16, 2006, that Medicare would not cover the CHARITETMArtificial Disc for the Medicare population over 60 years of age. For Medicare beneficiaries 60 years of age and under, local Medicare contractors have the discretion to determine coverage for lumbar artificial disc replacement procedures involving the CHARITETMArtificial Disc. The final NCD can be found on the CMS Web site at: http://www.cms.hhs.gov/mcd/viewncd.asp:ncd-id 150.10&ncd--

version1&basket=ncd%3A150%2E10%3A1%3ALumbar+Artificial+Disc+Replacement% 280ADR%29.

We agreed with a commenter on the FY 2007 IPPS proposed rule that it was not appropriate to consider a DRG revision at that time for the CHARITETMArtificial Disc, given the recent decision to limit coverage for surgical procedures involving this device. Although we had reviewed the Medicare charge data, we were concerned that there were a very small number of cases for patients under 60 years of age who had received the CHARITETMArtificial Disc. We believed it appropriate to base the decision of a DRG change on charge data only on the population for which the procedure is covered. We had an extremely small number of cases for Medicare beneficiaries under 60 on which to base such a decision. For this reason, we did not believe it was appropriate to modify the CMS DRGs in FY 2007 for CHARITETMcases.

For FY 2008, we collapsed CMS DRGs 499 and 500 (Back and Neck Procedures Except Spinal Fusion With and Without CC, respectively) and identified a total of 74,989 cases. Under the proposed MS-DRGs, the result of the analysis of the data supports that these CMS DRGs split into two severity levels: proposed MS-DRG 490 (Back and Neck Procedures Except Spinal Fusion with CC or MCC) and proposed MS-DRG 491 (Back and Neck Procedures Except Spinal Fusion Without CC or MCC). We found a total of 53 cases that used the CHARITETMArtificial Disc. Without any further modification to the proposed MS-DRGs, average charges are $26,481 for 6 cases with a CC or MCC and $37,324 for 47 CHARITETMcases

[[Page 24734]]

without a CC or MCC. (We find it counterintuitive that average charges for cases in the higher severity level are lower but checked our data and found it to be correct).

We also analyzed data for other spinal disc devices. Average charges for the X Stop Interspinous Process Decompression Device (code 84.58) are $31,400 for cases with a CC or MCC and $28,821 for cases without a CC or MCC. Average charges for other specified spinal devices described by code 84.59 (Coflex, Dynesys, M-Brace) are $34,002 for 18 cases with a CC or MCC and $33,873 for 65 cases without a CC or MCC. We compared these average charges to data in the proposed spinal fusion MS-DRGs 453 (Combined Anterior/Posterior Spinal Fusion With MCC), 454 (Combined Anterior/Posterior Spinal Fusion With CC), 455 (Combined Anterior/Posterior Spinal Fusion Without CC/MCC), 459 (Spinal Fusion Except Cervical With MCC), and 460 (Spinal Fusion Except Cervical Without MCC). These cases have lower average charges than the spinal fusion MS-DRGs. The following tables display the results:

Average Proposed MS-DRGs 490 and 491 Number of length of Average cases

stay charges

MS-DRG 490--All Cases............ 17,493

5.13 $29,656 MS-DRG 490--Cases with Procedure

3.33 26,481 Code 84.65 (CHARITETM).......... MS-DRG 491--All Cases............ 57,496

2.27 17,789 MS-DRG 491--Cases with Procedure

2.43 37,324 Code 84.65 (CHARITETM).......... MS-DRG 491--Cases without

57,449

2.27 17,773 Procedure Code 84.65 (CHARITETM)

Average Proposed MS-DRGs 490 and 491 Number of length of Average cases

stay charges

MS-DRG 490--All Cases............ 17,493

5.13 $29,656 MS-DRG 490--Cases with Procedure

179

2.65 31,400 Code 84.58 (X Stop)............. MS-DRG 490--Cases without

17,314

5.15 29,638 Procedure Code 84.58 (X Stop)... MS-DRG 491--All Cases............ 57,496

2.27 17,789 MS-DRG 491--Cases with Procedure

1,174

1.34 28,821 Code 84.58 (X Stop)............. MS-DRG 491--Cases without

56,322

2.29 17,559 Procedure Code 84.58 (X-Stop)...

Average Proposed MS-DRGs 490 and 491 Number of length of Average cases

stay charges

MS-DRG 490--All Cases............ 17,493

5.13 $29,656 MS-DRG 490--Cases with Procedure

5.56 34,002 Code 84.59 (Coflex/Dynesys/M- Brace).......................... MS-DRG 490--Cases without

17,475

5.13 29,651 Procedure Code 84.59 (Coflex/ Dynesys/M-Brace)................ MS-DRG 491--All Cases............ 57,496

2.27 17,789 MS-DRG 491--Cases with Procedure

2.35 33,873 Code 84.59 (Coflex/Dynesys/M- Brace).......................... MS-DRG 491--Cases without

57,431

2.27 17,770 Procedure Code 84.59 (Coflex/ Dynesys/M-Brace)................

Average Proposed MS-DRGs 453, 454, 455, Number of length of Average 459 and 460

cases

stay charges

MS-DRG 453--Combined Anterior/

792

15.84 $180,658 Posterior Spinal Fusion With MCC MS-DRG 454--Combined Anterior/

1,411

8.69 116,402 Posterior Spinal Fusion With CC. MS-DRG 455--Combined Anterior/

1,794

4.84 85,927 Posterior Spinal Fusion Without CC/MCC.......................... MS-DRG 459--Spinal Fusion Except

3,186

10.10 99,298 Cervical with MCC............... MS-DRG 460--Spinal Fusion Except

48,481

4.36 59,698 Cervical Without MCC............

The data demonstrate that the average charges for CHARITETMand the other devices are higher than other cases in proposed MS-DRGs 490 and 491 but lower than proposed MS-DRGs 453 through 55 and 459 and 460. For this reason, we do not believe that any of the cases that use these spine devices should be assigned to the spinal fusion MS-DRGs. However, we do believe that the average charges for cases using these spine devices are more similar to the higher severity level in MS-DRG 490.

As such, we are proposing to move cases with procedure codes 84.58, 84.59, and 84.65 into proposed MS-DRG 490 and revise the title to reflect disc devices. The proposed modified MS-DRG title would be: MS- DRG 490 (Back and Neck Procedures Except Spinal Fusion with CC or MCC or Disc Devices).

We believe these proposed changes to the spine DRGs are appropriate to recognize the similar utilization of resources, differences in levels of severity, and complexity of the services performed for various types of spinal procedures described above. We encourage commenters to provide input on this approach to better recognize the types of patients these procedures are being performed upon and their outcomes. d. Other Spinal DRGs

We did not identify any data to support moving cases in or out of CMS DRGs 496 (Combined Anterior/Posterior Spinal Fusion), 519 (Cervical Spinal Fusion With CC), or 520 (Cervical Spinal Fusion Without CC)). Under the proposed MS-DRG system, CMS DRG 496 would be split into three severity levels: proposed MS-DRG 453 (Combined Anterior/Posterior Spinal Fusion With MCC), proposed MS-DRG 454 (Combined Anterior/ Posterior Spinal Fusion With CC), and proposed MS-DRG 455 (Combined Anterior/Posterior Spinal Fusion Without CC).

[[Page 24735]]

CMS DRG 519 would also be split into three severity levels: proposed MS-DRG 471 (Cervical Fusion With MCC), proposed MS-DRG 472 (Cervical Fusion With CC), and proposed MS-DRG 473 (Cervical Fusion Without CC). We are not proposing changes to these DRGs at this time. 5. MDC 17 (Myeloproliferative Diseases and Disorders, Poorly Differentiated Neoplasm): Endoscopic Procedures

(If you choose to comment on issues in this section, please include the caption ``DRGs: Endoscopy'' at the beginning of your comment.)

We received a request from a manufacturer to review the DRG assignment of codes 33.71 (Endoscopic insertion or replacement of bronchial valve(s)), 33.78 (Endoscopic removal of bronchial device(s) or substances), and 33.79 (Endoscopic insertion of other bronchial device or substances) with the intent of moving these three codes out of CMS DRG 412 (History of Malignancy With Endoscopy) (proposed MS-DRGs 843, 844, and 845). The requestor has noted that CMS DRG 412 is titled to be a DRG for cases with a history of malignancy, and none of the three codes (33.71, 33.78, or 33.79) necessarily involve treatment for malignancies. In addition, the requestor believed the integrity of the DRG is compromised because the other endoscopy codes assigned to CMS DRG 412 are all diagnostic in nature, while codes 33.71, 33.78, and 33.79 represent therapeutic procedures.

The requestor also stated that while the diagnostic endoscopies in CMS DRG 412 do not have significant costs for equipment or pharmaceutical agents beyond the basic endoscopy, the therapeutic procedures described by codes 33.71, 33.78, and 33.79 involve substantial costs for devices or substances in relation to the cost of the endoscopic procedure itself. The requestor was concerned that, if these three codes continue to be assigned to CMS DRG 412, payment will be so inadequate as to constitute a substantial barrier to Medicare beneficiaries for these treatments.

ICD-9-CM procedure codes 33.71, 33.78, and 33.79 were all created for use beginning October 1, 2006. As these codes have been in use only for a few months, we have no data to make a different DRG assignment. We assigned these codes based on the advice of our medical officers to a DRG that includes similar clinical procedures.

On the matter of codes 33.71, 33.78, and 33.79 being therapeutic in nature while all other endoscopies assigned to CMS DRG 412 are diagnostic, we disagree with the commenter. CMS DRG 412 includes procedure codes for therapeutic endoscopic destruction of lesions of the bronchus, lung, stomach, anus, and duodenum, as well as codes for polypectomy of the intestine and rectum. In addition, we note that there are codes for insertion of therapeutic devices currently located in this DRG.

We believe it would be premature to assign these codes to another DRG without any supporting data. We will reconsider our decision for these codes if we have data suggesting that a DRG reassignment is warranted. Therefore, aside from the proposed changes to the MS-DRGs, we are not proposing to change the current DRG assignment for codes 33.71, 33.78, and 33.79 at this time. 6. Medicare Code Editor (MCE) Changes

(If you choose to comment on issues in this section, please include the caption ``Medicare Code Editor'' at the beginning of your comment.)

As explained under section II.B.1. of this preamble, the Medicare Code Editor (MCE) is a software program that detects and reports errors in the coding of Medicare claims data. Patient diagnoses, procedure(s), discharge status, and demographic information go into the Medicare claims processing systems and are subjected to a series of automated screens. The MCE screens are designed to identify cases that require further review before classification into a DRG.

For FY 2008, we are proposing to make the following changes to the MCE edits. a. Non-Covered Procedure Edit: Code 00.62 (Percutaneous angioplasty or atherectomy of intracranial vessel(s))

As discussed in II.G.2. of the preamble of this proposed rule, under MDC 1, code 00.62 is a covered service when performed in conjunction with code 00.65 (Percutaneous insertion of intracranial vascular stent(s)). Effective November 6, 2006, Medicare covers PTA and stenting of intracranial arteries for the treatment of cerebral artery stenosis in cases in which stenosis is 50 percent or greater in patients with intracranial atherosclerotic disease when furnished in accordance with the FDA-approved protocols governing Category B Investigational Device Exemption (IDE) clinical trials. CMS determines that coverage of intracranial PTA and stenting is reasonable and necessary under these circumstances. Therefore, we are proposing to make a conforming change and to add the following language to this edit: Procedure code 00.62 (PTA of intracranial vessel(s)) is identified as a noncovered procedure except when it is accompanied by procedure code 00.65 (Intracranial stent). b. Non-Specific Principal Diagnosis Edit 7 and Non-Specific O.R. Procedures Edit 10

When MCE Non-Specific Principal Diagnosis Edit 7 and Non-Specific O.R. Procedures Edit 10 were created at the beginning of the IPPS, it was with the intent that they were to encourage hospitals to code as specifically as possible. While the codes on both edits are valid according to the ICD-9-CM coding scheme, more precise codes are preferable to give a more complete understanding of the services provided on the Medicare claims. When the MCE was created, we had intended that these specific edits would allow educational contact between the provider and the contractor. It was never the intention that these edits would be used to deny/reject or return-to-provider claims submitted with non-specific codes. However, we found these two edits to be misunderstood, and found that claims were erroneously being denied, rejected, or returned. On November 11, 2006, CMS issued a Joint Signature Memorandum which instructed all fiscal intermediaries and all Part A and Part B Medicare Administrative Contractors (A/B MACs) to deactivate the Fiscal Intermediary Shared System Edits W1436 through W1439 and W1489 through W1491 which edited for Non-Specific Diagnoses and the Non-Specific Procedures.

Therefore, we are proposing to make a conforming change to the MCE by removing the following codes from Edit 7:

00320

1109

1543 01590

1129

1579 01591

1149

1589 01592

1279

1590 01593

129

1609 01594

1309

1619 01596

13100

1629 0369

1319

1639 0399

1329

1649 0528

1369

1709 05310

1370

1719 0538

1371

1729 05440

1372

1739 0548

1373

1749 0558

1374

1769 05600

138

179 0568

1390

1809 06640

1391

1839 07070

1398

1874 07071

1409

1879 0728

1419

1889 0738

1429

1899 07420

1439

1909 08240

1449

1929 0979

1469

1949 09810

1479

1969 09830

1509

1991

[[Page 24736]]

09950

1519

20490 0999

1529

20491 1009

1539

20590 20591

2779

36910 20690

2793

36911 20691

2799 20890

28730

36912 20891

28800

36913 2129

28850

36914 2139

28860

36915 2149

28950

36916 2159

3239

36917 2169

3249

36918 2189

326

36920 2199

32700

36921 2229

32710

36922 2239

32720

36923 2249

32730

36924 2259

32740

36925 2279

3309

3693 22800

3319

3694 2299

3349

36960 2306

3359

36961 2319

34120

36962 2329

3419

36963 2349

3439

36964 23690

3449

36965 23770

34690

36966 23875

34691

36967 2390

3489

36968 2391

3499

36969 2392

3509

36970 2393

3519

36971 2394

3529

36972 2396

3539

36973 2397

3569

36974 2398

3579

36975 2399

3589

36976 2469

3599

3698 2519

3609

3699 25200

3619

3709 2529

3629

3719 2539

3639

3729 2549

3649

3739 25510

3659

3749 2569

3669

3759 2579

3679

3769 2589

3689

3779 2681

36900

3789 2709

36901

37960 2719

36902

3809 2729

36903

3819 2739

36904

3829 27540

36905

3839 2759

36906

3849 27650

36907

3859 27730

36908

3879 38800

52140

6089 38810

5219

6109 38830

52320

6169 38840

52330

6170 38860

52340

61800 38870

5239

6184 3889

52400

6189 38900

52420

6199 38910

52430

6209 3897

52450

62130 3899

52460

6219 41090

52470

62210 41091

5249

6229 41092

52520

6239 412

52540

6249 4149

52550

6269 4179

52560

6279 42650

5259

62920 4275

5269

63390 4279

5279

63391 42820

52800

64090 42830

5299

64091 42840

5309

64093 4289

53640

64100 4299

5379

64110 4329

5539

64120 43390

56400

64130 43490

5649

64180 4379

5679

64190 4389

5689

64191 4419

56960

64193 4429

5699

64200 4449

5739

64210 44620

57510

64220 4479

5759

64230 4519

5769

64240 45340

5779

64250 4539

5799

64260 4579

5859

64270 4599

5889

64290 4619

5890

64300 46450

5891

64310 46451

5899

64320 4749

5909

64380 4919

5959

64390 5169

5969

64400 51900

5989

64410 5199

59960

64420 5209

5999

64600 52100

60090

64610 60091

64620 52110

6019

64630 52120

6029

64640 52130

60820

64650 64660

65290

65820 64670

65291

65830 64680

65293

65840 64690

65300

65880 64700

65310

65890 64710

65320

65891 64720

65330

65893 64730

65340

65900 64740

65350

65910 64750

65360

65920 64760

65370

65930 64780

65380

65940 64790

65390

65950 64791

65391

65960 64792

65393

65980 64793

65400

65990 64794

65410

65991 64800

65420

65993 64810

65430

66000 64820

65440

66010 64830

65450

66020 64840

65460

66030 64850

65470

66040 64860

65480

66050 64870

65490

66060 64880

65491

66070 64890

65492

66080 64900

65493

66090 64910

65494

66100 64920

65500

66110 64930

65510

66120 64940

65520

66130 64950

65530

66140 64960

65540

66190 65100

65550

66191 65110

65560

66193 65120

65570

66200 65130

65580

66210 65140

65590

66220 65150

65591

66230 65160

65593

66300 65180

65600

66310 65190

65610

66320 65191

65620

66330 65193

65630

66340 65200

65640

66350 65210

65650

66360 65220

65660

66380 65230

65670

66390 65240

65680

66391 65250

65690

66393 65260

65700

66400 65270

65800

66410 65280

65810

66420 66430

67110

7059 66440

67120

7069 66441

67130

70700 66444

67140

70710 66450

67150

7079 66480

67180

7149 66490

67190

71590 66491

67191

7179 66494

67192

71849 66500

67193

71850 66510

67194

71870 66520

67200

72230 66530

67300

72270 66540

67310

72280 66550

67320

72290 66560

67330

7239 66570

67380

7244 66580

67400

7289 66590

67410

73000 66591

67420

73010 66592

67430

73020 66593

67440

73030 66594

67450

73090 66600

67480

73091 66610

67490

73092 66620

67492

73093 66630

67494

73094 66700

67500

73095 66710

67510

73096 66800

67520

73097 66810

67580

73098 66820

67590

73099 66880

67600

73310 66890

67610

73340 66891

67620

73390 66892

67630

7359 66893

67640

73600 66894

67650

73620 66900

67660

73630 66910

67680

73670 66920

67690

7369 66930

67691

73810 66940

67692

7389 66950

67693

74100 66960

67694

74190 66970

677

7429 66980

6809

7439 66990

6819

7449 66991

6829

7459 66992

68600

7469 66993

6869

74760 66994

6949

7489 67000

7019

74900 67100

7049

74910 7509

7769

9009 7529

7789

9029 75310

7799

9039 75312

78031

9048 75320

78051

9049 7539

78052

9050 7559

78053

9051 75670

78054

9052 7579

78055

9053

[[Page 24737]]

7599

78057

9054 7600

78058

9055 7601

78079

9056 7602

7825

9057 7603

78261

9058 7604

78262

9059 7605

78340

9060 7606

78830

9061 76070

78900

9062 76072

78930

9063 76073

78940

9064 76074

78960

9065 76079

79009

9066 7608

7901

9067 7609

7904

9068 7610

7905

9069 7611

7906

9070 7612

79091

9071 7613

79092

9072 7614

79099

9073 7615

7929

9074 7616

79380

9075 7617

79500

9079 7618

7954

9080 7619

7964

9081 7629

7969

9082 7630

7993

9083 7631

79989

9084 7632

7999

9085 7633

8290

9086 7634

.......................

9089 7635

8291

9090 7636

8398

9091 7637

8399

9092 76383

8409

9093 7639

8419

9094 76520

8439

9095 7679

8469

9099 7689

8479

9219 77010

8489

9229 7709

8678

9239 77210

8679

9249 7729

86800

9269 7759

86810

9279 9289

94404

9659 9299

94405

9679 9349

94406

9699 9399

94407

9709 94100

94408

9739 94101

94500

9769 94102

94501

9779 94103

94502

9809 94104

94503

9849 94105

94504

9859 94106

94505

9889 94107

94506

9899 94108

94509

9929 94109

9460

9939 94200

9479

99520 94201

9490

99522 94202

9491

99523 94203

9492

99529 94204

9493

99550 94205

9494

99580 94209

9495

99590 94300

9519

99600 94301

9529

99630 94302

9539

99640 94303

9549

99660 94304

9559

99670 94305

9569

99680 94306

9579

99690 94309

95890

99700 94400

9599

99760 94401

9609

9989 94402

9639

...................... 94403

9649

......................

In addition, we are proposing to make a conforming change to the MCE by removing the following codes from Edit 10:

0650

3770

4400 0700

3800

4440 0763

3810

4500 0769

3830

4590 0780

3840

4610 2630

3850

4620 3500

3860

4640 3510

3880

4650 3520

4040

4660 3550

4050

4680 3560

4100

5300 3570

4210

5310 3610

4240

5640 3710

.......................

7550 7670

7880

8070 7700

7890

8080 7720

7910

8090 7760

7920

8100 7770

7930

8120 7780

7940

8130 7790

7950

8153 7800

7960

8155 7810

7980

8400 7820

7990

8440 7830

8000

8460 7840

8010

8469 7850

8020

8660 7870

8040

8670

c. Limited Coverage Edit 17

Edit 17 in the MCE contains ICD-9-CM procedure codes describing medically complex procedures, including lung volume reduction surgery, organ transplants, and implantable heart assist devices which are to be performed only in certain preapproved medical centers. CMS has established, through a regulation (CMS-3835-F: Medicare Conditions of Participation: Requirements for Approval and Reapproval of Transplant Centers to Perform Organ Transplants, published in the Federal Register on March 30, 2007 (72 FR 15198)), a survey and certification process for organ transplant programs. The organs covered in this regulation are heart, heart and lung combined, intestine, kidney, liver, lung, pancreas, and multivisceral. Historically, kidney transplants have been regulated under the End-Stage Renal Disease (ESRD) conditions for coverage. Other types of organ transplant facilities have been regulated under various NCDs.

The regulation becomes effective on June 28, 2007. Organ transplant programs will have 180 days from the June 28, 2007 effective date of the regulation to apply for participation in the Medicare program under the new survey and certification process. After these programs apply, we will survey and approve programs that meet the new Medicare conditions of participation. Until transplant facilities are surveyed and approved, kidney transplant facilities will continue to be regulated under the ESRD conditions for coverage, and other types of organ transplant facilities will continue to be regulated under the NCDs.

In this proposed rule, we are proposing to add conforming Medicare Part A payment edits to the MCE, consistent with the requirements of the organ transplant regulation (CMS-3835-F), to ensure that Medicare covers only those organ transplants performed in Medicare-approved facilities. We are proposing to add the following procedure codes to the existing list of limited coverage procedures under Edit 17:

55.69, Other kidney transplantation

52.80, Pancreatic transplant, not otherwise specified

52.82, Homotransplant of pancreas 7. Surgical Hierarchies

(If you choose to comment on issues in this section, please include the caption ``Surgical Hierarchies'' at the beginning of your comment.)

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. Therefore, it is necessary to have a decision rule within the GROUPER by which these cases are assigned to a single DRG. The surgical hierarchy, an ordering of surgical classes from most resource-intensive to least resource-intensive, performs that function. Application of this hierarchy ensures that cases involving multiple surgical procedures are assigned to the DRG associated with the most resource- intensive surgical class.

Because the relative resource intensity of surgical classes can shift as a function of DRG reclassification and recalibrations, we reviewed the surgical hierarchy of each MDC, as we have for previous reclassifications and recalibrations, to determine if the ordering of classes coincides with the intensity of resource utilization.

A surgical class can be composed of one or more DRGs. For example, in MDC 11, the surgical class ``kidney transplant'' consists of a single DRG (DRG 302) and the class ``kidney, ureter and major bladder procedures'' consists of three DRGs (DRGs 303, 304, and 305). 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 involves weighting the average resources for each

[[Page 24738]]

DRG by frequency to determine the weighted average resources for each surgical class. For example, assume surgical class A includes DRGs 1 and 2 and surgical class B includes DRGs 3, 4, and 5. Assume also that the average charge of DRG 1 is higher than that of DRG 3, but the average charges of DRGs 4 and 5 are higher than the average charge of DRG 2. To determine whether surgical class A should be higher or lower than surgical class B in the surgical hierarchy, we would weight the average charge of each DRG in the class 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 O.R. procedures'' as discussed below.

This methodology may occasionally result in assignment of a case involving multiple procedures to the lower-weighted DRG (in the highest, most resource-intensive surgical class) of the available alternatives. However, given that the logic underlying the surgical hierarchy provides that the GROUPER search for the procedure in the most resource-intensive surgical class, in cases involving multiple procedures, this result is sometimes unavoidable.

We note that, notwithstanding the foregoing discussion, there are a few instances when a surgical class with a lower average charge is ordered above a surgical class with a higher average charge. For example, the ``other O.R. procedures'' surgical class is uniformly ordered last in the surgical hierarchy of each MDC in which it occurs, regardless of the fact that the average charge for the DRG or DRGs in that surgical class may be higher than that for other surgical classes in the MDC. The ``other O.R. procedures'' class is a group of procedures that are only infrequently related to the diagnoses in the MDC, but are still occasionally performed on patients in the MDC with these diagnoses. Therefore, assignment to these surgical classes should only occur if no other surgical class more closely related to the diagnoses in the MDC is appropriate.

A second example occurs when the difference between the average charges for two surgical classes is very small. We have found that small differences generally do not warrant reordering of the hierarchy because, as a result of reassigning cases on the basis of the hierarchy change, the average charges are likely to shift such that the higher- ordered surgical class has a lower average charge than the class ordered below it.

For FY 2008, we are not proposing any revisions of the surgical hierarchy for any MDC. In general, the MS-DRGs that are being proposed for use in FY 2008 and discussed in section II.D. of the preamble of this proposed rule follow the same hierarchical order as the CMS DRGs they are to replace, except for DRGs that were deleted and consolidated. 8. CC Exclusion List Proposed for FY 2008

(If you choose to comment on issues in this section, please include the caption ``CC Exclusion List'' at the beginning of your comment.) a. Background

As indicated earlier in this preamble, under the IPPS DRG classification system, we have developed a standard list of diagnoses that are considered complications or comorbidities (CCs). Historically, we developed this list using physician panels that classified each diagnosis code based on whether the diagnosis, when present as a secondary condition, would be considered a substantial complication or comorbidity. A substantial complication or comorbidity was defined as a condition that, because of its presence with a specific principal diagnosis, would cause an increase in the length of stay by at least 1 day in at least 75 percent of the patients. We refer readers to section II.D.2. and 3. of the preamble of this proposed rule for a discussion of the refinement of CCs in relation to the MS-DRGs we are proposing to adopt for FY 2008. b. Proposed CC Exclusions List for FY 2008

In the September 1, 1987 final notice (52 FR 33143) concerning changes to the DRG classification system, we modified the GROUPER logic so that certain diagnoses included on the standard list of CCs would not be considered valid CCs in combination with a particular principal diagnosis. We created the CC Exclusions List for the following reasons: (1) To preclude coding of CCs for closely related conditions; (2) to preclude duplicative or inconsistent coding from being treated as CCs; and (3) to ensure that cases are appropriately classified between the complicated and uncomplicated DRGs in a pair. As we indicated above, we developed a list of diagnoses, 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 list of CCs, either by adding new CCs or deleting CCs already on the list.

In the May 19, 1987 proposed notice (52 FR 18877) and the September 1, 1987 final notice (52 FR 33154), 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.

Specific and nonspecific (that is, not otherwise specified (NOS)) diagnosis codes for the same condition should not be considered CCs for one another.

Codes for the same condition that cannot coexist, such as partial/total, unilateral/bilateral, obstructed/unobstructed, and benign/malignant, should not be considered CCs for one another.

Codes for 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. 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.\14\

\14\ See the FY 1989 final rule (53 FR 38485, September 30, 1988), for the revision made for the discharges occurring in FY 1989; the FY 1990 final rule (54 FR 36552, September 1, 1989), for the FY 1990 revision; the FY 1991 final rule (55 FR 36126, September 4, 1990), for the FY 1991 revision; the FY 1992 final rule (56 FR 43209, August 30, 1991) for the FY 1992 revision; the FY 1993 final rule (57 FR 39753), September 1, 1992), for the FY 1993 revision; the FY 1994 final rule (58 FR 46278, September 1, 1993), for the FY 1994 revisions; the FY 1995 final rule (59 FR 45334, September 1, 1994), for the FY 1995 revisions; the FY 1996 final rule (60 FR 45782, September 1, 1995), for the FY 1996 revisions; the FY 1997 final rule (61 FR 46171, August 30, 1996), for the FY 1997 revisions; the FY 1998 final rule (62 FR 45966, August 29, 1997) for the FY 1998 revisions; the FY 1999 final rule (63 FR 40954, July 31, 1998), for the FY 1999 revisions; the FY 2001 final rule (65 FR 47064, August 1, 2000), for the FY 2001 revisions; the FY 2002 final rule (66 FR 39851, August 1, 2001), for the FY 2002 revisions; the FY 2003 final rule (67 FR 49998, August 1, 2002), for the FY 2003 revisions; the FY 2004 final rule (68 FR 45364, August 1, 2003), for the FY 2004 revisions; the FY 2005 final rule (69 FR 49848, August 11, 2004), for the FY 2005 revisions; the FY 2006 final rule (70 FR 47640, August 12, 2005), for the FY 2006 revisions; and the FY 2007 final rule (71 FR 47870) for the FY 2007 revisions. In the FY 2000 final rule (64 FR 41490, July 30, 1999), we did not modify the CC Exclusions List because we did not make any changes to the ICD-9-CM codes for FY 2000.

For FY 2008, we are proposing to make limited revisions to the CC Exclusions List to take into account the changes that will be made in the ICD-

[[Page 24739]]

9-CM diagnosis coding system effective October 1, 2007. (See section II.G.10. of this preamble for a discussion of ICD-9-CM changes.) We are proposing to make these changes in accordance with the principles established when we created the CC Exclusions List in 1987. In addition, as discussed in section II.D.3. of the preamble of this proposed rule, we are proposing to indicate on the CC Exclusion List some updates to reflect the proposed exclusion of a few codes from being an MCC under the MS-DRG system that we are proposing to adopt for FY 2008.

Table 6I (which is available through the Internet on the CMS Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS) contains the

complete CC Exclusions List that will be effective for discharges occurring on or after October 1, 2007. Table 6I shows the principal diagnoses for which there is a CC exclusion. Each of these principal diagnoses is shown with an asterisk, and the conditions that will not count as a CC, are provided in an indented column immediately following the affected principal diagnosis. Tables 6G and 6H, Additions to and Deletions from the CC Exclusion List, respectively, are also available through the Internet on the CMS Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS. )

Beginning with discharges on or after October 1, 2007, the indented diagnoses will not be recognized by the GROUPER as valid CCs for the asterisked principal diagnosis.

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 CMS, is responsible for updating and maintaining the GROUPER program. The current DRG Definitions Manual, Version 24.0, is available for $225.00, which includes $15.00 for shipping and handling. Version 25.0 of this manual, which will include the final FY 2008 DRG changes, will be available in hard copy for $250.00. Version 25.0 of the manual is also available on a CD for $200.00; a combination hard copy and CD is available for $400.00. These manuals may be obtained by writing 3M/HIS at the following address: 100 Barnes Road, Wallingford, CT 06492; or by calling (203) 949-0303. Please specify the revision or revisions requested. 9. Review of Procedure Codes in CMS DRGs 468, 476, and 477

Each year, we review cases assigned to CMS DRG 468 (Extensive O.R. Procedure Unrelated to Principal Diagnosis), CMS DRG 476 (Prostatic O.R. Procedure Unrelated to Principal Diagnosis), and CMS DRG 477 (Nonextensive O.R. Procedure Unrelated to Principal Diagnosis) to determine whether it would be appropriate to change the procedures assigned among these CMS DRGs. Under the MS-DRGs that we are proposing to adopt for FY 2008, discussed in section II.D. of the preamble of this proposed rule, CMS DRG 468 would have a three-way split and would become proposed MS-DRGs 981, 982, and 983 (Extensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/ MCC). CMS DRG 476 would become proposed MS-DRGs 984, 985, and 986 (Prostatic O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and Without CC/MCC). CMS DRG 477 would become proposed MS-DRGs 987, 988, and 989 (Nonextensive O.R. Procedure Unrelated to Principal Diagnosis with MCC, with CC, and without CC/MCC).

Proposed MS-DRGs 981 through 983, 984 through 986, and 987 through 989 (formerly CMS DRGs 468, 476, and 477, respectively) are reserved for those cases in which none of the O.R. procedures performed are related to the principal diagnosis. These CMS DRGs are intended to capture atypical cases, that is, those cases not occurring with sufficient frequency to represent a distinct, recognizable clinical group. Proposed MS-DRGs 984 through 986 (previously CMS DRG 476) are 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, not elsewhere classified

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

60.96, Transurethral destruction of prostate tissue by microwave thermotherapy

60.97, Other transurethral destruction of prostate tissue by other thermotherapy

60.99, Other operations on prostate

All remaining O.R. procedures are assigned to proposed MS-DRGs 981 through 983 and 987 through 989 (previously CMS DRGs 468 and 477), with proposed MS-DRGs 987 through 989 (previously CMS DRG 477) assigned to those discharges in which the only procedures performed are nonextensive procedures that are unrelated to the principal diagnosis.\15\

For FY 2008, we are not proposing to change the procedures assigned among these CMS DRGs.

\15\ 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 FY 1989 final rule (53 FR 38591). As part of the FY 1991 final rule (55 FR 36135), the FY 1992 final rule (56 FR 43212), the FY 1993 final rule (57 FR 23625), the FY 1994 final rule (58 FR 46279), the FY 1995 final rule (59 FR 45336), the FY 1996 final rule (60 FR 45783), the FY 1997 final rule (61 FR 46173), and the FY 1998 final rule (62 FR 45981), we moved several other procedures from DRG 468 to DRG 477, and some procedures from DRG 477 to DRG 468. No procedures were moved in FY 1999, as noted in the final rule (63 FR 40962); in FY 2000 (64 FR 41496); in FY 2001 (65 FR 47064); or in FY 2002 (66 FR 39852). In the FY 2003 final rule (67 FR 49999) we did not move any procedures from DRG 477. However, we did move procedure codes from DRG 468 and place them in more clinically coherent DRGs. In the FY 2004 final rule (68 FR 45365), we moved several procedures from DRG 468 to DRGs 476 and 477 because the procedures are nonextensive. In the FY 2005 final rule (69 FR 48950), we moved one procedure from DRG 468 to 477. In addition, we added several existing procedures to DRGs 476 and 477. In the FY 2006 (70 FR 47317), we moved one procedure from DRG 468 and assigned it to DRG 477. In FY 2007, we moved one procedure from DRG 468 and assigned it to DRGs 479, 553, and 554.

a. Moving Procedure Codes From CMS DRG 468 (Proposed MS-DRGs 981 Through 983) or CMS DRG 477 (Proposed MS-DRGs 987 Through 989) to MDCs

We annually conduct a review of procedures producing assignment to CMS DRG 468 (proposed MS-DRGs 981 through 983) or CMS DRG 477 (proposed MS-DRGs 987 through 989) on the basis of volume, by procedure, to see if it would be appropriate to move procedure codes out of these DRGs into one of the surgical DRGs for the MDC into which the principal diagnosis falls. The data are arrayed in two ways for comparison purposes. We look at a frequency count of each major operative procedure code. We also compare procedures across MDCs by volume of procedure codes within each MDC.

We identify those procedures occurring in conjunction with certain principal diagnoses with sufficient frequency to justify adding them to one of the surgical DRGs for the MDC in which the diagnosis falls. Based on this

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year's review, we are not proposing to remove any procedures from CMS DRG 477 or CMS DRG 468 with assignment to one of the surgical DRGs. b. Reassignment of Procedures Among CMS DRGs 468, 476, and 477 (Proposed MS-DRGs 981 Through 983, 984 Through 986, and 987 Through 989)

We also annually review the list of ICD-9-CM procedures that, when in combination with their principal diagnosis code, result in assignment to CMS DRGs 468, 476, and 477 (proposed MS-DRGs 981 through 983, 984 through 986, and 987 through 989, respectively), to ascertain whether any of those procedures should be reassigned from one of these three DRGs to another of the three DRGs based on average charges and the length of stay. We look at the data for trends such as shifts in treatment practice or reporting practice that would make the resulting DRG assignment illogical. If we find these shifts, we would propose to move cases to keep the DRGs clinically similar or to provide payment for the cases in a similar manner. Generally, we move only those procedures for which we have an adequate number of discharges to analyze the data.

We are not proposing to move any procedure codes from CMS DRG 476 (proposed MS-DRGs 984, 985, and 986) to CMS DRG 468 (proposed MS-DRGs 981, 982, and 983) or to CMS DRG 477 (proposed MS-DRGs 987, 988, and 989), or from CMS DRG 477 (proposed MS-DRGs 987, 988, and 989) to CMS DRGs 468 (proposed MS-DRGs 981, 982, and 983) or to CMS DRG 476 (proposed MS-DRGs 984, 985, and 986) for FY 2008. c. Adding Diagnosis or Procedure Codes to MDCs

Based on our review this year, we are not proposing to add any diagnosis codes to MDCs for FY 2008. 10. Changes to the ICD-9-CM Coding System

(If you choose to comment on issues in this section, please include the caption ``ICD-9-CM Coding System'' at the beginning of your comment.)

As described in section II.B.1. of this preamble, the ICD-9-CM is a coding system 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, co-chaired by the National Center for Health Statistics (NCHS), the Centers for Disease Control and Prevention, and CMS, charged with maintaining and updating the ICD-9-CM system. The Committee is jointly responsible for 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 Official Version of the ICD-9-CM contains the list of valid diagnosis and procedure codes. (The Official Version of the ICD-9-CM is available from the Government Printing Office on CD-ROM for $25.00 by calling (202) 512-1800.) The Official Version of the ICD-9-CM is no longer available in printed manual form from the Federal Government; it is only available on CD-ROM. Users who need a paper version are referred to one of the many products available from publishing houses.

The NCHS has lead responsibility for the ICD-9-CM diagnosis codes included in the Tabular List and Alphabetic Index for Diseases, while CMS has lead responsibility for the ICD-9-CM procedure codes included in the Tabular List and Alphabetic Index for Procedures.

The Committee encourages participation in the above process by health-related organizations. In this regard, the Committee holds public meetings for discussion of educational issues and proposed coding changes. These meetings provide an opportunity for representatives of recognized organizations in the coding field, such as the American Health Information Management Association (AHIMA), the American Hospital Association (AHA), and various physician specialty groups, as well as individual physicians, 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 for implementation in FY 2008 at a public meeting held on September 28-29, 2006, and finalized the coding changes after consideration of comments received at the meetings and in writing by December 4, 2006. Those coding changes are announced in Tables 6A through 6F in the Addendum to this proposed rule. The Committee held its 2007 meeting on March 22-23, 2007. Proposed new codes for which there was a consensus of public support and for which complete tabular and indexing changes can be made by May 2007 will be included in the October 1, 2007 update to ICD-9-CM. Code revisions that were discussed at the March 22-23, 2007 Committee meeting could not be finalized in time to include them in the Addendum to this proposed rule. These additional codes will be included in Tables 6A through 6F of the final rule and are marked with an asterisk (*).

Copies of the minutes of the procedure codes discussions at the Committee's September 28-29, 2006 meeting can be obtained from the CMS Web site at: http://cms.hhs.gov/ICD9ProviderDiagnosticCodes/03_meetings.asp. The minutes of the diagnosis codes discussions at the

September 28-29, 2006 meeting are found at: http://www.cdc.gov/nchs/icd9.htm. Paper copies of these minutes are no longer available and the

mailing list has been discontinued. These Web sites also provide detailed information about the Committee, including information on requesting a new code, attending a Committee meeting, and timeline requirements and meeting dates.

We encourage commenters to address suggestions on coding issues involving diagnosis codes to: Donna Pickett, Co-Chairperson, ICD-9-CM Coordination and Maintenance Committee, NCHS, Room 2402, 3311 Toledo Road, Hyattsville, MD 20782. Comments may be sent by E-mail to: dfp4@cdc.gov.

Questions and comments concerning the procedure codes should be addressed to: Patricia E. Brooks, Co-Chairperson, ICD-9-CM Coordination and Maintenance Committee, CMS, Center for Medicare Management, Hospital and Ambulatory Policy Group, Division of Acute Care, C4-08-06, 7500 Security Boulevard, Baltimore, MD 21244-1850. Comments may be sent by E-mail to: patricia.brooks2@cms.hhs.gov.

The ICD-9-CM code changes that have been approved will become effective October 1, 2007. The new ICD-9-CM codes are listed, along with their DRG classifications, in Tables 6A and 6B (New Diagnosis Codes and New Procedure Codes, respectively) in the Addendum to this proposed rule. As we stated above, the code numbers and their titles were presented for public comment at the ICD-9-CM Coordination and Maintenance Committee meetings. Both oral and written comments were considered before the codes were approved. In this proposed rule, we are only soliciting

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comments on the proposed classification of these new codes.

For codes that have been replaced by new or expanded codes, the corresponding new or expanded diagnosis codes are included in Table 6A. New procedure codes are shown in Table 6B. Diagnosis codes that have been replaced by expanded codes or other codes or have been deleted are in Table 6C (Invalid Diagnosis Codes). These invalid diagnosis codes will not be recognized by the GROUPER beginning with discharges occurring on or after October 1, 2007. Table 6D contains invalid procedure codes. These invalid procedure codes will not be recognized by the GROUPER beginning with discharges occurring on or after October 1, 2007. Revisions to diagnosis code titles are in Table 6E (Revised Diagnosis Code Titles), which also includes the DRG assignments for these revised codes. Table 6F includes revised procedure code titles for FY 2008.

In the September 7, 2001 final rule implementing the IPPS new technology add-on payments (66 FR 46906), we indicated we would attempt to include proposals for procedure codes that would describe new technology discussed and approved at the Spring meeting as part of the code revisions effective the following October. As stated previously, ICD-9-CM codes discussed at the March 22-23, 2007 Committee meeting that received consensus and that were finalized by May 2007, will be included in Tables 6A through 6F of the Addendum to the final rule.

Section 503(a) of Pub. L. 108-173 included a requirement for updating ICD-9-CM codes twice a year instead of a single update on October 1 of each year. This requirement was included as part of the amendments to the Act relating to recognition of new technology under the IPPS. Section 503(a) amended section 1886(d)(5)(K) of the Act by adding a clause (vii) which states that the ``Secretary shall provide for the addition of new diagnosis and procedure codes on April 1 of each year, but the addition of such codes shall not require the Secretary to adjust the payment (or diagnosis-related group classification) * * * until the fiscal year that begins after such date.'' This requirement improves the recognition of new technologies under the IPPS system by providing information on these new technologies at an earlier date. Data will be available 6 months earlier than would be possible with updates occurring only once a year on October 1.

While section 1886(d)(5)(K)(vii) of the Act states that the addition of new diagnosis and procedure codes on April 1 of each year shall not require the Secretary to adjust the payment, or DRG classification, under section 1886(d) of the Act until the fiscal year that begins after such date, we have to update the DRG software and other systems in order to recognize and accept the new codes. We also publicize the code changes and the need for a mid-year systems update by providers to identify the new codes. Hospitals also have to obtain the new code books and encoder updates, and make other system changes in order to identify and report the new codes.

The ICD-9-CM Coordination and Maintenance Committee holds its meetings in the spring and fall in order to update the codes and the applicable payment and reporting systems by October 1 of each year. Items are placed on the agenda for the ICD-9-CM Coordination and Maintenance Committee meeting if the request is received at least 2 months prior to the meeting. This requirement allows time for staff to review and research the coding issues and prepare material for discussion at the meeting. It also allows time for the topic to be publicized in meeting announcements in the Federal Register as well as on the CMS Web site. The public decides whether or not to attend the meeting based on the topics listed on the agenda. Final decisions on code title revisions are currently made by March 1 so that these titles can be included in the IPPS proposed rule. A complete addendum describing details of all changes to ICD-9-CM, both tabular and index, is publicized on CMS and NCHS Web sites in May of each year. Publishers of coding books and software use this information to modify their products that are used by health care providers. This 5-month time period has proved to be necessary for hospitals and other providers to update their systems.

A discussion of this timeline and the need for changes are included in the December 4-5, 2005 ICD-9-CM Coordination and Maintenance Committee minutes. The public agreed that there was a need to hold the fall meetings earlier, in September or October, in order to meet the new implementation dates. The public provided comment that additional time would be needed to update hospital systems and obtain new code books and coding software. There was considerable concern expressed about the impact this new April update would have on providers.

In the FY 2005 IPPS final rule, we implemented section 1886(d)(5)(K)(vii) of the Act, as added by section 503(a) of Pub. L. 108-173, by developing a mechanism for approving, in time for the April update, diagnosis and procedure code revisions needed to describe new technologies and medical services for purposes of the new technology add-on payment process. We also established the following process for making these determinations. Topics considered during the Fall ICD-9-CM Coordination and Maintenance Committee meeting are considered for an April 1 update if a strong and convincing case is made by the requester at the Committee's public meeting. The request must identify the reason why a new code is needed in April for purposes of the new technology process. The participants at the meeting and those reviewing the Committee meeting summary report are provided the opportunity to comment on this expedited request. All other topics are considered for the October 1 update. Participants at the Committee meeting are encouraged to comment on all such requests. There were no requests for an expedited April l, 2007 implementation of an ICD-9-CM code at the September 28-29, 2006 Committee meeting. Therefore, there were no new ICD-9-CM codes implemented on April 1, 2007.

We believe that this process captures the intent of section 1886(d)(5)(K)(vii) of the Act. This requirement was included in the provision revising the standards and process for recognizing new technology under the IPPS. In addition, the need for approval of new codes outside the existing cycle (October 1) arises most frequently and most acutely where the new codes will identify new technologies that are (or will be) under consideration for new technology add-on payments. Thus, we believe this provision was intended to expedite data collection through the assignment of new ICD-9-CM codes for new technologies seeking higher payments.

Current addendum and code title information is published on the CMS Web site at: http://www.cms.hhs.gov/icd9ProviderDiagnosticCodes/01_overview.asp#TopofPage. Information on ICD-9-CM diagnosis codes, along

with the Official ICD-9-CM Coding Guidelines, can be found on the Web site at: http://www.cdc.gov/nchs/icd9.htm. Information on new, revised,

and deleted ICD-9-CM codes is also provided to the AHA for publication in the Coding Clinic for ICD-9-CM. AHA also distributes information to publishers and software vendors.

CMS also sends copies of all ICD-9-CM coding changes to its contractors for

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use in updating their systems and providing education to providers.

These same means of disseminating information on new, revised, and deleted ICD-9-CM codes will be used to notify providers, publishers, software vendors, contractors, and others of any changes to the ICD-9- CM codes that are implemented in April. The code titles are adopted as part of the ICD-9-CM Coordination and Maintenance Committee process. Thus, although we publish the code titles in the IPPS proposed and final rules, they are not subject to comment in the proposed or final rules. We will continue to publish the October code updates in this manner within the IPPS proposed and final rules. For codes that are implemented in April, we will assign the new procedure code to the same DRG in which its predecessor code was assigned so there will be no DRG impact as far as DRG assignment. This mapping was specified by section 1886(d)(5)(K)(vii) of the Act as added by section 503(a) of Pub. L. 108-173. Any midyear coding updates will be available through the Web sites indicated above and through the Coding Clinic for ICD-9-CM. Publishers and software vendors currently obtain code changes through these sources in order to update their code books and software systems. We will strive to have the April 1 updates available through these Web sites 5 months prior to implementation (that is, early November of the previous year), as is the case for the October 1 updates. 11. Other Issues

(If you choose to comment on issues in this section, please include the caption ``DRGs: Headaches and Seizures'' at the beginning of your comment.) a. Seizures and Headaches

After publication of the FY 2007 IPPS final rule (71 FR 47928), we received correspondence expressing concerns about the revisions we made to the seizure and headache DRGs effective on October 1, 2006. We created new DRGs 562 (Seizure Age >17 With CC), DRG 563 (Seizure Age >17 Without CC), and DRG 564 (Headaches Age >17) as an interim step to better recognize severity of illness among seizure and headache patients for FY 2007. Although national Medicare utilization data supported the revised DRGs, the commenter indicated that the change did not appropriately recognize hospital resources associated with the patients treated in the hospital's inpatient headache program. The commenter stated that patients who are admitted to the hospital's inpatient headache program suffer from chronic headache pain and require inpatient treatment that can last up to 12 days. The commenter noted that these patients are referred from around the country after several months of unsuccessful pain relief and treatment. The commenter indicated that the majority of patients treated at the hospital's inpatient headache program are drug dependent from being administered increasing dosages of pain relievers that have been unsuccessful in resolving chronic headache pain. Further, the commenter noted that the patients require detoxification before any headache treatment begins. The commenter urged CMS to subdivide the headache DRG to better recognize the higher level of severity associated with treating chronic headache patients in the hospital's program.

Although we are sympathetic to the commenter, it is not feasible to design a DRG system that addresses concerns that may be unique to one facility. Other than this one commenter, we did not receive any concern about our decision to create separate DRGs for seizures and headaches. However, we agreed to review this issue as part of our effort to redesign the DRG system to better recognize severity of illness for FY 2008.

As discussed in section II.C. of the preamble of this proposed rule, we are proposing to adopt MS-DRGs for FY 2008. While our current DRG structure did not support splitting the headache DRG based on the presence or absence of a CC, the proposed MS-DRGs support the creation of a split for the headache DRGs based on whether the patient has an MCC as shown below:

Number of Average length Average Proposed MS-DRG

cases

of stay

charges

MS-DRG 102 (Headaches with MCC).................................

1,268

5.04 19,077.33 MS-DRG 103 (Headaches without MCC)..............................

14,277

3.22 11,989.43

(The criteria for determining whether to subdivide a DRG are described in detail earlier in section II.D. of the preamble of this proposed rule.) Thus, we are proposing to create two MS-DRGs for headaches under the MS-DRGs as shown below:

Proposed MS-DRG 102 (Headaches With MCC)

Proposed MS-DRG 103 (Headaches Without MCC)

We believe this proposed structure would better recognize those headaches patients who are severely ill and require more resources as described by the commenter. We refer the readers to section II.D. of the preamble of this proposed rule for a detailed discussion of the MS- DRG proposal.

b. Devices That Are Replaced Without Cost or Where Credit for a Replaced Device Is Furnished to the Hospital

(If you choose to comment on issues in this section, please include the caption ``Replaced Devices'' at the beginning of your comment.) (1) Background

We addressed the topic of Medicare payment for devices that are replaced without costs or where credit for a replaced device is furnished to the hospital in the FY 2007 IPPS final rule (71 FR 47962). In that final rule, we included the following background information:

In recent years, there have been several field actions and recalls with regard to failure of implantable cardiac defibrillators (ICDs) and pacemakers. In many of these cases, the manufacturers have offered replacement devices without cost to the hospital or credit for the device being replaced if the patient required a more expensive device. In some circumstances, manufacturers have also offered, through a warranty package, to pay specified amounts for unreimbursed expenses to persons who had replacement devices implanted. Nonetheless, we believe that incidental device failures that are covered by manufacturer warranties occur routinely. While we understand that some device malfunctions may be inevitable as medical technology grows increasingly sophisticated, we believe that early recognition of problems would reduce the number of people who would be potentially adversely affected by these device problems. The medical community needs heightened and early awareness of patterns of device failures, voluntary field actions, and recalls so that it can take appropriate corrective action to care for patients. Systematic efforts must be undertaken by all interested and involved parties, including manufacturers, insurers, and the medical community, to ensure that

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device problems are recognized, and are addressed as early as possible so that patients' quality of health care is protected and high quality medical care, equipment, and technologies are provided. We are taking several steps to assist in the early recognition and analysis of patterns of device problems to minimize the potential for harm from device-related defects to Medicare beneficiaries and the public in general.

In recent years, CMS has recognized the importance of data collection as a condition of Medicare coverage for selected services. In 2005, we issued an NCD that expanded coverage of ICDs and also required registry participation when the devices were implanted for certain clinical indications. The NCD included this requirement in order to ensure that the medical care received by Medicare beneficiaries was reasonable and necessary and, therefore, that the provider or supplier would be appropriately paid. Presently, the American College of Cardiology--National Cardiovascular Data Registry (ACC-NCDR) collects these data and maintains the registry.

In addition to ensuring appropriate payment of claims, collection, and ongoing analysis of ICD implantation, registry data can facilitate public response to the quality of health care issues in the event of future device recalls. Analysis of registry data may uncover patterns of device malfunction, device-related infection, or early battery depletion that would trigger a more specific investigation. Patterns found in registry data may identify problems in patient outcomes earlier than the currently available mechanisms, which do not systematically collect detailed information about each patient who receives an ICD.

We encourage the medical community to work to develop additional registries for implantable devices, so that timely and comprehensive information is available regarding devices, recipients of those devices, and patients' quality of health care status and medical outcomes. While participation in an ICD registry is required as a Medicare condition of coverage for ICD implantation for certain clinical conditions, we believe that the potential benefits of other data collection extend well beyond their application in Medicare's specific NCDs. As medical technology continues to advance swiftly, data collection regarding the short-term and long-term medical outcomes of new technologies, especially concerning implanted devices that may remain in the bodies of patients for their lifetimes, will be essential to the timely recognition of any specific device-related problems, patterns of complications, and health-related outcomes. This information will facilitate early interventions to mitigate any harm potentially imposed upon Medicare beneficiaries and the public, and to improve the quality and efficiency of health care services provided.

Moreover, published data from registries may further help the development of high quality, evidence-based clinical practice guidelines for the care of patients who may receive device implants. In turn, widespread use of evidence-based guidelines may reduce variation in medical practice, leading to improved personal care and overall public health. Registry information may also contribute to the development of more comprehensive and refined quality metrics that may be used to systematically assess the collected data, and then improve the safety and quality of health care provided to Medicare beneficiaries. Such improvements in the quality of care that result in better personal health will require the sustained commitment of industry, payers, health care providers, and others to progressively work towards that goal, and to ensure excellent and open communication and rapid systemwide responses.

One strategy for this data collection involves adding information to the claims forms. CMS has a long history of collecting hemoglobin or hematocrit data from ESRD patients on the claims form. Modification of claims forms was necessary to do that. CMS is exploring the use of claims data to collect other types of clinical or technical data such as device manufacturer and model number. The systematic recording of model numbers can enhance knowledge of device-related outcomes and complications. We look forward to further discussions with the public about new strategies to both recognize device-related problems early as well as recognize health-related outcomes of new technologies.

In addition, we believe that the routine identification of Medicare claims for certain device implantation procedures in situations where a payment adjustment is appropriate may enhance the medical community's recognition of device-related problems, potentially leading to more timely improvements in medical device technologies. This systematic approach, which enables hospitals to identify and then appropriately report selected services when devices are replaced without cost to the hospital, or with full or partial credit to the hospital for the cost of the replaced device, should provide comprehensive information regarding the hospitals' experiences with Medicare beneficiaries who have specific medical devices that are being replaced. Because Medicare beneficiaries are common recipients of implanted devices, the claims information may be particularly helpful in identifying patterns of device-related problems early in their natural history, so that appropriate strategies to reduce future problems may be developed. One possible strategy would be for the Medicare program to use information obtained through the use of bar coding of medical devices. The FDA issued a final rule in the Federal Register on February 26, 2004 (69 FR 9119), that required bar codes for human drugs and biological product labels effective April 26, 2006. In the final rule, FDA deferred action on requiring bar codes for medical devices, noting the difficulty in standardizing medical devices, as compared to drugs and biologicals, which have the unique NDC numbering system. This rule can be reviewed on the Federal Register's Web site at: http://www.docket.access.gpo.gov/2004/04-4249.htm .

We intend to monitor FDA's work in this area to determine how this technology could help CMS promote higher quality through better clinical decision making and, as discussed below, assist in improving the accuracy of the Medicare payment system.

In addition to our concern for overall public health, we also have a fiduciary responsibility to the Medicare Trust Fund to ensure that Medicare pays only for covered services. Therefore, in the FY 2007 IPPS final rule, we indicated that we believe we need to consider whether it is appropriate to reduce the Medicare payment in cases in which an implanted device is replaced at reduced or no cost to the hospital or with partial or full credit for the removed device. Such consideration could cover certain devices for which credit for the replaced medical device is given, or medical devices that are replaced as a result of or pursuant to a warranty, field action, voluntary recall, or involuntary recall, and medical devices that are provided free of charge. We indicated that conveying this information to the Medicare beneficiary could provide for a reduction in the IPPS payment if we determine that the device is replaced without cost to the provider or beneficiary or when the provider receives full credit for the cost of a replaced device.

In FY 2007 IPPS final rule, we indicated a need to develop a methodology to determine the amount of the reduction to the otherwise

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payable IPPS payment for medical devices furnished to Medicare beneficiaries. We believe that this policy is appropriate because, in these cases, the full cost of the replaced device is not incurred and, therefore, an adjustment to the payment is necessary to remove the cost of the device. (2) Current and Proposed Policies

In the CY 2007 OPPS final rule (71 FR 68071 through 68077), we adopted a policy that requires a reduced payment to a hospital or ambulatory surgical center when a device is provided to them at no cost. From our experience with the OPPS, we understand that a manufacturer will often provide a credit or partial credit for the recalled device rather than a free replacement. In other situations, a manufacturer will provide either a full or partial credit for a device that needs to be replaced only during the manufacturer's warranty period. In either of these situations, the original implantation of the device was paid for either by Medicare, another third party on behalf of the beneficiary by making payment directly to the hospital, or the implantation was paid for directly by the beneficiary. Therefore, we believe that Medicare should not pay the hospital for the full cost of the replacement if the hospital is receiving a partial or full credit, either due to a recall or service during the warranty period. The device was already paid for at the time of initial implantation, and Medicare should retain the credit that is being provided to the hospital for service to a Medicare beneficiary.

Moreover, we also believe that a proposed adjustment is consistent with section 1862(a)(2) of the Act, which excludes from Medicare coverage an item or service for which neither the beneficiary, nor anyone on his or her behalf, has an obligation to pay. Payment of the full IPPS payment amount in cases in which the device was replaced under warranty or in which there was a full or partial credit for the price of the recalled or failed device effectively results in Medicare payment for a noncovered item. Therefore, we are proposing to adjust the IPPS payment amount in these circumstances under the authority of section 1886(d)(5)(I) of the Act, which permits the Secretary to make ``exceptions and adjustments to such payment amounts * * * as the Secretary deems appropriate.''

Under the OPPS, we currently only apply the reduced payment amount in situations where the hospital received a replacement device at no cost or at full credit for the replacement device. Unlike the current OPPS policy, we are proposing for purposes of the IPPS to apply the policy for partial as well as full credit for a replacement device. As we indicated above, our experience with the OPPS suggests that the policy should be applied beyond full replacement of a recalled device. We are proposing to reduce the amount of the Medicare IPPS payment when a full or partial credit towards a replacement device is made or the device is replaced without cost to the hospital or with full credit for the removed device. However, we do not believe that the IPPS policy should apply to all DRGs and all situations in which a device is replaced without cost to the hospital for the device or with full or partial credit for the removed device. We recognize that, in many cases, the cost of the device is a relatively modest part of the IPPS payment. In other situations, we believe the amount of the credit will also be nominal. In these cases, we believe that the averaging nature of payments under the IPPS would incorporate any significant savings from a warranty replacement, field action, or recall into the payment rate for the associated DRG, and that no specific adjustment would be necessary or appropriate. For this reason, we are proposing to apply the policy only to those DRGs under the IPPS where the implantation of the device determines the base DRG assignment and situations where the hospital received a credit equal to 20 percent or more of the cost of the device. We believe a credit that is equal to or more than this percentage is substantial, and Medicare should not pay for the full cost of these replacement devices because hospitals have received significant savings from the manufacturer for its replacement costs. We are seeking comment on the application of this percentage amount. We further believe that it is appropriate to limit application of the policy only to those DRGs where implantation of the device determines the DRG assignment. In making a decision to assign a case based on whether a device was implanted, we recognized that the device cost was a significant portion of the overall costs faced by the hospital that treats the case. Therefore, we believe that Medicare should not make full payment for those DRGs where the assignment of the case is made based on implantation of the device when the hospital is receiving either a full or significant partial credit for the device. We have listed the CMS DRGs that would be subject to this proposed policy below. We have also listed, in parentheses after the CMS DRG title, the proposed new MS-DRG title to which these cases would be assigned.

CMS DRGs Subject to Proposed Policy

MDC

CMS DRG Narrative Description of DRG

PRE....................

103 Heart Transplant or Implant of Heart Assist System (Proposed MS-DRGs 1 and 2, Heart Transplant or Implant of Heart Assist System With and Without MCC, respectively). 1......................

1 Craniotomy Age > 17 With CC (Proposed MS-DRG 25 and 26, Craniotomy and Endovascular Intracranial Procedure With MCC or Without CC, respectively). 1......................

2 Craniotomy Age > 17 Without CC (Proposed MS-DRGs 26 and 27, Craniotomy and Endovascular Intracranial Procedure Without CC/ MCC). 1......................

7 Peripheral & Cranial Nerve & Other Nervous System Procedures With CC (Proposed MS-DRGs 40 and 41, Peripheral & Cranial Nerve & Other Nervous System Procedure With MCC or With CC, respectively). 1......................

8 Peripheral & Cranial Nerve & Other Nervous System Procedures Without CC (Proposed MS-DRG 42, Peripheral & Cranial Nerve & Other Nervous System Procedure Without CC/MCC). 1......................

543 Craniotomy With Major Device Implant or Acute Complex Central Nervous System Principal Diagnosis (Proposed MS-DRGs 23 and 24, Craniotomy with Major Device Implant or Acute Complex Central Nervous System Principal Diagnosis With and Without MCC, respectively). 3......................

49 Major Head & Neck Procedures (Proposed MS-DRGs 129 and 130, Major Head & Neck Procedures With CC/MCC or Major Device or Without CC/MCC, respectively). 5......................

104 Cardiac Valve & Other Major Cardiothoracic Procedures with Cardiac Catheterization (Proposed MS-DRGs 216, 217, and 218, Cardiac Valve & Other Major Cardiothoracic Procedure With Cardiac Catheterization With MCC, or Without CC, or Without CC/MCC, respectively).

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5......................

105 Cardiac Valve & Other Major Cardiothoracic Procedures Without Cardiac Catheterization (Proposed MS-DRGs 219, 220, and 221, Cardiac Valve & Other Major Cardiothoracic Procedure Without Cardiac Catheterization With MCC, or With CC, or Without CC/MCC, respectively). 5......................

110 Major Cardiovascular Procedures With CC (Proposed MS-DRG 237, Major Cardiovascular Procedures With MCC). 5......................

111 Major Cardiovascular Procedures Without CC (Proposed MS-DRG 238, Major Cardiovascular Procedures Without MCC). 5......................

117 Cardiac Pacemaker Revision Except Device Replacement (Proposed MS- DRGs 260, 261, and 262, Cardiac Pacemaker Revision Except Device Replacement With MCC, or With CC, or Without CC/MCC, respectively). 5......................

118 Cardiac Pacemaker Device Replacement (Proposed MS-DRGs 258 and 259, Cardiac Pacemaker Device Replacement With MCC, and Without MCC, respectively). 5......................

515 Cardiac Defibrillator Implant Without Cardiac Catheterization (Proposed MS-DRGs 226 and 227, Cardiac Defibrillator Implant Without Cardiac Catheterization With MCC and Without MCC, respectively). 5......................

525 Other Heart Assist System Implant (Proposed MS-DRG 215, Other Heart Assist System Implant). 5......................

535 Cardiac Defibrillator Implant With Cardiac Catheterization With Acute Myocardial Infarction/Heart Failure/ Shock (Proposed MS-DRGs 222 and 223, Cardiac Defibrillator Implant With Cardiac Catheterization With Acute Myocardial Infarction/Heart Failure/Shock With MCC and Without MCC, respectively). 5......................

536 Cardiac Defibrillator Implant With Cardiac Catheterization Without Acute Myocardial Infarction/Heart Failure/Shock (Proposed MS-DRGs 224 and 225, Cardiac Defibrillator Implant With Cardiac Catheterization Without Acute Myocardial Infarction/Heart Failure/ Shock With MCC and Without MCC, respectively). 5......................

551 Permanent Cardiac Pacemaker Implant With Major Cardiovascular Diagnosis or AICD Lead or Generator (Proposed MS-DRGs 242, 243, and 244, Permanent Cardiac Pacemaker Implant With MCC, With CC, and Without CC/ MCC, respectively). 5......................

552 Other Permanent Cardiac Pacemaker Implant Without Major Cardiovascular Diagnosis (Proposed MS-DRGs 242, 243, and 244, Permanent Cardiac Pacemaker Implant With MCC, With CC, and Without CC/ MCC, respectively). 8......................

471 Bilateral or Multiple Major Joint Procedures of Lower Extremity (Proposed MS-DRGs 461 and 462, Bilateral or Multiple Major Joint Procedures of Lower Extremity With MCC, or Without MCC, respectively). 8......................

544 Major Joint Replacement or Reattachment of Lower Extremity (Proposed MS-DRGs 469 and 470, Major Joint Replacement or Reattachment of Lower Extremity With MCC or Without MCC, respectively). 8......................

545 Revision of Hip or Knee Replacement (Proposed MS-DRGs 466, 467, and 468, Revision of Hip or Knee Replacement With MCC, With CC, or Without CC/MCC, respectively).

CMS has requested and received new condition codes from the National Uniform Billing Committee to describe claims where a provider has received a device or product without cost. We will use these condition codes to reduce payment when the hospital used a device for which full or partial credit is given, or the item was replaced as a result of or under a warranty, field action, voluntary recall, involuntary recall, or otherwise provided free of charge. On November 4, 2005, we issued Change Request 4058, Transmittal 741, in the Medicare Claims Processing Manual. The effective date of this transmittal was April 1, 2006, and the implementation date was April 3, 2006. This transmittal specifies that the following two new condition codes have been created. They are defined below:

Condition Code 49--Product Replacement within Product Lifecycle. Replacement of a product earlier than the anticipated lifecycle due to an indication that the product is not functioning properly.

Condition Code 50--Product Replacement for Known Recall of a Product. The manufacturer or the FDA has identified the product for recall and therefore replacement.

Hospitals must report these codes on any claim for IPPS services that includes a replacement device or product for which they received full or partial credit. Hospital billing offices would report one of these condition codes in addition to the specific code for the type of procedure performed (for example, replacement of a defibrillator). When this code is received by Medicare and the discharge is assigned to a DRG that is subject to this policy, we are proposing to suspend the claim so that it does not automatically process and the fiscal intermediary (or, if applicable, the MAC) makes a manual payment determination. We are proposing to require the hospital to provide invoices or other information indicating its normal cost of the device and the amount of the credit it received.

This transmittal can be accessed at the following Web site: http://www.cms.hhs.gov/Transmittals/downloads/R741CP.pdf .

Under our policy, the fiscal intermediary (or, if applicable, the MAC) would manually process claims involving DRGs that are subject to this policy that include a device that is replaced without cost to the hospital for the device or with full or partial credit for the removed device as identified by condition codes 49 or 50. For a device provided to the hospital without cost, the fiscal intermediary (or, if applicable, the MAC) would subtract the cost of the device from the DRG payment. For a device for which the hospital received a full or partial credit, the fiscal intermediary (or, if applicable, the MAC) would subtract the amount credited from the DRG payment. We are proposing to require the hospital to provide invoices or other information indicating the cost of the device and the amount of credit it received. We are seeking comment on the best approach to making this payment adjustment and what types of documentation hospitals should provide to the fiscal intermediary or MAC.

We are proposing to invoke our special exceptions and adjustment authority under section 1886(d)(5)(I)(i) of the Act to make this adjustment. The special exceptions and adjustment authority authorizes us to provide ``for such other exceptions and adjustments to [IPPS] payment amounts* * *as the Secretary deems appropriate.'' We believe it would be appropriate to adjust payments for surgical procedures to replace certain devices by providing payments to hospitals only for the nondevice-related procedural costs when such a device is replaced without cost to the hospital for the device or with full credit for the removed device.

To codify in regulations the proposed policies for the IPPS discussed above, we are proposing to add a new paragraph (g) to Sec. 412.2 and a new

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Sec. 412.89 to 42 CFR Part 412, Subpart F. We are also proposing to make a technical, conforming change to the heading of Subpart F and to add an uncoded center heading before the proposed new Sec. 412.89.

H. Recalibration of DRG Weights

(If you choose to comment on issues in this section, please include the caption ``Recalibration of DRG Weights'' at the beginning of your comment.)

In section II.D.3. of the preamble of this proposed rule, we stated that we are proposing to continue to implement the cost-based DRG relative weights under a 3-year transition period such that, in FY 2008, year two of the transition, the relative weights would be recalibrated using a blend of 67 percent of the cost relative weight and 33 percent of the charge relative weight. By FY 2009, the relative weights will be 100 percent cost-based. We are proposing a few minor changes to the cost-weighting methodology that we adopted in the FY 2007 IPPS final rule (71 FR 47962 through 47971). However, in section II.E.2. of the preamble of this proposed rule, we request public comments about whether to adopt any of the short-term recommendations to the cost relative weighting methodology for FY 2008 made by RTI. Therefore, if we were to adopt any of the RTI recommendations based on public comment, our description of the cost-weighting methodology shown below would be modified accordingly in the IPPS final rule.

In developing the FY 2008 proposed system of weights, we used two data sources: claims data and cost report data. As in previous years, the claims data source is the MedPAR file. This file is based on fully coded diagnostic and procedure data for all Medicare inpatient hospital bills. The FY 2006 MedPAR data used in this proposed rule include discharges occurring on October 1, 2005, through September 30, 2006, based on bills received by CMS through December 2006, from all hospitals subject to the IPPS and short-term acute care hospitals in Maryland (which are under a waiver from the IPPS under section 1814(b)(3) of the Act). The FY 2006 MedPAR file used in calculating the relative weights includes data for approximately 11,748,387 Medicare discharges from IPPS providers. Discharges for Medicare beneficiaries enrolled in a Medicare Advantage managed care plan are excluded from this analysis. The data exclude CAHs, including hospitals that subsequently became CAHs after the period from which the data were taken. The second data source used in the cost relative weight methodology is the FY 2005 Medicare cost report data files from HCRIS, which represents the most recent full set of cost report data available. We used the December 31, 2006 update of the HCRIS cost report files for FY 2005 in setting the proposed relative cost based weights.

Because we are implementing the relative weights on a transitional basis, it is necessary to calculate both charge-based and cost-based relative weights. The charge-based methodology used to calculate the DRG relative weights from the MedPAR data is the same methodology that was in place for FY 2006 and FY 2007 and was applied as follows:

To the extent possible, all the claims were regrouped using the MS-DRGs being proposed for FY 2008, as discussed in section II.D. of this preamble.

The transplant cases that were used to establish the relative weight for heart and heart-lung, liver and/or intestinal, and lung transplants (proposed MS-DRGs 001, 002, 005, 006, and 007, respectively; previously CMS DRGs 103, 480, and 495) were limited to those Medicare-approved transplant centers that have cases in the FY 2005 MedPAR file. (Medicare coverage for heart, heart-lung, liver and/ or intestinal, and lung transplants is limited to those facilities that have received approval from CMS as transplant centers.)

Organ acquisition costs for kidney, heart, heart-lung, liver, lung, pancreas, and intestinal (or multivisceral organs) transplants continue to be paid on a reasonable cost basis. Because these acquisition costs are paid separately from the IPPS rates, it was necessary to subtract 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.

Total charges were standardized to remove the effects of differences in area wage levels, indirect medical education and disproportionate share payments, and, for hospitals in Alaska and Hawaii, the applicable cost-of-living adjustment.

Statistical outliers were eliminated by removing all cases that were beyond 3.0 standard deviations from the mean of the log distribution of both the standardized charges per case and the standardized charges per day for each DRG.

The average charge for each DRG was then recomputed (excluding the statistical outliers). To compute the average DRG charge, we sum the standardized charges by DRG and divide by the transfer adjusted case count. A transfer case is counted as a fraction of a case based on the ratio of its transfer payment under the per diem payment methodology to the full DRG payment for nontransfer cases. That is, a transfer case receiving payment under the transfer methodology equal to half of what the case would receive as a nontransfer would be counted as 0.5 of a total case. The average charge per DRG is then divided by the national average standardized charge per case to determine the relative weight.

The new charge-based weights were then normalized by an adjustment factor of 1.50808 so that the average case weight after recalibration was equal to the average case weight before recalibration. This normalization adjustment is intended to ensure that recalibration by itself neither increases nor decreases total payments under the IPPS as required by section 1886(d)(4)(C)(iii) of the Act.

The methodology we used to calculate the DRG cost-based weights from the FY 2006 MedPAR claims data and FY 2005 Medicare cost report data is as follows:

To the extent possible, all the claims were regrouped using the FY 2008 proposed MS-DRG classifications discussed in section II.D. of this preamble.

The transplant cases that were used to establish the relative weight for heart and heart-lung, liver and/or intestinal, and lung transplants (proposed MS-DRGs 001, 002, 005, 006, and 007, respectively; previously CMS DRGs 103, 480, and 495) were limited to those Medicare-approved transplant centers that have cases in the FY 2006 MedPAR file. (Medicare coverage for heart, heart-lung, liver and/ or intestinal, and lung transplants is limited to those facilities that have received approval from CMS as transplant centers.)

Organ acquisition costs for kidney, heart, heart-lung, liver, lung, pancreas, and intestinal (or multivisceral organs) transplants continue to be paid on a reasonable cost basis. Because these acquisition costs are paid separately from the prospective payment rate, it is necessary to subtract the acquisition charges from the total charges on each transplant bill that showed acquisition charges before computing the average cost for each DRG and before eliminating statistical outliers.

Claims with total charges or total length of stay less than or equal to zero were deleted. Claims that had an amount in the total charge field that differed by more than $10.00 from the sum of the routine day charges, intensive care charges, pharmacy charges, special equipment charges, therapy services charges, operating

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room charges, cardiology charges, laboratory charges, radiology charges, other service charges, labor and delivery charges, inhalation therapy charges and anesthesia charges were also deleted.

At least 94 percent of the providers in the MedPAR file had charges for 10 of the 13 cost centers. Claims for providers that did not have charges greater than zero for at least 10 of the 13 cost centers were deleted.

Statistical outliers were eliminated by removing all cases that were beyond 3.0 standard deviations from the mean of the log distribution of both the total charges per case and the total charges per day for each DRG.

Once the MedPAR data were trimmed and the statistical outliers were removed, the charges for each of the 13 cost groups for each claim were standardized to remove the effects of differences in area wage levels, indirect medical education and disproportionate share payments, and for hospitals in Alaska and Hawaii, the applicable cost-of-living adjustment. Charges were then summed by DRG for each of the 13 cost groups such that each DRG had 13 standardized charge totals. These charges were then adjusted to cost by applying the national average CCRs developed from the FY 2005 cost report data.

The 13 cost centers that we used in the relative weight calculation are shown in the following table. In addition, the table shows the lines on the cost report that we used to create the national cost center CCRs that we used to adjust the DRG charges to cost. For FY 2008, we are proposing to make minor revisions to the Cardiology, Laboratory, Radiology, and Other Services CCRs we are using to calculate the DRG relative weights, as follows:

The costs for cases involving Electroencephalography (EEG), cost report line 54, are currently in the Cardiology cost center group. However, MedPAR categorizes the claims data for EEG under Laboratory Charges (revenue codes 0740 and 0749). In order to maintain consistency with matching costs on the cost report to charges on MedPAR claims, we are proposing to move cost report line 54 for EEG out of the Cardiology cost center group into the Laboratory cost center group.

In the FY 2007 IPPS proposed rule, we originally included the costs for Radioisotopes, cost report line 43, in the Radiology cost center group. However, in response to comments, we moved Radioisotopes to the Other Services cost center group. After researching this issue further over the past year, we believe that Radioisotopes is a radiology-related service that more appropriately belongs in the Radiology cost center group. Accordingly, for FY 2008, we are proposing to move the cost report line item for line 43, Radioisotopes, out of the Other Services cost center group and into the Radiology cost center group. The proposed version of the 13 cost center groupings are in the table below: BILLING CODE 4120-01-P

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BILLING CODE 4120-01-C

We developed the national average CCRs as follows:

Taking the FY 2005 cost report data, we removed CAHs, Indian Health Service hospitals, all-inclusive rate hospitals, and cost reports that represented time periods of less than 1 year (365 days). We included hospitals located in Maryland as we are including their charges in our claims database. We then created CCRs for each provider for each cost center (see prior table for line items used in the calculations) and removed any CCRs that were greater than 10 or less than 0.01. We normalized the departmental CCRs by dividing the CCR for each department by the total CCR for the hospital for the purpose of trimming the data. We then took the logs of the normalized cost center CCRs and removed any cost center CCRs where the log of the cost center CCR was greater or less than the mean log plus/minus 3 times the standard deviation for the log of that cost center CCR. Once the cost report data were trimmed, we calculated a Medicare-specific CCR. The Medicare-specific CCR was determined by taking

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the Medicare charges for each line item from Worksheet D, Part 4 and deriving the Medicare specific costs by applying the hospital-specific departmental CCRs to the Medicare-specific charges for each line item from Worksheet D, Part 4. Once each hospital's Medicare-specific costs were established, we summed the total Medicare-specific costs and divided by the sum of the total Medicare-specific charges to produce national average, charge-weighted CCRs.

After we multiplied the total charges for each DRG in each of the 13 cost centers by the corresponding national average CCR, we summed the 13 ``costs'' across each DRG to produce a total standardized cost for the DRG. The average standardized cost for each DRG was then computed as the total standardized cost for the DRG divided by the transfer adjusted case count for the DRG. The average cost for each DRG was then divided by the national average standardized cost per case to determine the relative weight.

The new cost-based weights were then normalized by an adjustment factor of 1.50988 so that the average case weight after recalibration was equal to the average case weight before recalibration. Since more trims were applied to the data under the cost-based weights methodology than under the charge-based methodology, a smaller universe of claims was used in the cost-based methodology. In this instance, the different universe of claims also resulted in a slightly higher cost-based normalization factor than the normalization factor derived for charge- based weights. The normalization adjustment is intended to ensure that recalibration by itself neither increases nor decreases total payments under the IPPS as required by section 1886(d)(4)(C)(iii) of the Act.

The 13 proposed national average CCRs for FY 2008 are as follows:

Group

CCR

Routine Days.................................................... 0.52 Intensive Days.................................................. 0.48 Drugs........................................................... 0.21 Supplies & Equipment............................................ 0.34 Therapy Services................................................ 0.42 Laboratory...................................................... 0.17 Operating Room.................................................. 0.30 Cardiology...................................................... 0.19 Radiology....................................................... 0.18 Other Services.................................................. 0.37 Labor & Delivery................................................ 0.47 Inhalation Therapy.............................................. 0.19 Anesthesia...................................................... 0.14

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 used that same case threshold in recalibrating the DRG weights for FY 2008. Using the FY 2006 MedPAR data set, there are 7 proposed MS-DRGs that contain fewer than 10 cases. Under the proposed MS-DRGs, we have fewer low-volume DRGs than under the CMS DRGs because we no longer have separate DRGs for patients age 0 to 17 years. With the exception of newborns, we previously separated some DRGs based on whether the patient was age 0-17 or age 17 and older. Other than the age split, cases grouping to these DRGs are identical. The DRGs for patients age 0 to 17 years generally have very low volumes because children are typically ineligible for Medicare. In the past, we have found that the low volume of cases for the pediatric DRGs could lead to significant year-to-year instability in their relative weights. Although we have always encouraged non-Medicare payers to develop weights applicable to their own patient populations, we have heard frequent complaints from providers about the use of the Medicare relative weights in the pediatric population. We believe that eliminating this age split in the proposed MS-DRGs will provide more stable payment for pediatric cases by determining their payment using adult cases that are much higher in total volume. All of the low-volume DRGs listed below are for newborns. Newborns are unique and require separate DRGs that are not mirrored in the adult population. Therefore, it remains necessary to retain separate DRGs for newborns. In FY 2008, because we do not have sufficient MedPAR data to set accurate and stable cost weights for these low-volume DRGs, we are proposing to compute weights for the low-volume DRGs by adjusting their FY 2007 weights by the percentage change in the average weight of the cases in other DRGs. The crosswalk table we are proposing is shown below:

Low-volume DRG

DRG title

Crosswalk to DRG

789................ Neonates, Died or FY 2007 FR weight (adjusted Transferred to

by percent change in Another Acute Care average weight of the Facility.

cases in other DRGs). 790................ Extreme Immaturity or FY 2007 FR weight (adjusted Respiratory Distress by percent change in Syndrome, Neonate. average weight of the cases in other DRGs). 791................ Prematurity With Major FY 2007 FR weight (adjusted Problems.

by percent change in average weight of the cases in other DRGs). 792................ Prematurity Without FY 2007 FR weight (adjusted Major Problems.

by percent change in average weight of the cases in other DRGs). 793................ Full-term Neonate With FY 2007 FR weight (adjusted Major Problems.

by percent change in average weight of the cases in other DRGs). 794................ Neonate With Other FY 2007 FR weight (adjusted Significant Problems. by percent change in average weight of the cases in other DRGs). 795................ Normal Newborn........ FY 2007 FR weight (adjusted by percent change in average weight of the cases in other DRGs).

I. Proposed MS-LTC-DRG Reclassifications and Relative Weights for LTCHs for FY 2008

(If you choose to comment on issues in this section, please include the caption ``MS-LTC-DRGs'' at the beginning of your comment.) 1. Background

In the June 6, 2003 LTCH PPS final rule (68 FR 34122), we changed the LTCH PPS annual payment rate update cycle to be effective July 1 through June 30 instead of October 1 through September 30. In addition, because the patient classification system utilized under the LTCH PPS uses the same CMS DRGs as those currently used under the IPPS for acute care hospitals, in that same final rule, we explained that the annual update of the long-term care diagnosis-related group (LTC-DRG) classifications and relative weights will continue to remain linked to the annual reclassification and recalibration of the CMS DRGs used under the IPPS. Therefore, we specified that we will continue to update the LTC-DRG

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classifications and relative weights to be effective for discharges occurring on or after October 1 through September 30 each year. We further stated that we will publish the annual proposed and final update of the LTC-DRGs in same notice as the proposed and final update for the IPPS (69 FR 34125).

In the past, the annual update to the IPPS CMS DRGs has been based on the annual revisions to the ICD-9-CM codes and was effective each October 1. As discussed in the FY 2007 IPPS final rule (71 FR 47971 through 47994) and in the Rate Year (RY) 2008 LTCH PPS proposed rule (72 FR 4783 through 4789), with the implementation of section 503(a) of Pub. L. 108-173, there is the possibility that one feature of the GROUPER software program may be updated twice during a Federal fiscal year (October 1 and April 1) as required by the statute for the IPPS. Section 503(a) of Pub. L. 108-173 amended section 1886(d)(5)(K) of the Act by adding a new clause (vii) which states that ``the Secretary shall provide for the addition of new diagnosis and procedure codes in

[sic] April 1 of each year, but the addition of such codes shall not require the Secretary to adjust the payment (or diagnosis-related group classification) * * * until the fiscal year that begins after such date.'' This requirement improves the recognition of new technologies under the IPPS by accounting for those ICD-9-CM codes in the MedPAR claims data earlier than the agency had accounted for new technology in the past. In implementing the statutory change, the agency has provided that ICD-9-CM diagnosis and procedure codes for new medical technology may be created and assigned to existing CMS DRGs in the middle of the Federal fiscal year, on April 1. However, this policy change will not impact the DRG relative weights in effect for that year, which will continue to be updated only once a year (October 1), nor will it have any impact on Medicare payments. The use of the ICD-9-CM code set is also compliant with the current requirements of the Transactions and Code Sets Standards regulations at 45 CFR Parts 160 and 162, promulgated in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub. L. 104-191.

As noted above, the patient classification system used under the LTCH PPS (LTC-DRGs) is based on the patient classification system used under the IPPS (CMS DRGs). Therefore, the ICD-9-CM codes currently used under both the IPPS and LTCH PPS may be updated as often as twice a year. This requirement is included as part of the amendments to the Act relating to recognition of new medical technology under the IPPS.

Because we do not publish a midyear IPPS rule, any April 1 ICD-9-CM coding update will not be published midyear. Rather, we will assign any new diagnosis or procedure codes to the same DRG in which its predecessor code was assigned, so that there will be no impact on the DRG assignments (as also discussed in section II.G.10. of this preamble). Any coding updates will be available through the Web sites provided in section II.G.10. of this preamble and through the Coding Clinic for ICD-9-CM, a product of the American Hospital Association. Publishers and software vendors currently obtain code changes through these sources in order to update their code books and software system. If new codes are implemented on April 1, revised code books and software systems, including the GROUPER software program, will be necessary because we must use current ICD-9-CM codes. Therefore, for purposes of the LTCH PPS, because each ICD-9-CM code must be included in the GROUPER algorithm to classify each case into a LTC-DRG, the GROUPER software program used under the LTCH PPS would need to be revised to accommodate any new codes.

In implementing section 503(a) of Pub. L. 108-173, there will only be an April 1 update if new technology codes are requested and approved. We note that any new codes created for April 1 implementation will be limited to those diagnosis and procedure code revisions primarily needed to describe new technologies and medical services. However, we reiterate that the process of discussing updates to the ICD-9-CM is an open process through the ICD-9-CM Coordination and Maintenance Committee. Requestors will be given the opportunity to present the merits for a new code and to make a clear and convincing case for the need to update ICD-9-CM codes for purposes of the IPPS new technology add-on payment process through an April 1 update (as also discussed in section II.G.10. of this preamble).

As we discussed in the RY 2008 LTCH PPS proposed rule (72 FR 4783 through 4789), at the September 28, 2006 ICD-9-CM Coordination and Maintenance Committee meeting, there were no requests for an April 1, 2007 implementation of ICD-9-CM codes. Therefore, the next update to the ICD-9-CM coding system will not occur until October 1, 2007 (FY 2008). Because there were no coding changes suggested for an April 1, 2007 update, the ICD-9-CM coding set implemented on October 1, 2006, will continue through September 30, 2007 (FY 2008). The update to the ICD-9-CM coding system for FY 2008 is discussed above in section II.G.10. of this preamble. Accordingly, in this proposed rule, as discussed in greater detail below, we are proposing to modify and revise the LTC-DRG classifications and relative weights, to be effective October 1, 2007 through September 30, 2008 (FY 2008). In addition, we will notify LTCHs of any revisions to the GROUPER software used under the IPPS and the LTCH PPS that may be implemented on April 1, 2008. The proposed LTC-DRGs and proposed relative weights for FY 2008 in this proposed rule are based on the proposed IPPS MS-DRGs (GROUPER Version 25.0) discussed in section II.B. of the preamble to this proposed rule. 2. Proposed Changes in the LTC-DRG Classifications a. Background

Section 123 of Pub. L. 106-113 specifically requires that the agency implement a PPS for LTCHs that is a per discharge system with a DRG-based patient classification system reflecting the differences in patient resources and costs in LTCHs while maintaining budget neutrality. Section 307(b)(1) of Pub. L. 106-554 modified the requirements of section 123 of Pub. L. 106-113 by specifically requiring that the Secretary examine ``the feasibility and the impact of basing payment under such a system [the LTCH PPS] on the use of existing (or refined) hospital diagnosis-related groups (DRGs) that have been modified to account for different resource use of long-term care hospital patients as well as the use of the most recently available hospital discharge data.''

In accordance with section 123 of Pub. L. 106-113 as amended by section 307(b)(1) of Pub. L. 106-554 and Sec. 412.515 of our existing regulations, the LTCH PPS uses information from LTCH patient records to classify patient cases into distinct LTC-DRGs based on clinical characteristics and expected resource needs. As described in II.D. of the preamble of this proposed rule, we are proposing to adopt MS-DRGs under the IPPS because we believe that adopting this system will result in a significant improvement in the DRG system's recognition of severity of illness and resource usage. We believe these improvements in the DRG system would be equally applicable to the LTCH PPS. The changes we are currently proposing for the IPPS would be reflected in the FY 2008 GROUPER,

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Version 25.0, to be effective for discharges occurring on or after October 1, 2007 through September 30, 2008. Currently, the LTC-DRGs used as the patient classification component of the LTCH PPS correspond to the current CMS DRGs applicable under the IPPS for acute care hospitals

Consistent with our historical practice of having LTC-DRGs correspond to the DRGs applicable under the IPPS, under the broad authority of section 123(a) of Pub. L. 106-113, as modified by section 307(b) of Pub. L. 106-554, we are proposing to use MS-LTC-DRGs which correspond to the proposed MS-DRGs. In addition, as stated above, we are proposing to use the FY 2008 GOUPER Version 25.0, to be effective for discharges occurring on or after October 1, 2007 through September 30, 2008. The proposed changes to the current CMS DRG classification system used under the IPPS for FY 2008 (GROUPER Version 25.0) are discussed in section II.D. of the preamble to this proposed rule.

As noted above, the patient classification system used under the LTCH PPS (LTC-DRGs) is based on the patient classification system used under the IPPS (CMS DRGs), which historically has been updated annually as authorized by section 1886(d)(4)(C) of the Act and is effective for discharges occurring on or after October 1 through September 30 of each year. As such, the proposed updates to the CMS DRG classification system used under the IPPS for FY 2008 (GROUPER Version 25.0), discussed in section II.D. of the preamble of this proposed rule, would be applicable to updates under the LTCH PPS. In conjunction with the proposed changes to the existing CMS DRGs for the IPPS by adoption of the proposed MS-DRGs, we are proposing to adopt the MS-DRGs for the LTCH PPS, as both sets of DRGs are based on the same DRG structure. However, we refer to the proposed DRGs under the LTCH PPS as MS-LTC- DRGs. This proposed conforming change, that is, to replicate the MS- LTC-DRG structure after the proposed MS-DRG structure is appropriate in order to maintain consistency and uniformity among a number of stakeholders, such as acute care hospitals, LTCHs, epidemiologists, ratesetting organizations, and payors, among others.

Under the LTCH PPS, as described in greater detail below, we determine relative weights for each of the DRGs to account for the difference in resource use by patients exhibiting the case complexity and multiple medical problems characteristic of LTCH patients. (Unless otherwise noted in this proposed rule, our MS-LTC-DRG analysis is based on LTCH data from the December 2006 update of the FY 2006 MedPAR file, which contains hospital bills received through December 31, 2006, for discharges occurring in FY 2006.)

LTCHs do not typically treat the full range of diagnoses as do acute care hospitals. Therefore, as we discussed in the August 30, 2002 LTCH PPS final rule (67 FR 55985), which implemented the LTCH PPS, and the FY 2006 IPPS final rule (70 FR 47324), we use low-volume quintiles in determining the LTC-DRG relative weights for LTC-DRGs with less than 25 LTCH cases (low-volume LTC-DRGs). Specifically, we group those low- volume LTC-DRGs into 5 quintiles based on average charges per discharge. (A listing of the composition of low-volume quintiles for the FY 2007 LTC-DRGs (based on FY 2005 MedPAR data) appears in section II.I.2.d. of the FY 2007 IPPS final rule (71 FR 47975 through 47978).) We also adjust for cases in which the stay at the LTCH is less than or equal to five-sixths of the geometric average length of stay; that is, short-stay outlier cases (Sec. 412.529), as discussed below in section II.I.4. of this preamble. b. Patient Classifications into DRGs

Generally, under the LTCH PPS, Medicare payment is made at a predetermined specific rate for each discharge; that is, payment varies by the LTC-DRG to which a beneficiary's stay is assigned. Just as cases have been classified into the proposed MS-DRGs for acute care hospitals under the IPPS (section II. of the preamble of this proposed rule), cases have been classified into proposed MS-LTC-DRGs for payment under the LTCH PPS 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 the ICD-9-CM codes. Under the proposed MS-DRGs for the IPPS and the proposed MS-LTC- DRGs for the LTCH PPS, these factors will not change.

Section II.B. of the preamble of this proposed rule discusses the organization of the existing CMS DRGs, which we are proposing to maintain under the proposed MS-DRG and MS-LTC-DRG systems. As noted above, the patient classification system for the LTCH PPS is derived from the CMS DRGs and is similarly organized into 25 major diagnostic categories (MDCs). Most of these MDCs are based on a particular organ system of the body and the remainder involves multiple organ systems (such as MDC 22, Burns). Accordingly, the principal diagnosis determines MDC assignment. Within most MDCs, cases are then divided into surgical DRGs and medical DRGs. Under the present CMS DRGs, some surgical and medical DRGs are further differentiated based on the presence or absence of CCs. The existing LTC-DRGs are similarly categorized. (See section II.B. of the preamble of this proposed rule for further discussion of surgical DRGs and medical DRGs.)

The proposed MS-DRGs and the proposed MS-LTC-DRGs contain base DRGs that have been subdivided into one, two, or three severity levels. The most severe level has at least one code that is a major CC, referred to as ``with MCC''. The next lower severity level contains cases with at least one CC, referred to as ``with CC''. Those DRGs without an MCC or a CC are referred to as ``without CC/MCC''. When data did not support the creation of three severity levels, the base DRG was divided into either two levels or the base was not subdivided. The proposed two- level subdivisions consist of one of the following subdivisions:

With CC/MCC

Without CC/MCC

In this type of subdivision, cases with at least one code that is on the CC or MCC list are assigned to the ``with CC/MCC'' DRG. Cases without a CC or an MCC are assigned to the ``without CC/MCC'' DRG.

The other type of proposed two-level subdivision is as follows:

With MCC

Without MCC

In this type of subdivision, cases with at least one code that is on the MCC list are assigned to the ``with MCC'' DRG. Cases that do not have an MCC are assigned to the ``without MCC'' DRG. This type of subdivision could include cases with a CC code, but no MCC.

As under the present LTC-DRG system, we are proposing that the assignment of a case to a particular MS-LTC-DRG will determine the amount that is paid for the case. Therefore, it is important that the coding is accurate. Classifications and terminology used under the LTCH PPS are consistent with the ICD-9-CM and the Uniform Hospital Discharge Data Set (UHDDS), as recommended to the Secretary by the National Committee on Vital and Health Statistics (``Uniform Hospital Discharge Data: Minimum Data Set, National Center for Health Statistics, April 1980'') and as revised in 1984 by the Health Information Policy Council (HIPC) of the U.S. Department of Health and Human Services. Again, we point

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out that the ICD-9-CM coding terminology and the definitions of principal and other diagnoses of the UHDDS are consistent with the requirements of the Transactions and Code Sets Standards under HIPAA (45 CFR Parts 160 and 162).

The emphasis on the need for proper coding cannot be overstated. As under the present LTC-DRG system, inappropriate coding of cases under the proposed MS-LTC-DRG system could adversely affect the uniformity of cases in each proposed MS-LTC-DRG and produce inappropriate weighting factors at recalibration and result in inappropriate payments under the LTCH PPS. LTCHs are required to follow the same coding guidelines established under the IPPS, described in section II.G.10 of the preamble of this proposed rule established under the IPPS. It is mandatory that the coders continue to report the same principal diagnosis on all claims and include all diagnosis codes for conditions that coexist at the time of admission, for conditions that are subsequently developed, or for conditions that affect the treatment received. Similarly, all procedures performed in a LTCH, or paid for under arrangements by a LTCH (Sec. 412.509), during that stay are to be reported on each claim. Consistent with current practice, there will be only one proposed MS-LTC-DRG assigned to each discharge of the patient from a LTCH.

Under the proposed MS-LTC-DRG classification system, as is required under existing policy, upon the discharge of the patient from a LTCH, the LTCH must assign appropriate diagnosis and procedure codes from the ICD-9-CM. Completed claim forms are to be submitted electronically to the LTCH's fiscal intermediary (or, if applicable, MAC). The fiscal intermediary or MAC enters the clinical and demographic information into their claims processing systems and subject this information to a series of automated screening processes called the MCE. These screens are designed to identify cases that require further review before assignment into a LTC-DRG can be made.

After screening through the MCE, each LTCH claim will be classified into the appropriate LTC-DRG by the Medicare LTCH GROUPER. The LTCH GROUPER is specialized computer software and is the same GROUPER used under the IPPS. After the LTC-DRG is assigned, the fiscal intermediary or MAC determines the prospective payment by using the Medicare LTCH PPS PRICER program, which accounts for LTCH hospital-specific adjustments and payment rates. As provided for under the IPPS, we provide an opportunity for the LTCH to review the LTC-DRG assignments made by the fiscal intermediary or MAC and to submit additional information, if necessary, within a specified timeframe (Sec. 412.513(c)). Under the proposed adoption of the MS-LTC-DRG, there would be no changes in this procedure.

The LTCH GROUPER is used both to classify past cases in order to measure relative hospital resource consumption to establish the proposed MS-LTC-DRG weights and to classify current cases for purposes of determining payment. The records for all Medicare hospital inpatient discharges are maintained in the MedPAR file. The data in this file are used to evaluate possible DRG classification changes and to recalibrate the DRG weights during our annual update (as discussed in section II.H. of the preamble of this proposed rule). The proposed MS-LTC-DRG relative weights are based on data for the population of LTCH discharges. 3. Development of the Proposed FY 2008 MS-LTC-DRG Relative Weights a. General Overview of Development of the Proposed MS-LTC-DRG Relative Weights

As we stated in the August 30, 2002 LTCH PPS final rule (67 FR 55981), one of the primary goals for the implementation of the LTCH PPS is to pay each LTCH an appropriate amount for the efficient delivery of medical care to Medicare patients. The system must be able to account adequately for each LTCH's case-mix in order to ensure both fair distribution of Medicare payments and access to adequate care for those Medicare patients whose care is more costly. To accomplish these goals, we have annually adjusted the LTCH PPS standard Federal prospective payment system rate by the applicable LTC-DRG relative weight in determining payment to LTCHs for each case. (As we have noted above, we are proposing to adopt the MS-LTC-DRGs for the LTCH PPS for FY 2008. However, this proposed change in the patient classification system does not affect the basic principles of the development of relative weights under a DRG-based prospective payment system. For purposes of clarity, in the general discussion below in which we describe the basic methodology of the patient classification system, in use since the start of the LTCH PPS, we use ``MS-LTC-DRG'' to specify the proposed DRG system to be used by the LTCH prospective payment system in FY 2008.)

Although the proposed adoption of the MS-LTC-DRGs will result in some modifications of existing procedures for assigning weights in cases of zero volume and/or nonmonotonicity, discussed in detail in the following sections, the basic methodology for developing the proposed FY 2008 MS-LTC-DRG relative weights in this proposed rule continue to be determined in accordance with the general methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55989 through 55991). (Therefore, as noted above, in this preamble, ``LTC-DRGs'' will be used in descriptions of the basic methodology established at the beginning of the LTCH PPS that will remain unchanged if we adopt the proposed MS- LTC-DRGs. Use of ``MS-LTC-DRGs'' will indicate a discussion of specifics aspects of our proposed adoption of the severity-weighted patient classification system for FY 2008.)

Under the LTCH PPS, relative weights for each proposed MS-LTC-DRG are a primary element used to account for the variations in cost per discharge and resource utilization among the payment groups (Sec. 412.515). To ensure that Medicare patients classified to each proposed MS-LTC-DRG have access to an appropriate level of services and to encourage efficiency, we calculate a relative weight for each proposed MS-LTC-DRG that represents the resources needed by an average inpatient LTCH case in that proposed MS-LTC-DRG. For example, cases in a proposed MS-LTC-DRG with a relative weight of 2 will, on average, cost twice as much to treat as cases in a proposed MS-LTC-DRG with a weight of 1. b. Data

To calculate the proposed MS-LTC-DRG relative weights for FY 2008 in his proposed rule, we obtained total Medicare allowable charges from FY 2006 Medicare LTCH bill data from the December 2006 update of the MedPAR file, which are the best available data at this time, and we used the proposed Version 25.0 of the CMS GROUPER used under the IPPS (as discussed in section II.B. of the preamble of this proposed rule) to classify cases. To calculate the final MS-LTC-DRG relative weights for FY 2008, we are proposing that, if more recent data are available (that is, data from the March 2007 update of the MedPAR file), we would use those data and the finalized Version 25.0 of the CMS GROUPER used under the IPPS.

As we discussed in the FY 2007 IPPS final rule (71 FR 47974), we have excluded the data from LTCHs that are

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all-inclusive rate providers and LTCHs that are reimbursed in accordance with demonstration projects authorized under section 402(a) of Pub. L. 90-248. Data from demonstration projects authorized under section 222(a) of Pub. L. 92-603 are also excluded. Therefore, in the development of the proposed FY 2008 MS-LTC-DRG relative weights in this proposed rule, we have excluded the data of the 19 all-inclusive rate providers and the 3 LTCHs that are paid in accordance with demonstration projects that had claims in the FY 2006 MedPAR file. c. Hospital-Specific Relative Value Methodology

By nature, LTCHs often specialize in certain areas, such as ventilator-dependent patients and rehabilitation and wound care. Some case types (DRGs) may be treated, to a large extent, in hospitals that have, from a perspective of charges, relatively high (or low) charges. This nonarbitrary distribution of cases with relatively high (or low) charges in specific proposed MS-LTC-DRGs has the potential to inappropriately distort the measure of average charges. To account for the fact that cases may not be randomly distributed across LTCHs, we use a hospital-specific relative value (HSRV) method to calculate the proposed MS-LTC-DRG relative weights instead of the methodology used to determine the proposed CMS DRG relative weights under the IPPS described in section II.H. of the preamble this proposed rule. We believe this method will remove this hospital-specific source of bias in measuring LTCH average charges. Specifically, we reduce the impact of the variation in charges across providers on any particular LTC-DRG relative weight by converting each LTCH's charge for a case to a relative value based on that LTCH's average charge.

Under the HSRV method, we standardize charges for each LTCH by converting its charges for each case to hospital-specific relative charge values and then adjusting those values for the LTCH's case-mix. The adjustment for case-mix is needed to rescale the hospital-specific relative charge values (which, by definition, average 1.0 for each LTCH). The average relative weight for a LTCH is its case-mix, so it is reasonable to scale each LTCH's average relative charge value by its case-mix. In this way, each LTCH's relative charge value is adjusted by its case-mix to an average that reflects the complexity of the cases it treats relative to the complexity of the cases treated by all other LTCHs (the average case-mix of all LTCHs).

In accordance with the methodology established under Sec. 412.523, as implemented in the August 30, 2002 LTCH PPS final rule (67 FR 55989 through 55991), we continue to standardize charges for each case by first dividing the adjusted charge for the case (adjusted for short- stay outliers under Sec. 412.529 as described in section II.I.4. (step 3) of the preamble of this proposed rule) by the average adjusted charge for all cases at the LTCH in which the case was treated. Short- stay outliers under Sec. 412.529 are cases with a length of stay that is less than or equal to five-sixths the average length of stay of the proposed MS-LTC-DRG. The average adjusted charge reflects the average intensity of the health care services delivered by a particular LTCH and the average cost level of that LTCH. The resulting ratio is multiplied by that LTCH's case-mix index to determine the standardized charge for the case.

Multiplying by the LTCH's case-mix index accounts for the fact that the same relative charges are given greater weight at a LTCH with higher average costs than they would at a LTCH with low average costs, which is needed to adjust each LTCH's relative charge value to reflect its case-mix relative to the average case-mix for all LTCHs. Because we standardize charges in this manner, we count charges for a Medicare patient at a LTCH with high average charges as less resource intensive than they would be at a LTCH with low average charges. For example, a $10,000 charge for a case at a LTCH with an average adjusted charge of $17,500 reflects a higher level of relative resource use than a $10,000 charge for a case at a LTCH with the same case-mix, but an average adjusted charge of $35,000. We believe that the adjusted charge of an individual case more accurately reflects actual resource use for an individual LTCH because the variation in charges due to systematic differences in the markup of charges among LTCHs is taken into account. d. Proposed Treatment of Severity Levels in Developing Relative Weights

With the implementation of the LTCH PPS for FY 2003, we established a procedure to address setting relative weights for LTC-DRG ``pairs'' that were differentiated on the presence or absence of CCs (71 FR 47979). For FY 2008, we are proposing to adopt a severity-based patient classification system for the LTCH PPS, the MS-LTC-DRGs described above, which requires us to adapt our existing procedures for dealing with setting relative weights for the severity levels within a specific base DRG. We are also proposing to modify our existing methodology for maintaining monotonicity when setting relative weights for the proposed MS-LTC-DRGs.

As under the existing procedure, under the proposed MS-LTC-DRGs, for purposes of the annual setting of the relative weights, there continue to be three different categories of DRGs based on volume of cases within specific LTC-DRGs. DRGs with at least 25 cases are each assigned a relative weight; low-volume proposed MS-LTC-DRGs (that is, proposed MS-LTC-DRGs that contain between one and 24 cases annually) are grouped into quintiles (described below) and assigned the weight of the quintile. Cases with no-volume proposed MS-LTC-DRGs (that is, no cases in the databases were assigned to those proposed MS-LTC-DRGs) are crosswalked to other proposed MS-LTC-DRGs based on the clinical similarities and assigned the weight of the quintile that is closest to the relative weight of the crosswalked proposed MS-LTC-DRG. (We provide in-depth discussions of our proposals regarding weightsetting for low- volume MS-LTC-DRGs in section II.I.3.e. of the preamble of this proposed rule and for no-volume MS-LTC-DRGs, under Step 4 in section II.I.4. of the preamble of this proposed rule.)

As described above, in response to the need to account for severity and pay appropriately for cases, we have developed a severity-adjusted patient classification system which we are proposing for both the IPPS and the LTCH PPS. As described in greater detail above, the proposed MS-LTC-DRG system can accommodate three severity levels: MCC (most severe); without CC/MCC (the least severe), and with CC, with each level assigned an individual MS-LTC-DRG number. In cases with two subdivisions, the levels are either with CC/MCC and without CC/MCC or with MCC and without MCC. Two parallel numbering systems have been developed, based on the MS-DRG patient classification system proposed under the IPPS, to describe proposed MS-LTC-DRGs. That is, while each severity level in each DRG category gets a unique MS-LTC-DRG number, in conjunction, each of the severity levels in a single DRG category are also assigned the same ``base-DRG'' number. We are proposing that the term ``base DRG'' is actually the MS-LTC-DRG number of the highest severity level and would be used when we refer to the MS-LTC-DRG category that encompasses all the levels of severity for that DRG. Therefore, under the proposed system, multiple sclerosis and cerebellar ataxia with MCC is MS-LTC-DRG 58; multiple sclerosis and

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cerebellar ataxia with CC is MS-LTC-DRG 59; and multiple sclerosis and cerebellar ataxia without CC/MCC is MS-LTC-DRG 59, and the base MS-LTC- DRG for each is 58.

As noted above, for FY 2008, we are proposing to adopt the MS-DRGs for use in both the LTCH PPS and the IPPS. While the LTCH PPS and the IPPS use the same patient classification system, the methodology that is used to set the DRG weights for use in each payment system differs because the overall volume of cases in the LTCH PPS is much less than in the IPPS. As a general rule, we are proposing to set the weights for the MS-LTC-DRGs using the following steps: (1) If an MS-LTC-DRG has at least 25 cases, it is assigned its own relative weight; (2) if an MS- LTC-DRGs has between 1 and 24 cases, it is assigned to a quintile to which we will assign a relative weight; and (3) if an MS-LTC-DRG has no cases, it is crosswalked to another DRG based upon clinical similarities and assigned the appropriate relative weight (as described in detail in Step 5, below).

Theoretically, as with the existing LTC-DRG system, cases under the proposed MS-LTC-DRG system that are more severe require greater expenditure of medical care resources and will result in higher average charges. Therefore, in the three severity levels, weights should increase with severity, from lowest to highest. If the weights do not increase (that is, if based on the weight calculation, a proposed MS- LTC-DRG with MCC would have a lower relative weight than one with CC, or the DRG without CC/MCC would have a higher relative weight than either of the others), there is a problem with monotonicity. Since the start of the LTCH PPS for FY 2003 (67 FR 55990), we have adjusted the setting of the LTC-DRG relative weight in order to maintain monotonicity by grouping both sets of cases together and establishing a new relative weight that is assigned to both LTC-DRGs. Similarly, we are proposing a procedure for dealing with nonmonotonicity under the proposed MS-LTC-DRG classification system that we describe in detail in our explanation of our methodology for setting the proposed FY 2008 relative weights for the LTCH PPS, which is discussed in section II.F.4 of the preamble of this proposed rule. e. Low-Volume Proposed MS-LTC-DRGs

In order to account for LTC-DRGs with low volume (that is, with fewer than 25 LTCH cases), under current policy, in accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55984), we group those ``low-volume LTC-DRGs'' (that is, DRGs that contained between 1 and 24 cases annually) into one of five categories (quintiles) based on average charges, for the purposes of determining relative weights. For this FY 2008 IPPS proposed rule, we are proposing to continue to employ this treatment of low-volume proposed MS-LTC-DRGs with a modification to combine proposed MS-LTC-DRGs for the purpose of computing a relative weight in cases where necessary to maintain monotonicity in determining the proposed FY 2008 MS-LTC-DRG relative weights using the best available LTCH data. In this proposed rule, using LTCH cases from the December 2006 update of the FY 2006 MedPAR file, we identified 307 proposed MS-LTC-DRGs that contained between 1 and 24 cases. This list of proposed MS-LTC-DRGs was then divided into one of the 5 low-volume quintiles, each containing a minimum of 61 proposed MS-LTC-DRGs (307/5 = 61, with a remainder of 2 proposed MS- LTC-DRGs). Consistent with our current methodology, we are proposing to make an assignment to a specific low-volume quintile by sorting the low-volume proposed MS-LTC-DRGs in ascending order by average charge. For this proposed rule, this results in a proposed assignment to a specific low-volume quintile of the sorted 307 low-volume proposed MS- LTC-DRGs by ascending order by average charge. Because the number of low-volume proposed MS-LTC-DRGs for FY 2008 is not evenly divisible by five, to determine the composition of the low-volume quintiles in accordance with our established methodology, the average charge of the low-volume proposed MS-LTC-DRG was used to determine which low-volume quintile received the additional proposed MS-LTC-DRGs. After sorting the 307 low-volume proposed MS-LTC-DRGs in ascending order, we grouped the first fifth (1st through 61st) of low-volume proposed MS-LTC-DRGs (with the lowest average charge) into Quintile 1. Because the average charge of the 62nd proposed MS-LTC-DRG in the sorted list is closer to the 61st proposed MS-LTC-DRGs average charge (assigned to Quintile 1) than to the average charge of the 63rd proposed MS-LTC-DRG in the sorted list (to be assigned to Quintile 2), we placed the 62nd proposed MS-LTC-DRG into Quintile 1. This process was repeated through the remaining low-volume proposed MS-LTC-DRGs so that 2 low-volume quintiles contain 62 proposed MS-LTC-DRGs and 3 low-volume quintiles contain 61 proposed MS-LTC-DRGs. The highest average charge cases were grouped into Quintile 5.

In order to determine the proposed relative weights for the proposed MS-LTC-DRGs with low-volume for FY 2008, based on the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55984), we are proposing to use the five low-volume quintiles described above. In addition, in cases where the initial assignment of the low-volume proposed MS-LTC-DRGs to quintiles results in nonmonotonicity within a base DRG, we are proposing to combine those proposed MS-LTC-DRGs for the purpose of computing a relative weight and set the same relative weight to each of the proposed MS-LTC-DRGs within the base DRG that required combining. The treatment of low-volume proposed MS-LTC-DRGs to preserve monotonicity is further discussed in detail in section II.I.4 (Step 6 of the methodology for determining the proposed FY 2008 MS-LTC-DRG relative weights). The composition of each of the proposed five low-volume quintiles shown in the chart below was used in determining the proposed MS-LTC-DRG relative weights for FY 2008. We would determine a proposed relative weight and (geometric) average length of stay for each of the proposed five low-volume quintiles using the methodology that we apply to the regular proposed MS-LTC-DRGs (25 or more cases), as described below in section II.I.4. of the preamble of this proposed rule. We are proposing to assign the same relative weight and average length of stay to each of the proposed MS-LTC-DRGs that make up an individual proposed low-volume quintile. We note that, as this system is dynamic, it is possible that the number and specific type of MS-LTC-DRGs with a low volume of LTCH cases will vary in the future. We use the best available claims data in the MedPAR file to identify low-volume MS-LTC-DRGs and to calculate the relative weights based on our methodology. Therefore, we are proposing that, if we have updated data for the final rule, we will use that data to determine the finalized FY 2008 relative weights.

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Proposed Composition of Low-Volume Quintiles for FY 2008

Proposed MS-LTC-DRG

Proposed MS-LTC-DRG description

QUINTILE 1

30.......................... Spinal procedures w/o CC/MCC. 32.......................... Ventricular shunt procedures w CC. 33.......................... Ventricular shunt procedures w/o CC/MCC. 58.......................... Multiple sclerosis & cerebellar ataxia w MCC*. 60.......................... Multiple sclerosis & cerebellar ataxia w/o CC/MCC*. 66.......................... Intracranial hemorrhage or cerebral infarction w/o CC/MCC. 67.......................... Nonspecific CVA & precerebral occlusion w/ o infarct w MCC. 68.......................... Nonspecific CVA & precerebral occlusion w/ o infarct w/o MCC. 69.......................... Transient ischemia. 72.......................... Nonspecific cerebrovascular disorders w/o CC/MCC. 76.......................... Viral meningitis w/o CC/MCC. 79.......................... Hypertensive encephalopathy w/o CC/MCC. 88.......................... Concussion w MCC***. 133......................... Other ear, nose, mouth & throat O.R. procedures w CC/MCC***. 122......................... Acute major eye infections w/o CC/MCC. 123......................... Neurological eye disorders. 149......................... Dysequilibrium. 153......................... Otitis media & URI w/o MCC. 182......................... Respiratory neoplasms w/o CC/MCC. 183......................... Major chest trauma w MCC. 184......................... Major chest trauma w CC**. 201......................... Pneumothorax w/o CC/MCC. 261......................... Cardiac pacemaker revision except device replacement w CC. 262......................... Cardiac pacemaker revision except device replacement w/o CC/MCC. 313......................... Chest pain. 328......................... Stomach, esophageal & duodenal proc w/o CC/ MCC. 331......................... Major small & large bowel procedures w/o CC/MCC. 349......................... Anal & stomal procedures w/o CC/MCC. 376......................... Digestive malignancy w/o CC/MCC. 434......................... Cirrhosis & alcoholic hepatitis w/o CC/ MCC*. 446......................... Disorders of the biliary tract w/o CC/MCC. 505......................... Foot procedures w/o CC/MCC. 512......................... Shoulder, elbow or forearm proc, exc major joint proc w/o CC/MCC. 544......................... Pathological fractures & musculoskelet & conn tiss malig w/o CC/MCC. 547......................... Connective tissue disorders w/o CC/MCC. 563......................... Fx, sprn, strn & disl except femur, hip, pelvis & thigh w/o MCC. 598......................... Malignant breast disorders w CC***. 630......................... Other endocrine, nutrit & metab O.R. proc w/o CC/MCC. 645......................... Endocrine disorders w/o CC/MCC. 661......................... Kidney & ureter procedures for non- neoplasm w/o CC/MCC. 688......................... Kidney & urinary tract neoplasms w/o CC/ MCC. 696......................... Kidney & urinary tract signs & symptoms w/ o MCC. 714......................... Transurethral prostatectomy w/o CC/MCC. 718......................... Other male reproductive system O.R. proc exc malignancy w/o CC/MCC. 724......................... Malignancy, male reproductive system w/o CC/MCC. 726......................... Benign prostatic hypertrophy w/o MCC. 756......................... Malignancy, female reproductive system w/o CC/MCC. 759......................... Infections, female reproductive system w/o CC/MCC. 761......................... Menstrual & other female reproductive system disorders w/o CC/MCC. 825......................... Lymphoma & non-acute leukemia w other O.R. proc w/o CC/MCC. 836......................... Acute leukemia w/o major O.R. procedure w/ o CC/MCC. 869......................... Other infectious & parasitic diseases diagnoses w/o CC/MCC. 876......................... O.R. procedure w principal diagnoses of mental illness. 881......................... Depressive neuroses. 882......................... Neuroses except depressive. 883......................... Disorders of personality & impulse control. 886......................... Behavioral & developmental disorders. 894......................... Alcohol/drug abuse or dependence, left ama. 895......................... Alcohol/drug abuse or dependence w rehabilitation therapy. 906......................... Hand procedures for injuries. 916......................... Allergic reactions w/o MCC. 922......................... Other injury, poisoning & toxic effect diag w MCC. 923......................... Other injury, poisoning & toxic effect diag w/o MCC.

QUINTILE 2

75.......................... Viral meningitis w CC/MCC. 77.......................... Hypertensive encephalopathy w MCC.

[[Page 24761]]

78.......................... Hypertensive encephalopathy w CC**. 83.......................... Traumatic stupor & coma, coma >1 hr w CC. 84.......................... Traumatic stupor & coma, coma >1 hr w/o CC/ MCC. 99.......................... Non-bacterial infect of nervous sys exc viral meningitis w/o CC/MCC. 102......................... Headaches w MCC***. 113......................... Orbital procedures w CC/MCC. 121......................... Acute major eye infections w CC/MCC. 125......................... Other disorders of the eye w/o MCC. 148......................... Ear, nose, mouth & throat malignancy w/o CC/MCC. 152......................... Otitis media & URI w MCC. 156......................... Nasal trauma & deformity w/o CC/MCC. 157......................... Dental & Oral Diseases w MCC***. 158......................... Dental & Oral Diseases w CC***. 184......................... Major chest trauma w CC***. 188......................... Pleural effusion w/o CC/MCC*. 200......................... Pneumothorax w CC. 245......................... AICD lead & generator procedures. 282......................... Circulatory disorders w AMI, discharged alive w/o CC/MCC. 285......................... Circulatory disorders w AMI, expired w/o CC/MCC*. 304......................... Hypertension w MCC. 311......................... Angina pectoris. 336......................... Peritoneal adhesiolysis w CC. 382......................... Complicated peptic ulcer w/o CC/MCC. 384......................... Uncomplicated peptic ulcer w/o MCC. 390......................... G.I. obstruction w/o CC/MCC. 433......................... Cirrhosis & alcoholic hepatitis w CC*. 437......................... Malignancy of hepatobiliary system or pancreas w/o CC/MCC. 443......................... Disorders of liver except malig, cirr, alc hepa w/o CC/MCC. 499......................... Local excision & removal int fix devices of hip & femur w/o CC/MCC. 514......................... Hand or wrist proc, except major thumb or joint proc w/o CC/MCC. 534......................... Fractures of femur w/o MCC. 535......................... Fractures of hip & pelvis w MCC. 553......................... Bone diseases & arthropathies w MCC. 555......................... Signs & symptoms of musculoskeletal system & conn tissue w MCC. 556......................... Signs & symptoms of musculoskeletal system & conn tissue w/o MCC. 578......................... Skin graft &/or debrid exc for skin ulcer or cellulitis w/o CC/MCC. 598......................... Malignant breast disorders w CC**. 599......................... Malignant breast disorders w/o CC/MCC**. 600......................... Non-malignant breast disorders w CC/MCC. 601......................... Non-malignant breast disorders w/o CC/MCC. 642......................... Inborn errors of metabolism. 660......................... Kidney & ureter procedures for non- neoplasm w CC. 687......................... Kidney & urinary tract neoplasms w CC. 693......................... Urinary stones w/o ESW lithotripsy w MCC. 694......................... Urinary stones w/o ESW lithotripsy w/o MCC**. 723......................... Malignancy, male reproductive system w CC. 730......................... Other male reproductive system diagnoses w/ o CC/MCC. 744......................... D&C, conization, laparoscopy & tubal interruption w CC/MC 769......................... Postpartum & post abortion diagnoses w O.R. procedure. 803......................... Other O.R. proc of the blood & blood forming organs w CC. 815......................... Reticuloendothelial & immunity disorders w CC. 816......................... Reticuloendothelial & immunity disorders w/ o CC/MCC**. 842......................... Lymphoma & non-acute leukemia w/o CC/MCC. 848......................... Chemotherapy w/o acute leukemia as secondary diagnosis w/o CC/MCC. 864......................... Fever of unknown origin. 897......................... Alcohol/drug abuse or dependence w/o rehabilitation therapy w/o MCC. 903......................... Wound debridements for injuries w/o CC/ MCC. 905......................... Skin grafts for injuries w/o CC/MCC. 917......................... Poisoning & toxic effects of drugs w MCC. 918......................... Poisoning & toxic effects of drugs w/o MCC. 929......................... Full thickness burn w skin graft or inhal inj w/o CC/MCC. 956......................... Limb reattachment, hip & femur proc for multiple significant trauma. 964......................... Other multiple significant trauma w CC. 965......................... Other multiple significant trauma w/o CC/ MCC. 977......................... HIV w or w/o other related condition.

QUINTILE 3

42.......................... Periph & cranial nerve & other nerv syst proc w/o CC/MCC. 53.......................... Spinal disorders & injuries w/o CC/MCC.

[[Page 24762]]

78.......................... Hypertensive encephalopathy w CC***. 102......................... Headaches w MCC**. 103......................... Headaches w/o MCC. 133......................... Other ear, nose, mouth & throat O.R. procedures w CC/MCC**. 134......................... Other ear, nose, mouth & throat O.R. procedures w/o CC/MCC**. 157......................... Dental & Oral Diseases w MCC**. 158......................... Dental & Oral Diseases w CC**. 159......................... Dental & Oral Diseases w/o CC/MCC**. 238......................... Major cardiovascular procedures w/o MCC. 246......................... Percutaneous cardiovascular proc w drug- eluting stent w MCC. 250......................... Perc cardiovasc proc w/o coronary artery stent or AMI w MCC. 263......................... Vein ligation & stripping. 284......................... Circulatory disorders w AMI, expired w CC*. 287......................... Circulatory disorders except AMI, w card cath w/o MCC. 294......................... Deep vein thrombophlebitis w CC/MCC. 347......................... Anal & stomal procedures w MCC. 348......................... Anal & stomal procedures w CC. 352......................... Inguinal & femoral hernia procedures w/o CC/MCC. 354......................... Hernia procedures except inguinal & femoral w CC. 358......................... Other digestive system O.R. procedures w/o CC/MCC. 380......................... Complicated peptic ulcer w MCC. 381......................... Complicated peptic ulcer w CC. 383......................... Uncomplicated peptic ulcer w MCC. 387......................... Inflammatory bowel disease w/o CC/MCC*. 420......................... Hepatobiliary diagnostic procedures w MCC. 421......................... Hepatobiliary diagnostic procedures w CC. 424......................... Other hepatobiliary or pancreas O.R. procedures w CC. 425......................... Other hepatobiliary or pancreas O.R. procedures w/o CC/MCC. 494......................... Lower extrem & humer proc except hip, foot, femur w/o CC/MCC. 502......................... Soft tissue procedures w/o CC/MCC. 504......................... Foot procedures w CC. 507......................... Major shoulder or elbow joint procedures w CC/MCC. 517......................... Other musculoskelet sys & conn tiss O.R. proc w/o CC/MCC. 533......................... Fractures of femur w MCC. 597......................... Malignant breast disorders w MCC. 599......................... Malignant breast disorders w/o CC/MCC***. 604......................... Trauma to the skin, subcut tiss & breast w MCC. 618......................... Amputat of lower limb for endocrine, nutrit, & metabol dis w/o CC/MCC. 619......................... O.R. procedures for obesity w MCC. 620......................... O.R. procedures for obesity w CC**. 624......................... Skin grafts & wound debrid for endoc, nutrit & metab dis w/o CC/MCC. 644......................... Endocrine disorders w CC. 657......................... Kidney & ureter procedures for neoplasm w CC. 662......................... Minor bladder procedures w MCC. 665......................... Prostatectomy w MCC. 667......................... Prostatectomy w/o CC/MCC. 694......................... Urinary stones w/o ESW lithotripsy w/o MCC***. 695......................... Kidney & urinary tract signs & symptoms w MCC. 711......................... Testes procedures w CC/MCC***. 722......................... Malignancy, male reproductive system w MCC. 746......................... Vagina, cervix & vulva procedures w CC/ MCC. 749......................... Other female reproductive system O.R. procedures w CC/MCC. 755......................... Malignancy, female reproductive system w CC. 809......................... Major hematol/immune diag exc sickle cell crisis & coagul w CC. 810......................... Major hematol/immune diag exc sickle cell crisis & coagul w/o CC/MCC. 816......................... Reticuloendothelial & immunity disorders w/ o CC/MCC***. 821......................... Lymphoma & leukemia w major O.R. procedure w CC. 826......................... Myeloprolif disord or poorly diff neopl w maj O.R. proc w MCC. 834......................... Acute leukemia w/o major O.R. procedure w MCC. 835......................... Acute leukemia w/o major O.R. procedure w CC. 838......................... Chemo w acute leukemia as sdx or w high dose chemo agent w CC. 843......................... Other myeloprolif dis or poorly diff neopl diag w MCC***. 844......................... Other myeloprolif dis or poorly diff neopl diag w CC***. 855......................... Infectious & parasitic diseases w O.R. procedure w/o CC/MCC. 896......................... Alcohol/drug abuse or dependence w/o rehabilitation therapy w MCC. 963......................... Other multiple significant trauma w MCC. 989......................... Non-extensive O.R. proc unrelated to principal diagnosis w/o CC/MCC.

QUINTILE 4

28.......................... Spinal procedures w MCC.

[[Page 24763]]

29.......................... Spinal procedures w CC. 38.......................... Extracranial procedures w CC. 39.......................... Extracranial procedures w/o CC/MCC. 88.......................... Concussion w MCC**. 89.......................... Concussion w CC. 124......................... Other disorders of the eye w MCC. 168......................... Other resp system O.R. procedures w/o CC/ MCC. 241......................... Amputation for circ sys disorders exc upper limb & toe w/o CC/MCC 242......................... Permanent cardiac pacemaker implant w MCC***. 244......................... Permanent cardiac pacemaker implant w/o CC/MCC. 254......................... Other vascular procedures w/o CC/MCC. 257......................... Upper limb & toe amputation for circ system disorders w/o CC/MCC*. 286......................... Circulatory disorders except AMI, w card cath w MCC. 351......................... Inguinal & femoral hernia procedures w CC. 368......................... Major esophageal disorders w MCC. 369......................... Major esophageal disorders w CC. 370......................... Major esophageal disorders w/o CC/MCC**. 408......................... Biliary tract proc except only cholecyst w or w/o c.d.e. w MCC***. 407......................... Pancreas, liver & shunt procedures w/o CC/ MCC. 412......................... Cholecystectomy w c.d.e. w CC. 414......................... Cholecystectomy except by laparoscope w/o c.d.e. w MCC. 415......................... Cholecystectomy except by laparoscope w/o c.d.e. w CC. 418......................... Laparoscopic cholecystectomy w/o c.d.e. w CC. 423......................... Other hepatobiliary or pancreas O.R. procedures w MCC. 472......................... Cervical spinal fusion w CC. 476......................... Amputation for musculoskeletal sys & conn tissue dis w/o CC/MCC*. 478......................... Biopsies of musculoskeletal system & connective tissue w CC. 479......................... Biopsies of musculoskeletal system & connective tissue w/o CC/MCC. 482......................... Hip & femur procedures except major joint w/o CC/MCC. 486......................... Knee procedures w pdx of infection w CC. 487......................... Knee procedures w pdx of infection w/o CC/ MCC. 490......................... Back & neck procedures except spinal fusion w CC/MCC or disc devices. 493......................... Lower extrem & humer proc except hip, foot, femur w CC. 497......................... Local excision & removal int fix devices exc hip & femur w/o CC/MCC. 503......................... Foot procedures w MCC. 511......................... Shoulder, elbow or forearm proc, exc major joint proc w CC. 516......................... Other musculoskelet sys & conn tiss O.R. proc w CC. 562......................... Fx, sprn, strn & disl except femur, hip, pelvis & thigh w MCC. 576......................... Skin graft &/or debrid exc for skin ulcer or cellulitis w MCC. 577......................... Skin graft &/or debrid exc for skin ulcer or cellulitis w CC. 584......................... Breast biopsy, local excision & other breast procedures w CC/MCC. 620......................... O.R. procedures for obesity w CC***. 659......................... Kidney & ureter procedures for non- neoplasm w MCC. 675......................... Other kidney & urinary tract procedures w/ o CC/MCC. 709......................... Penis procedures w CC/MCC. 711......................... Testes procedures w CC/MCC**. 712......................... Testes procedures w/o CC/MCC**. 717......................... Other male reproductive system O.R. proc exc malignancy w CC/MCC. 725......................... Benign prostatic hypertrophy w MCC. 754......................... Malignancy, female reproductive system w MCC. 760......................... Menstrual & other female reproductive system disorders w CC/MCC. 776......................... Postpartum & post abortion diagnoses w/o O.R. procedure. 781......................... Other antepartum diagnoses w medical complications. 823......................... Lymphoma & non-acute leukemia w other O.R. proc w MCC. 824......................... Lymphoma & non-acute leukemia w other O.R. proc w CC. 843......................... Other myeloprolif dis or poorly diff neopl diag w MCC**. 844......................... Other myeloprolif dis or poorly diff neopl diag w CC**. 845......................... Other myeloprolif dis or poorly diff neopl diag w/o CC/MCC**. 880......................... Acute adjustment reaction & psychosocial dysfunction. 909......................... Other O.R. procedures for injuries w/o CC/ MCC. 928......................... Full thickness burn w skin graft or inhal inj w CC/MCC. 933......................... Extensive burns or full thickness burns w MV 96+ hrs w/o skin graft. 958......................... Other O.R. procedures for multiple significant trauma w CC. 983......................... Extensive O.R. procedure unrelated to principal diagnosis w/o CC/MCC. 985......................... Prostatic O.R. procedure unrelated to principal diagnosis w CC. 986......................... Prostatic O.R. procedure unrelated to principal diagnosis w/o CC/MCC.

QUINTILE 5

12.......................... Tracheostomy for face, mouth & neck diagnoses w CC.

[[Page 24764]]

26.......................... Craniotomy & endovascular intracranial procedures w CC. 31.......................... Ventricular shunt procedures w MCC. 37.......................... Extracranial procedures w MCC. 131......................... Cranial/facial procedures w CC/MCC. 134......................... Other ear, nose, mouth & throat O.R. procedures w/o CC/MCC***. 137......................... Mouth procedures w CC/MCC. 139......................... Salivary gland procedures. 159......................... Dental & Oral Diseases w/o CC/MCC***. 164......................... Major chest procedures w CC. 226......................... Cardiac defibrillator implant w/o cardiac cath w MCC. 227......................... Cardiac defibrillator implant w/o cardiac cath w/o MCC. 237......................... Major cardiovascular procedures w MCC. 242......................... Permanent cardiac pacemaker implant w MCC**. 243......................... Permanent cardiac pacemaker implant w CC. 248......................... Percutaneous cardiovasc proc w non-drug- eluting stent w MCC. 258......................... Cardiac pacemaker device replacement w MCC. 260......................... Cardiac pacemaker revision except device replacement w MCC. 327......................... Stomach, esophageal & duodenal proc w CC. 329......................... Major small & large bowel procedures w MCC. 330......................... Major small & large bowel procedures w CC. 335......................... Peritoneal adhesiolysis w MCC. 350......................... Inguinal & femoral hernia procedures w MCC. 370......................... Major esophageal disorders w/o CC/MCC***. 405......................... Pancreas, liver & shunt procedures w MCC. 406......................... Pancreas, liver & shunt procedures w CC. 408......................... Biliary tract proc except only cholecyst w or w/o c.d.e. w MCC**. 409......................... Biliary tract proc except only cholecyst w or w/o c.d.e. w CC. 417......................... Laparoscopic cholecystectomy w/o c.d.e. w MCC. 454......................... Combined anterior/posterior spinal fusion w CC. 456......................... Spinal fusion exc cerv w spinal curv, malig or 9+ fusions w MCC. 459......................... Spinal fusion except cervical w MCC. 460......................... Spinal fusion except cervical w/o MCC. 466......................... Revision of hip or knee replacement w MCC. 467......................... Revision of hip or knee replacement w CC. 469......................... Major joint replacement or reattachment of lower extremity w MCC. 470......................... Major joint replacement or reattachment of lower extremity w/o MCC. 471......................... Cervical spinal fusion w MCC. 477......................... Biopsies of musculoskeletal system & connective tissue w MCC. 480......................... Hip & femur procedures except major joint w MCC. 481......................... Hip & femur procedures except major joint w CC. 485......................... Knee procedures w pdx of infection w MCC. 488......................... Knee procedures w/o pdx of infection w CC/ MCC. 492......................... Lower extrem & humer proc except hip, foot, femur w MCC. 498......................... Local excision & removal int fix devices of hip & femur w CC/MCC. 513......................... Hand or wrist proc, except major thumb or joint proc w CC/MCC. 582......................... Mastectomy for malignancy w CC/MCC. 664......................... Minor bladder procedures w/o CC/MCC. 668......................... Transurethral procedures w MCC. 669......................... Transurethral procedures w CC. 670......................... Transurethral procedures w/o CC/MCC. 691......................... Urinary stones w esw lithotripsy w CC/MCC. 712......................... Testes procedures w/o CC/MCC***. 713......................... Transurethral prostatectomy w CC/MCC. 715......................... Other male reproductive system O.R. proc for malignancy w CC/MCC. 802......................... Other O.R. proc of the blood & blood forming organs w MCC. 829......................... Myeloprolif disord or poorly diff neopl w other O.R. proc w CC/MCC. 837......................... Chemo w acute leukemia as sdx or w high dose chemo agent w MCC. 845......................... Other myeloprolif dis or poorly diff neopl diag w/o CC/MCC***. 957......................... Other O.R. procedures for multiple significant trauma w MCC. 969......................... HIV w extensive O.R. procedure w MCC. 970......................... HIV w extensive O.R. procedure w/o MCC. 984......................... Prostatic O.R. procedure unrelated to principal diagnosis w MCC

* One of the original 307 low-volume proposed MS-LTC-DRGs initially assigned to this proposed low-volume quintile; removed from this proposed low-volume quintile in addressing nonmonotonicity (see step 6 below). ** One of the original 307 low-volume proposed MS-LTC-DRGs initially assigned to a different proposed low-volume quintile but moved to this proposed low-volume quintile in addressing nonmonotonicity (see step 6 below). *** One of the original 307 low-volume proposed MS-LTC-DRGs initially assigned to this proposed low-volume quintile but moved to a different proposed low-volume quintile in addressing nonmonotonicity (see step 6 below).

[[Page 24765]]

We note that we will continue to monitor the volume (that is, the number of LTCH cases) in these low-volume quintiles to ensure that our proposed quintile assignment results in appropriate payment for such cases and does not result in an unintended financial incentive for LTCHs to inappropriately admit these types of cases.

4. Steps for Determining the Proposed FY 2008 MS-LTC-DRG Relative Weights

As we noted previously, although the proposed adoption of the MS- LTC-DRGs will result in some modifications of existing procedures for assigning weights in cases of zero volume and/or nonmonotonicity, described in detail elsewhere in this section, the proposed FY 2008 MS- LTC-DRG relative weights in this proposed rule are based on the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55989 through 55991). In summary, for FY 2008, LTCH cases would be grouped to the appropriate MS-LTC-DRG, while taking into account the low-volume proposed MS-LTC-DRGs as described above, before the proposed FY 2008 MS-LTC-DRG relative weights can be determined. After grouping the cases to the appropriate proposed MS-LTC-DRG, we are proposing to calculate the proposed relative weights for FY 2008 by first removing statistical outliers and cases with a length of stay of 7 days or less, as discussed in greater detail below. Next, we are proposing to adjust the number of cases in each proposed MS-LTC-DRG for the effect of short-stay outlier cases under Sec. 412.529, as also discussed in greater detail below. The short-stay adjusted discharges and corresponding charges are used to calculate ``relative adjusted weights'' in each proposed MS-LTC-DRG using the HSRV method described above.

Below we discuss in detail the steps for calculating the proposed FY 2008 MS-LTC-DRG relative weights. We note that, as we stated above in section II.I.3.b. of the preamble of this proposed rule, we have excluded the data of all-inclusive rate LTCHs and LTCHs that are paid in accordance with demonstration projects that had claims in the FY 2006 MedPAR file.

Step 1--Remove statistical outliers.

The first step in the calculation of the proposed FY 2008 MS-LTC- DRG relative weights is to remove statistical outlier cases. We define statistical outliers as cases that are outside of 3.0 standard deviations from the mean of the log distribution of both charges per case and the charges per day for each proposed MS-LTC-DRG. These statistical outliers are removed prior to calculating the proposed relative weights. As noted above, we believe that they may represent aberrations in the data that distort the measure of average resource use. Including those LTCH cases in the calculation of the proposed relative weights could result in an inaccurate relative weight that does not truly reflect relative resource use among the proposed MS-LTC- DRGs.

Step 2--Remove cases with a length of stay of 7 days or less.

The proposed FY 2008 MS-LTC-DRG relative weights reflect the average of resources used on representative cases of a specific type. Generally, cases with a length of stay of 7 days or less do not belong in a LTCH because these stays do not fully receive or benefit from treatment that is typical in a LTCH stay, and full resources are often not used in the earlier stages of admission to a LTCH. As explained above, if we were to include stays of 7 days or less in the computation of the proposed FY 2008 MS-LTC-DRG relative weights, the value of many relative weights would decrease and, therefore, payments would decrease to a level that may no longer be appropriate. We do not believe that it would be appropriate to compromise the integrity of the payment determination for those LTCH cases that actually benefit from and receive a full course of treatment at a LTCH, by including data from these very short-stays. Thus, as explained above, in determining the proposed FY 2008 MS-LTC-DRG relative weights, we remove LTCH cases with a length of stay of 7 days or less.

Step 3--Adjust charges for the effects of short-stay outliers.

After removing cases with a length of stay of 7 days or less, we are left with cases that have a length of stay of greater than or equal to 8 days. The next step in the calculation of the proposed FY 2008 MS- LTC-DRG relative weights is to adjust each LTCH's charges per discharge for those remaining cases for the effects of short-stay outliers as defined in Sec. 412.529(a). (We note that even if a case was removed in Step 2 (that is, cases with a length of stay of 7 days or less), it was paid as a short-stay outlier if its length of stay was less than or equal to five-sixths of the average length of stay of the MS-LTC-DRG, in accordance with Sec. 412.529.)

We make this adjustment by counting a short-stay outlier as a fraction of a discharge based on the ratio of the length of stay of the case to the average length of stay for the proposed MS-LTC-DRG for non- short-stay outlier cases. This has the effect of proportionately reducing the impact of the lower charges for the short-stay outlier cases in calculating the average charge for the proposed MS-LTC-DRG. This process produces the same result as if the actual charges per discharge of a short-stay outlier case were adjusted to what they would have been had the patient's length of stay been equal to the average length of stay of the proposed MS-LTC-DRG.

As we explained in the FY 2007 IPPS final (71 FR 47979), counting short-stay outlier cases as full discharges with no adjustment in determining the proposed MS-LTC-DRG relative weights would lower the proposed LTC-DRG relative weight for affected proposed MS-LTC-DRGs because the relatively lower charges of the short-stay outlier cases would bring down the average charge for all cases within a proposed MS- LTC-DRG. This would result in an ``underpayment'' for nonshort-stay outlier cases and an ``overpayment'' for short-stay outlier cases. Therefore, we adjust for short-stay outlier cases under Sec. 412.529 in this manner because it results in more appropriate payments for all LTCH cases.

Step 4--Calculate the proposed FY 2008 MS-LTC-DRG relative weights on an iterative basis.

The process of calculating the proposed MS-LTC-DRG relative weights using the HSRV methodology is iterative. First, for each LTCH case, we calculate a hospital-specific relative charge value by dividing the short-stay outlier adjusted charge per discharge (see step 3) of the LTCH case (after removing the statistical outliers (see step 1)) and LTCH cases with a length of stay of 7 days or less (see step 2) by the average charge per discharge for the LTCH in which the case occurred. The resulting ratio is then multiplied by the LTCH's case-mix index to produce an adjusted hospital-specific relative charge value for the case. An initial case-mix index value of 1.0 is used for each LTCH.

For each proposed DRG, the proposed FY 2008 MS-LTC-DRG relative weight is calculated by dividing the average of the adjusted hospital- specific relative charge values (from above) for the proposed MS-LTC- DRG by the overall average hospital-specific relative charge value across all cases for all LTCHs. Using these proposed recalculated MS- LTC-DRG relative weights, each LTCH's average relative weight for all of its cases (case-mix) is calculated by dividing the sum of all the LTCH's proposed MS-LTC-DRG relative weights by its total number of cases. The LTCHs' hospital-specific relative charge values above are multiplied by these hospital-specific case-mix indexes. These hospital- specific case-mix

[[Page 24766]]

adjusted relative charge values are then used to calculate a new set of proposed MS-LTC-DRG relative weights across all LTCHs. In this proposed rule, this iterative process is continued until there is convergence between the weights produced at adjacent steps, for example, when the maximum difference is less than 0.0001.

Step 5--Determine a proposed FY 2007 MS-LTC-DRG relative weight for proposed MS-LTC-DRGs with no LTCH cases.

As we stated above, we determine the proposed relative weight for each proposed MS-LTC-DRG using total Medicare allowable charges reported in the December 2006 update of the FY 2006 MedPAR file. Of the 745 proposed MS-LTC-DRGs for FY 2008, we identified 124 proposed MS- LTC-DRGs for which there were no LTCH cases in the database. That is, based on data from the FY 2006 MedPAR file used in this proposed rule, no patients who would have been classified to those proposed MS-LTC- DRGs were treated in LTCHs during FY 2006 and, therefore, no charge data were reported for those proposed MS-LTC-DRGs. Thus, in the process of determining the proposed MS-LTC-DRG relative weights, we are unable to determine weights for these 124 proposed MS-LTC-DRGs using the methodology described in Steps 1 through 4 above. However, because patients with a number of the diagnoses under these proposed MS-LTC- DRGs may be treated at LTCHs beginning in FY 2008, for this proposed rule, we are proposing to assign relative weights to each of the 124 no-volume proposed MS-LTC-DRGs based on clinical similarity and relative costliness to one of the remaining 621 (745-124 = 621) proposed MS-LTC-DRGs for which we are able to determine proposed relative weights, based on FY 2006 LTCH claims data. In general, we determined proposed relative weights for the 124 proposed MS-LTC-DRGs with no LTCH cases in the FY 2006 MedPAR file used in this proposed rule by crosswalking these proposed MS-LTC-DRGs to other proposed MS- LTC-DRGs and then grouping them to the appropriate proposed low-volume quintile. This methodology is consistent with our methodology used in determining relative weights to account for the low-volume proposed MS- LTC-DRGs described above.

Our proposed methodology for determining the relative weights for the no-volume MS-LTC-DRGs is as follows: We crosswalk the no-volume proposed MS-LTC-DRG to a proposed MS-LTC-DRG for which there are LTCH cases in the FY 2006 MedPAR file and to which it is similar clinically and in intensity of use of resources as determined by care provided during the period of time surrounding surgery, surgical approach (if applicable), length of time of surgical procedure, postoperative care, and length of stay. If the proposed MS-LTC-DRG to which it is crosswalked is grouped to one of the proposed low-volume quintiles, we assign the relative weight for the applicable low-volume quintile to the no volume proposed MS-LTC-DRG. However, if the proposed MS-LTC-DRG to which the no-volume proposed MS-LTC-DRG is crosswalked is not one of the proposed MS-LTC-DRGs in a low-volume quintile, we do the following: (1) compare the relative weight of the proposed MS-LTC-DRG to which the no-volume proposed MS-LTC-DRG is crosswalked to the relative weights of each of the five quintiles; (2) assign the no volume proposed MS-LTC- DRG the relative weight of the low-volume quintile with the relative weight that is closest to the proposed MS-LTC-DRG to which the no volume proposed MS-LTC-DRG is crosswalked. (We note that in the infrequent case where nonmonotonicity involving a no volume proposed MS-LTC-DRG results, additional measures as described in Step 6 are required in order to maintain monotonically increasing relative weights.) or this proposed rule, a list of the no-volume proposed FY 2008 MS-LTC-DRGs and the proposed FY 2008 MS-LTC-DRG to which it is crosswalked is shown in the chart below.

No-Volume Proposed MS-LTC-DRG Crosswalk for FY 2008

Proposed Proposed MS-LTC-DRG

Proposed MS-LTC-DRG crosswalked MS- description

LTC-DRG

9........................ Bone marrow transplant.......

823 20....................... Intracranial vascular

31 procedures w PDX hemorrhage w MCC. 21....................... Intracranial vascular

32 procedures w PDX hemorrhage w CC. 22....................... Intracranial vascular

33 procedures w PDX hemorrhage w/o CC/MCC. 23....................... Craniotomy w major device

31 implant or acute complex CNS PDX w MCC. 24....................... Craniotomy w major device

33 implant or acute complex CNS PDX w/o MCC. 34....................... Carotid artery stent

37 procedure w MCC. 35....................... Carotid artery stent

38 procedure w CC. 36....................... Carotid artery stent

39 procedure w/o CC/MCC. 61....................... Acute ischemic stroke w use

70 of thrombolytic agent w MCC. 62....................... Acute ischemic stroke w use

71 of thrombolytic agent w CC. 63....................... Acute ischemic stroke w use

72 of thrombolytic agent w/o CC/ MCC. 115...................... Extraocular procedures except

125 orbit. 116...................... Intraocular procedures w CC/

125 MCC. 117...................... Intraocular procedures w/o CC/

125 MCC. 129...................... Major head & neck procedures

146 w CC/MCC or major device. 130...................... Major head & neck procedures

148 w/o CC/MCC. 135...................... Sinus & mastoid procedures w

133 CC/MCC. 136...................... Sinus & mastoid procedures w/

133 o CC/MCC. 150...................... Epistaxis w MCC..............

152 151...................... Epistaxis w/o MCC............

153 215...................... Other heart assist system

238 implant. 216...................... Cardiac valve & oth maj

237 cardiothoracic proc w card cath w MCC. 217...................... Cardiac valve & oth maj

238 cardiothoracic proc w card cath w CC. 218...................... Cardiac valve & oth maj

250 cardiothoracic proc w card cath w/o CC/MCC. 219...................... Cardiac valve & oth maj

237 cardiothoracic proc w/o card cath w MCC. 220...................... Cardiac valve & oth maj

238 cardiothoracic proc w/o card cath w CC. 221...................... Cardiac valve & oth maj

250 cardiothoracic proc w/o card cath w/o CC/MCC.

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222...................... Cardiac defib implant w

242 cardiac cath w AMI/HF/shock w MCC. 223...................... Cardiac defib implant w

243 cardiac cath w AMI/HF/shock w/o MCC. 224...................... Cardiac defib implant w

242 cardiac cath w/o AMI/HF/ shock w MCC. 225...................... Cardiac defib implant w

243 cardiac cath w/oAMI/HF/shock w/o MCC. 228...................... Other cardiothoracic

252 procedures w MCC. 229...................... Other cardiothoracic

253 procedures w CC. 230...................... Other cardiothoracic

254 procedures w/o CC/MCC. 231...................... Coronary bypass w PTCA w MCC.

237 232...................... Coronary bypass w PTCA w/o

238 MCC. 233...................... Coronary bypass w cardiac

237 cath w MCC. 234...................... Coronary bypass w cardiac

238 cath w/o MCC. 235...................... Coronary bypass w/o cardiac

237 cath w MCC. 236...................... Coronary bypass w/o cardiac

238 cath w/o MCC. 296...................... Cardiac arrest, unexplained w

283 MCC. 297...................... Cardiac arrest, unexplained w

284 CC. 298...................... Cardiac arrest, unexplained w/

285 o CC/MCC. 332...................... Rectal resection w MCC.......

356 333...................... Rectal resection w CC........

357 334...................... Rectal resection w/o CC/MCC..

358 338...................... Appendectomy w complicated

371 principal diag w MCC. 339...................... Appendectomy w complicated

372 principal diag w CC. 340...................... Appendectomy w complicated

373 principal diag w/o CC/MCC. 341...................... Appendectomy w/o complicated

371 principal diag w MCC. 342...................... Appendectomy w/o complicated

372 principal diag w CC. 343...................... Appendectomy w/o complicated

373 principal diag w/o CC/MCC. 344...................... Minor small & large bowel

371 procedures w MCC. 345...................... Minor small & large bowel

372 procedures w CC. 346...................... Minor small & large bowel

373 procedures w/o CC/MCC. 457...................... Spinal fusion exc cerv w

456 spinal curv, malig or 9+ fusions w CC. 461...................... Bilateral or multiple major

480 joint procs of lower extremity w MCC. 462...................... Bilateral or multiple major

482 joint procs of lower extremity w/o MCC. 483...................... Major joint & limb

480 reattachment proc of upper extremity w CC/MCC. 484...................... Major joint & limb

482 reattachment proc of upper extremity w/o CC/MCC. 506...................... Major thumb or joint

514 procedures. 509...................... Arthroscopy..................

505 537...................... Sprains, strains, &

505 dislocations of hip, pelvis & thigh w CC/MCC. 538...................... Sprains, strains, &

505 dislocations of hip, pelvis & thigh w/o CC/MCC. 614...................... Adrenal & pituitary

629 procedures w CC/MCC. 615...................... Adrenal & pituitary

630 procedures w/o CC/MCC. 625...................... Thyroid, parathyroid &

628 thyroglossal procedures w MCC. 626...................... Thyroid, parathyroid &

629 thyroglossal procedures w CC. 627...................... Thyroid, parathyroid &

630 thyroglossal procedures w/o CC/MCC. 653...................... Major bladder procedures w

659 MCC. 654...................... Major bladder procedures w CC

660 655...................... Major bladder procedures w/o

661 CC/MCC. 666...................... Prostatectomy w CC...........

665 671...................... Urethral procedures w CC/MCC.

687 672...................... Urethral procedures w/o CC/

688 MCC. 697...................... Urethral stricture...........

688 707...................... Major male pelvic procedures

660 w CC/MCC. 708...................... Major male pelvic procedures

661 w/o CC/MCC. 734...................... Pelvic evisceration, rad

717 hysterectomy & rad vulvectomy w CC/MCC. 735...................... Pelvic evisceration, rad

718 hysterectomy & rad vulvectomy w/o CC/MCC. 736...................... Uterine & adnexa proc for

754 ovarian or adnexal malignancy w MCC. 737...................... Uterine & adnexa proc for

755 ovarian or adnexal malignancy w CC. 738...................... Uterine & adnexa proc for

756 ovarian or adnexal malignancy w/o CC/MCC. 739...................... Uterine,adnexa proc for non-

754 ovarian/adnexal malig w MCC. 740...................... Uterine,adnexa proc for non-

755 ovarian/adnexal malig w CC. 741...................... Uterine,adnexa proc for non-

756 ovarian/adnexal malig w/o CC/ MCC. 742...................... Uterine & adnexa proc for non-

755 malignancy w CC/MCC. 743...................... Uterine & adnexa proc for non-

756 malignancy w/o CC/MCC. 748...................... Female reproductive system

749 reconstructive procedures. 765...................... Cesarean section w CC/MCC....

744 766...................... Cesarean section w/o CC/MCC..

769 767...................... Vaginal delivery w

769 sterilization &/or D&C. 768...................... Vaginal delivery w O.R. proc

769 except steril &/or D&C. 770...................... Abortion w D&C, aspiration

769 curettage or hysterotomy. 774...................... Vaginal delivery w

769 complicating diagnoses. 775...................... Vaginal delivery w/o

769 complicating diagnoses. 777...................... Ectopic pregnancy............

769

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778...................... Threatened abortion..........

759 779...................... Abortion w/o D&C.............

759 780...................... False labor..................

759 782...................... Other antepartum diagnoses w/

759 o medical complications. 789...................... Neonates, died or transferred

761 to another acute care facility. 790...................... Extreme immaturity or

761 respiratory distress syndrome, neonate. 791...................... Prematurity w major problems.

760 792...................... Prematurity w/o major

761 problems. 793...................... Full term neonate w major

760 problems. 794...................... Neonate w other significant

760 problems. 795...................... Normal newborn...............

761 799...................... Splenectomy w MCC............

423 800...................... Splenectomy w CC.............

424 801...................... Splenectomy w/o CC/MCC.......

425 827...................... Myeloprolif disord or poorly

823 diff neopl w maj O.R. proc w CC. 887...................... Other mental disorder

881 diagnoses. 927...................... Extensive burns or full

933 thickness burns w MV 96+ hrs w skin graft. 955...................... Craniotomy for multiple

26 significant trauma.

To illustrate this methodology for determining the proposed relative weights for the 124 proposed MS-LTC-DRGs with no LTCH cases, we are providing the following example, which refers to the no volume proposed MS-LTC-DRGs crosswalk information for FY 2008 provided in the chart above.

Example 1:

There were no cases in the FY 2006 MedPAR file used for this proposed rule for proposed MS-LTC-DRG 22 (Intracranial vascular procedures w PDX hemorrhage w/o CC/MCC). We determined that proposed MS-LTC-DRG 33 (Ventricular shunt procedures w/o CC/MCC), which is assigned to low-volume Quintile 1 for the purpose of determining the proposed FY 2008 relative weights, is similar clinically and based on resource use to proposed MS-LTC-DRG 22. Therefore, we are proposing to assign the same relative weight of proposed MS-LTC-DRG 33 of 0.48011 (Quintile 1) for FY 2008 (Table 11 in the Addendum to this proposed rule) to proposed MS-LTC-DRG 22.

Furthermore, for FY 2008 we are proposing to establish proposed MS- LTC-DRG relative weights of 0.0000 for the following transplant proposed MS-LTC-DRGs: Heart transplant or implant of heart assist system w MCC (proposed LTC-DRG 1); Heart transplant or implant of heart assist system w/o MCC (proposed LTC-DRG 2); Liver transplant w MCC or intestinal transplant (proposed LTC-DRG 5); Liver transplant w/o MCC (proposed LTC-DRG 6); Lung transplant (proposed LTC-DRG 7); Simultaneous pancreas/kidney transplant (proposed LTC-DRG 8); and Pancreas transplant (proposed LTC-DRG 10). This is because Medicare will only cover these procedures if they are performed at a hospital that has been certified for the specific procedures by Medicare and presently no LTCH has been so certified. Based on our research, we found that most LTCHs only perform minor surgeries, such as minor small and large bowel procedures, to the extent any surgeries are performed at all. Given the extensive criteria that must be met to become certified as a transplant center for Medicare, we believe it is unlikely that any LTCHs will become certified as a transplant center. In fact, in the nearly 20 years since the implementation of the IPPS, there has never been a LTCH that even expressed an interest in becoming a transplant center.

If in the future a LTCH applies for certification as a Medicare- approved transplant center, we believe that the application and approval procedure would allow sufficient time for us to determine appropriate weights for the proposed MS-LTC-DRGs affected. At the present time, we would only include these seven proposed transplant MS- LTC-DRGs in the GROUPER program for administrative purposes only. Because we use the same GROUPER program for LTCHs as is used under the IPPS, removing these proposed MS-LTC-DRGs would be administratively burdensome.

Again, we note that, as this system is dynamic, it is entirely possible that the number of proposed MS-LTC-DRGs with no volume of LTCH cases based on the system will vary in the future. We used the most recent available claims data in the MedPAR file to identify no volume proposed MS-LTC-DRGs and to determine the proposed relative weights in this proposed rule.

Table 11 in the Addendum to this proposed rule lists the proposed MS-LTC-DRGs and their respective proposed relative weights, geometric mean length of stay, and five-sixths of the geometric mean length of stay (to assist in the determination of short-stay outlier payments under Sec. 412.529) for FY 2008.

Step 6--Adjust the proposed FY 2008 MS-LTC-DRG relative weights to account for nonmonotonically increasing relative weights.

As explained in section II.B. of this preamble, the IPPS proposed FY 2008 MS-DRGs, on which the proposed FY 2008 MS-LTC-DRGs are based, provide a significant improvement in the DRG system's recognition of severity of illness and resource usage. The proposed MS-DRGs contain base DRGs that have been subdivided into one, two, or three severity levels. Where there are three severity levels, the most severe level has at least one code that is referred to as an MCC. The next lower severity level contains cases with at least one code that is a CC. Those cases without a MCC or a CC are referred to as without CC/MCC. When data did not support the creation of three severity levels, the base was divided into either two levels or the base was not subdivided. The two-level subdivisions could consist of the CC/MCC and the without CC/MCC. Alternatively, the other type of two level subdivision could consist of the MCC and without MCC. In base DRGs with two levels, cases classified into a ``without CC/MCC'' proposed MS-LTC-DRG are expected to have lower resource use

[[Page 24769]]

(and lower costs) than the ``with CC/MM'' and ``with MCC.''

That is, theoretically, cases that are more severe typically require greater expenditure of medical care resources and will result in higher average charges. Therefore, in the three severity levels, relative weights should increase by severity, from lowest to highest. If the weights do not increase (that is, if within a base MS-LTC-DRG, a proposed MS-LTC-DRG with MCC has a lower relative weight than one with CC, or the proposed MS-LTC-DRG without CC/MCC has a higher relative weight than either of the others, they are nonmonotonic. We continue to believe that utilizing nonmonotonic relative weights to adjust Medicare payments would result in inappropriate payments. Consequently, we are proposing that, in general, we would combine proposed MS-LTC-DRG severity levels within a proposed base MS-LTC-DRG for the purpose of computing a relative weight when necessary to ensure that monotonicity is maintained. Specifically, under each of the example scenarios provided below, we would combine severity levels within a proposed base MS-LTC-DRG as follows:

The first example of nonmonotonically increasing relative weights for MS-LTC-DRG pertains to base DRGs with a three-level split and each of the three levels has 25 or more LTCH cases and, therefore, did not fall into one of the proposed five low-volume quintiles. If nonmonotonicity is detected in the relative weights of proposed MS-LTC- DRGs in adjacent severity levels (for example, the relative weight of the ``with MCC'' (the highest severity level) is less than the ``with CC'' (the middle level), or the ``with CC'' is less than the ``without CC/MCC''), we are proposing to combine the adjacent proposed MS-LTC- DRGs and determine one relative weight based on the case-weighted average of the combined LTCH cases of the nonmonotonic proposed MS-LTC- DRG. The case-weighted average charge is determined by dividing the total charges for all LTCH cases in both severity levels by the total number of LTCH cases for the combined proposed MS-LTC-DRGs. We are proposing to apply this relative weight to both affected levels of the proposed base MS-LTC-DRG. If nonmonotonicity remains an issue because the above process results in a relative weight that is still nonmonotonic to the remaining proposed MS-LTC-DRG, we are proposing to combine all three of the severity levels to determine one relative weight which is assigned to each of the proposed MS-LTC-DRG in that proposed base MS-LTC-DRG.

A second scenario of nonmonotonically increasing relative weights for an MS-LTC-DRG pertains to the situation where one or more of the severity levels within a base DRG has less than 25 LTCH cases (that is, low volume). If nonmonotonicity occurs in the case where either the highest or lowest severity level (with MCC'' or ``without CC/MCC'') has 25 LTCH cases or more and the other two severity levels are low volume (and therefore the other two severity levels would otherwise be assigned to quintiles), we are proposing to combine the data for the cases in the two adjacent low-volume proposed MS-LTC-DRGs for the purpose of determining a relative weight. If the combination results in at least 25 cases, we are proposing to calculate one relative weight and assign it to both of the proposed severity levels. If the combination results in less than 25 cases, based on the case-weighted average charge of the combined low-volume MS-LTC-DRGs, both MS-LTC- DRGs, are assigned the relative weight of the quintile that has the closest relative weight to the case weighted average change of the combined low volume case. If nonmonotonicity persists, we are proposing to combine all three severity levels and one relative weight would be assigned to all three levels based on the case weighted average of the combined severity level. Similarly, in nonmonotonic cases where the middle level has 25 cases or more but either or both the lowest or highest severity level has less than 25 cases (that is, low volume), we are proposing to combine the nonmonotonic low-volume proposed MS-LTC- DRG with the middle level proposed MS-LTC-DRG of the base DRG. We are proposing to calculate one relative weight and apply it to both of the affected proposed MS-LTC-DRGs. If the nonmonotonicity persists, we are proposing to combine all three levels for the purpose of determining a relative weight, and apply that relative weight to all three levels.

A third scenario addresses nonmonotonicity in a base DRG where at least one of the severity levels has no cases. As discussed in greater detail in Step 5, based on clinical similarity, we would cross-walk the proposed MS-LTC-DRG to a proposed MS-LTC-DRG to which it is similar clinically and in intensity of resource use and then assign it to a quintile with the relative weight closest to that of the MS-LTC-DRG to which the no-volume MS-LTC-DRG had been cross-walked. If this results in nonmonotonicity, in the case where the no-volume proposed MS-LTC-DRG is either the lowest or highest severity level, we are proposing to assign to the no-volume proposed MS-LTC-DRG the same relative weight that is assigned to the middle level of the MS-LTC-DRG in that base DRG. If nonmonotonicity persists, we are proposing that all three severity levels be combined for the purpose of calculating one relative weight which is applied to each of the three levels. We note that this is a departure from our current treatment of no-volume LTC-DRGs which results in an ultimate assignment to a quintile. However, we propose that in the infrequent case where nonmonotonicity involves a no-volume proposed MS-LTC-DRG, we believe it is appropriate to resolve the nonmonotonicity by assigning the no-volume proposed MS-LTC-DRG the relative weight of the proposed MS-LTC-DRG(s) in the base DRG, regardless of whether the other proposed MS-LTC-DRG(s) is low volume (therefore assigned a relative weight of a quintile) or high volume (assigned its own relative weight). We believe this treatment achieves monotonically increasing relative weights while providing appropriate payment for the no-volume proposed MS-LTC-DRG because the relative weight assigned to the no-volume proposed MS-LTC-DRG is based on the average charges of services rendered within the same proposed base MS- LTC-DRG, rather than a quintile which contains proposed MS-LTC-DRGs from different proposed base MS-LTC-DRGs.

We are proposing to apply the same process where the proposed base MS-LTC-DRG contains a two-level split. For example, if nonmonotonicity occurs in a proposed base MS-LTC-DRG with two severity levels (that is, the higher severity level relative weight is less than the lower severity level), where both of the MS-LTC-DRGs have at least 25 cases or where one or both of the proposed MS-LTC-DRGs is low volume, we are proposing to combine the two proposed MS-LTC-DRGs of that proposed base MS-LTC-DRG for the purpose of determining a case-weighted relative weight. If the combination still results in at least 25 cases, we are proposing to calculate one relative weight and assign it to both of the proposed MS-LTC-DRGs. If the combination results in less than 25 cases, we determine the quintile assignment for both MS-LTC-DRGs based on the case-weighted average charge and assign both MS-LTC-DRGs the same relative weight of the appropriate quintile.

Step 7--Calculate the proposed FY 2008 budget neutrality factor.

[[Page 24770]]

As we stated in the FY 2008 LTCH PPS proposed rule (72 FR 4784 through 4786), under the broad authority conferred upon the Secretary under section 123 of Pub. L. 106-113 as amended by section 307(b) of Pub. L. 106-554 to develop the LTCH PPS, we proposed that, beginning with the MS-LTC-DRG update for FY 2008, the annual update to the proposed MS-LTC-DRG classifications and relative weights would be done in a budget neutral manner such that estimated aggregate LTCH PPS payments would be unaffected, that is, would be neither greater than nor less than the estimated aggregate LTCH PPS payments that would have been made without the proposed MS-LTC-DRG classification and relative weight changes. Currently under Sec. 412.517, the LTC-DRG classifications and relative weights are adjusted annually to reflect changes in factors affecting the relative use of LTCH resources, such as treatment patterns, technology and number of discharges. In addition, there are currently no statutory or regulatory requirements that the annual update to the LTC-DRG classifications and relative weights be done in a budget neutral manner. Since the initial implementation of the LTCH PPS in FY 2003, we have updated the LTC-DRG relative weights each year without a budget neutrality adjustment based on the most recent available LTCH claims data, which reflect current LTCH patient mix and coding practices, and appropriately reflected more or less resource use than the previous year's LTC-DRG relative weights (71 FR 47991). Historically, we have not updated the LTC-DRGs in a budget neutral manner because we believed that past fluctuations in the LTC-DRG relative weights were primarily due to changes in LTCH coding practices. We believe that changes in the LTCH PPS payment rates, including the LTC-DRG relative weights, should accurately reflect changes in LTCHs' true cost of treating patients (real CMI increase), and should not be influenced by changes in coding practices (apparent CMI increase). Because LTCH 2006 claims data does not appear to significantly reflect changes in LTCH coding practices in response to the implementation of the LTCH PPS, we believe that it may be appropriate to update the LTC-DRGs so that estimated aggregate LTCH PPS payments would neither increase nor decrease. Thus, in the FY 2008 LTCH PPS proposed rule (72 FR 4784), we proposed that the annual update to the LTC-DRG classifications and relative weights be done in a budget neutral manner. (For a detailed discussion on updating the LTC-DRG classifications and relative weights in a budget neutral manner, refer to the FY 2008 LTCH PPS proposed rule (72 FR 4784 through 4786). Updating the LTC-DRGs in a budget neutral manner would result in an annual update to the individual LTC-DRG classifications and relative weights based on the most recent available data to reflect changes in relative LTCH resource use, and the LTC-DRG relative weights would be uniformly adjusted to ensure that estimated aggregate payments under the LTCH PPS would not be affected (that is, decreased or increased). Consistent with that proposal, we are proposing to update the proposed MS-LTC-DRG classifications and relative weights for FY 2008 based on the most recent available data and include a budget neutrality adjustment.

To ensure budget neutrality in updating the MS-LTC-DRG classifications and relative weights under the proposed change to Sec. 412.517, we are proposing to use a method that is similar to the methodology used under the IPPS. (A discussion of the IPPS DRG budget neutrality adjustment can be found in the FY 2007 IPPS final rule (71 FR 47970).) Specifically, we are proposing that, after recalibrating the proposed MS-LTC-DRG relative weights, as we do under the methodology as described in detail in Steps 1 through 6 above, we would calculate and apply a normalization factor to the proposed MS-LTC-DRG relative weights to ensure that estimated payments are not influenced by changes in the composition of case types or changes made to the classification system. That is, the normalization adjustment is intended to ensure that the recalibration of the proposed MS-LTC-DRG relative weights (that is, the process itself) neither increases nor decreases total estimated payments. To calculate the normalization factor, we are proposing to use the most recent available claims data (FY 2006) and apply the proposed GROUPER (Version 25.0) to calculate the proposed relative weights. Furthermore, we are proposing to use the most recent available claims data in the analysis for the final rule. These weights are determined such that the average CMI value is 1.0. Then, we are proposing to group the same claims data (FY 2006) using the current GROUPER (Version 24.0) and current relative weights. The average CMI is calculated for the claims data using the current GROUPER and relative weights. Finally, the ratio of the average CMI of the claims data set under the current GROUPER and the proposed GROUPER is calculated as the proposed normalization factor. For FY 2008, based on the latest available data, the proposed normalization factor is estimated as 1.020302, which is applied to each proposed MS-LTC-DRG relative weight. (However, if more current data become available prior to publication of the final rule, we will use those data to determine the normalization factor.) That is, each proposed MS-LTC-DRG relative weight is multiplied by 1.020302 in the first step of the budget neutrality process. We are also proposing to ensure that estimated aggregate LTCH PPS payments (based on the most recent available LTCH claims data) after recalibration (the proposed relative weights) would be equal to estimated aggregate LTCH PPS payments (for the same most recent available LTCH claims data) before recalibration (the existing relative weights). Therefore, we are proposing to calculate the budget neutrality adjustment factor by simulating estimated payments under both sets of GROUPERs and relative weights. We are proposing to simulate total estimated payments under the current payment policies (RY 2007) using the most recent available claims data (FY 2006) and using the proposed GROUPER (Version 25.0), and normalized relative weights. Then, we are proposing to simulate estimated payments using the most recent available claims data (FY 2006) and apply the proposed GROUPER (Version 25.0). We next calculate payments using the same claims data (FY 2006) with the current GROUPER (Version 24.0). The ratio of the estimated average payment under the current GROUPER and the proposed GROUPER is calculated as the proposed budget neutrality factor. Then each of the proposed normalized relative weights is multiplied by the budget neutrality factor to determine the proposed budget neutral relative weight for each proposed MS-LTC-DRG. Accordingly, based on the most recent available data, we are proposing a budget neutrality factor of 1.003924 that is applied to the relative weights after normalizing. If more current data become available prior to publication of the final rule, we will use those data to determine the budget neutrality factor. The relative weights in Table 11 in the Addendum of this proposed rule reflect those budget neutral weights. If, as a result of comments, we decide not to finalize the proposed budget neutrality policy, the proposed weights in Table 11 of the Addendum to this proposed

[[Page 24771]]

rule change by the two factors discussed herein.

Step 8--Apply the proposed case-mix budget neutrality factor to the proposed MS-LTC-DRG relative weight.

As discussed under section II.D.6. of the preamble of this proposed rule, we are proposing a budget neutral adjustment for FY 2008 and FY 2009 to eliminate the effect of changes in coding or classification of discharges that do not reflect real change in case-mix because we believe that adoption of the proposed MS-LTC-DRGs would create a risk of increased aggregate levels of payment as a result of increased documentation and coding. The additional step 8 would be necessary for FY 2008 and FY 2009 to ensure that estimated aggregate LTCH PPS payments would be neither greater than nor less than the estimated aggregate LTCH PPS payments that would have been made without the adoption of the proposed MS-LTC-DRG patient classification system. Accordingly, each of the relative weights in Table 11 of the Addendum to this proposed rule reflects this proposed adjustment. That is, each proposed MS-LTC-DRG relative weight is multiplied by a factor of 0.976 to account for changes in coding or classification of discharges resulting from the adoption of the new patient classification system.

J. Proposed Add-On Payments for New Services and Technologies

(If you choose to comment on issues in this section, please include the caption ``New Technology'' at the beginning of your comment.) 1. Background

Sections 1886(d)(5)(K) and (L) of the Act establish a process of identifying and ensuring adequate payment for new medical services and technologies (sometimes collectively referred to in this section as ``new technologies'') under the IPPS. Section 1886(d)(5)(K)(vi) of the Act specifies that a medical service or technology will be considered new if it meets criteria established by the Secretary after notice and opportunity for public comment. Section 1886(d)(5)(K)(ii)(I) of the Act specifies that the process must apply to a new medical service or technology if, ``based on the estimated costs incurred with respect to discharges involving such service or technology, the DRG prospective payment rate otherwise applicable to such discharges under this subsection is inadequate.''

The regulations implementing this provision establish three criteria for new medical services and technologies to receive an additional payment. First, Sec. 412.87(b)(2) defines when a specific medical service or technology will be considered new for purposes of new medical service or technology add-on payments. The statutory provision contemplated the special payment treatment for new medical services or technologies until such time as data are available to reflect the cost of the technology in the DRG weights through recalibration. There is a lag of 2 to 3 years from the point a new medical service or technology is first introduced on the market and when data reflecting the use of the medical service or technology are used to calculate the DRG weights. For example, data from discharges occurring during FY 2006 are used to calculate the proposed FY 2008 DRG weights in this proposed rule. Section 412.87(b)(2) provides that, ``a medical service or technology may be considered new within 2 or 3 years after the point at which data begin to become available reflecting the ICD-9-CM code assigned to the new medical service or technology (depending on when a new code is assigned and data on the new medical service or technology become available for DRG recalibration). After CMS has recalibrated the DRGs based on available data to reflect the costs of an otherwise new medical service or technology, the medical service or technology will no longer be considered `new' under the criterion for this section.''

The 2-year to 3-year period during which a medical service or technology can be considered new would ordinarily begin with FDA approval, unless there was some documented delay in bringing the product onto the market after that approval (for instance, component production or drug production has been postponed until FDA approval due to shelf life concerns or manufacturing issues). After the DRGs have been recalibrated to reflect the costs of an otherwise new medical service or technology, the special add-on payment for new medical services or technologies ceases (Sec. 412.87(b)(2)). For example, an approved new technology that received FDA approval in October 2006 and entered the market at that time may be eligible to receive add-on payments as a new technology until FY 2010 (discharges occurring before October 1, 2009), when data reflecting the costs of the technology could be used to recalibrate the DRG weights. Because the FY 2009 DRG weights would be calculated using FY 2007 MedPAR data, the costs of such a new technology would be reflected in the FY 2009 DRG weights.

Section 412.87(b)(3) further provides that new medical services or technologies must be inadequately paid otherwise under the DRG system to receive the add-on payment. To assess whether technologies would be inadequately paid under the DRGs, we establish thresholds to evaluate applicants for new technology add-on payments. In the FY 2004 IPPS final rule (68 FR 45385), we established the threshold at the geometric mean standardized charge for all cases in the DRG plus 75 percent of 1 standard deviation above the geometric mean standardized charge (based on the logarithmic values of the charges and transformed back to charges) for all cases in the DRG to which the new medical service or technology is assigned (or the case-weighted average of all relevant DRGs, if the new medical service or technology occurs in many different DRGs).

However, section 503(b)(1) of Pub. L. 108-173 amended section 1886(d)(5)(K)(ii)(I) of the Act to provide for ``applying a threshold * * * that is the lesser of 75 percent of the standardized amount (increased to reflect the difference between cost and charges), or 75 percent of 1 standard deviation for the diagnosis-related group involved.'' The provisions of section 503(b)(1) apply to classification for fiscal years beginning with FY 2005. (Refer to section IV.D. of the preamble to the FY 2005 IPPS final rule (69 FR 49084) for a discussion of the revision of the regulations to incorporate the change made by section 503(b)(1) of Pub. L. 108-173.) Table 10 of the Addendum to the FY 2007 IPPS final rule (71 FR 48319) contained the final thresholds that are being used to evaluate applications for new technology add-on payments for FY 2008. An applicant must demonstrate that the cost threshold is met using information from inpatient hospital claims.

We were recently asked to revisit the issue of whether the HIPAA Privacy Rule at 45 CFR Parts 160 and 164 applies to claims information that providers submit with applications for new technology add-on payments. We previously addressed this issue in the September 7, 2001 final rule (66 FR 46917) that established the new technology add-on payment regulations. In the preamble to that final rule, we explained that health plans, including Medicare, and providers that conduct certain transactions electronically, including the hospitals that would be receiving payment under the FY 2001 IPPS final rule, are required to comply with the HIPAA Privacy Rule. We further explained how such entities could meet the applicable HIPAA

[[Page 24772]]

requirements by discussing how the HIPAA Privacy Rule permitted providers to share with health plans information needed to ensure correct payment, if they have obtained consent from the patient to use that patient's data for treatment, payment, or health care operations. We also explained that because the information to be provided within applications for new technology add-on payment would be needed to ensure correct payment, no additional consent would be required. The HHS Office of Civil Rights has since amended the HIPAA Privacy Rule, but the results remain. The HIPAA Privacy Rule no longer requires covered entities to obtain consent from patients to use or disclose individually identifiable health information for treatment, payment, or health care operations, and expressly permits such entities to use or to disclose individually identifiable health information to covered entities for any of these purposes (45 CFR Sec. Sec. 164.502(a)(1)(ii), and 506(c)(1) and (c)(3); and the Standards for Privacy of Individually Identifiable Health Information published in the Federal Register on August 14, 2002 for a full discussion of changes in consent requirements).

Section 412.87(b)(1) of our existing regulations provides that a new technology is an appropriate candidate for an additional payment when it represents ``an advance that substantially improves, relative to technologies previously available, the diagnosis or treatment of Medicare beneficiaries.'' For example, a new technology represents a substantial clinical improvement when it reduces mortality, decreases the number of hospitalizations or physician visits, or reduces recovery time compared to the technologies previously available. (Refer to the September 7, 2001 final rule (66 FR 46902) for a complete discussion of this criterion.)

The new medical service or technology add-on payment policy provides additional payments for cases with high costs involving eligible new medical services or technologies while preserving some of the incentives under the average-based payment system. The payment mechanism is based on the cost to hospitals for the new medical service or technology. Under Sec. 412.88, Medicare pays a marginal cost factor of 50 percent for the costs of a new medical service or technology in excess of the full DRG payment. If the actual costs of a new medical service or technology case exceed the DRG payment by more than the 50- percent marginal cost factor of the new medical service or technology, Medicare payment is limited to the DRG payment plus 50 percent of the estimated costs of the new technology.

The Congressional report language accompanying section 533 of Pub. L. 106-554 indicated Congress' intent to require the Secretary to implement the new mechanism on a budget neutral basis (H.R. Conf. Rep. No. 106-1033, 106th Cong., 2nd Sess. at 897 (2000)). Section 1886(d)(4)(C)(iii) of the Act requires that the adjustments to annual DRG classifications and relative weights must be made in a manner that ensures that aggregate payments to hospitals are not affected. Therefore, in the past, we accounted for projected payments under the new medical service and technology provision during the upcoming fiscal year at the same time we estimated the payment effect of changes to the DRG classifications and recalibration. The impact of additional payments under this provision was then included in the budget neutrality factor, which was applied to the standardized amounts and the hospital-specific amounts.

Section 1886(d)(5)(K)(ii)(III) of the Act, as amended by section 503(d)(2) of Pub. L. 108-173, provides that there shall be no reduction or adjustment in aggregate payments under the IPPS due to add-on payments for new medical services and technologies. Therefore, add-on payments for new medical services or technologies for FY 2005 and later years have not been budget neutral.

Applicants for add-on payments for new medical services or technologies for FY 2009 must submit a formal request, including a full description of the clinical applications of the medical service or technology and the results of any clinical evaluations demonstrating that the new medical service or technology represents a substantial clinical improvement, along with a significant sample of data to demonstrate the medical service or technology meets the high-cost threshold. Complete application information, along with final deadlines for submitting a full application, will be available on our web site after publication of the IPPS FY 2008 final rule at: http://www.cms.hhs.gov/AcuteInpatientPPS/08_newtech.asp. To allow interested

parties to identify the new medical services or technologies under review before the publication of the proposed rule for FY 2009, the web site will also list the tracking forms completed by each applicant. 2. Public Input Before Publication of a Notice of Proposed Rulemaking on Add-On Payments

Section 1886(d)(5)(K)(viii) of the Act, as amended by section 503(b)(2) of Pub. L. 108-173, provides for a mechanism for public input before publication of a notice of proposed rulemaking regarding whether a medical service or technology represents a substantial clinical improvement or advancement. The process for evaluating new medical service and technology applications requires the Secretary to--

Provide, before publication of a proposed rule, for public input regarding whether a new service or technology represents an advance in medical technology that substantially improves the diagnosis or treatment of Medicare beneficiaries.

Make public and periodically update a list of the services and technologies for which applications for add-on payments are pending.

Accept comments, recommendations, and data from the public regarding whether a service or technology represents a substantial clinical improvement.

Provide, before publication of a proposed rule, for a meeting at which organizations representing hospitals, physicians, manufacturers, and any other interested party may present comments, recommendations, and data regarding whether a new medical service or technology represents a substantial clinical improvement to the clinical staff of CMS.

In order to provide an opportunity for public input regarding add- on payments for new medical services and technologies for FY 2008 before publication of the FY 2008 IPPS proposed rule, we published a notice in the Federal Register on December 22, 2006 (71 FR 77031), and held a town hall meeting at the CMS Headquarters Office in Baltimore, MD, on February 22, 2007. In the announcement notice for the meeting, we stated that the opinions and alternatives provided during the meeting would assist us in our evaluations of applications by allowing public discussion of the substantial clinical improvement criterion for each of the FY 2008 new medical service and technology add-on payment applications before the publication of the FY 2008 IPPS proposed rule.

Approximately 70 individuals attended the town hall meeting in person, while additional participants listened over an open telephone line. Boston Scientific presented data on how its product (Wingspan[reg] Stent System with Gateway\TM\ PTA Balloon Catheter) meets the substantial clinical improvement criterion, as well as the need for additional payments to ensure its access to Medicare beneficiaries. No other attendees at the town hall meeting

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made a presentation with regard to the Wingspan[reg] new technology add-on payment application.

We considered Boston Scientific's presentation made at the town hall meeting, as well as written comments submitted with their application, in our evaluation of the Wingspan[reg] new technology application for FY 2008 in this proposed rule. We have summarized these comments under section I.4. of this preamble.

We did not receive any other comments regarding substantial clinical improvement of Wingspan[reg]. However, there were a number of public comments made at the town hall meeting suggesting that CMS provide more specific detail about how it would apply the substantial clinical improvement criterion. For example, the public commenters at the town hall meeting suggested that CMS provide clear guidance with respect to the type of data that applicants should submit to support an application for add-on payments for new medical services and technologies. We were asked to work with stakeholders, including researchers, clinicians, representatives of patients, and manufacturers, to develop specific criteria and data quality standards that would make determinations of ``substantial clinical improvement'' more predictable and transparent.

We welcome public comment on this issue. In particular, we are interested in any ``specific criteria or data quality standards'' that the commenters believe we should adopt to improve the new technology add-on application process, or any concerns or challenges that commenters believe we may encounter in undertaking this effort. Again, as we stated at the new technology town hall meeting, we are always interested in working with our stakeholders to improve the inpatient new technology add-on payment process. We are interested in ensuring that the latest medical technology that improves care for the Medicare patient population continues to be available to our beneficiaries. 3. FY 2008 Status of Technologies Approved for FY 2007 Add-On Payments a. Endovascular Graft Repair of the Thoracic Aorta

W. L. Gore & Associates, Inc. submitted an application for consideration of its Endovascular Graft Repair of the Thoracic Aorta (GORE TAG) for new technology add-on payments for FY 2006. The manufacturer argued that endovascular stent-grafting of the descending thoracic aorta provides a less invasive alternative to the traditional open surgical approach required for the management of descending thoracic aortic aneurysms. The GORE TAG device is a tubular stent-graft mounted on a catheter-based delivery system, and it replaces the synthetic graft normally sutured in place during open surgery. The device was initially identified using ICD-9-CM procedure code 39.79 (Other endovascular repair (of aneurysm) of other vessels). The applicant also requested a unique ICD-9-CM procedure code. As noted in Table 6B of the FY 2006 IPPS final rule (70 FR 47637), new procedure code 39.73 (Endovascular implantation of graft in thoracic aorta) was assigned to this technology.

In the FY 2006 IPPS final rule (70 FR 47356), we approved the GORE TAG device for new technology add-on payment for FY 2006. FDA approved GORE TAG on March 23, 2005. Because the technology remained within the 2-to 3-year period during which it could be considered new for FY 2007, we continued add-on payments for the endovascular graft repair of the thoracic aorta in the FY 2007 IPPS final rule (71 FR 47999). GORE TAG will have been on the market for more than 3 years as of March 23, 2008, or less than 6 months of FY 2008. Our practice has been to begin and end new technology add-on payments on the basis of a fiscal year. In general, we extend add-on payments for an additional year only if the 3-year anniversary date of the product's entry on the market occurs in the latter half of the fiscal year (70 FR 47362). Because the 3-year anniversary date of GORE TAG's entry onto the market was in the first half of the fiscal year, we are proposing to discontinue its new technology add-on payment for FY 2008. b. Restore[supreg] Rechargeable Implantable Neurostimulator

Medtronic Neurological submitted an application for new technology add-on payments for its Restore[supreg] Rechargeable Implantable Neurostimulator for FY 2006. The Restore[supreg] Rechargeable Implantable Neurostimulator is designed to deliver electrical stimulation to the spinal cord to block the sensation of pain. The technology standard for neurostimulators uses internal sealed batteries as the power source to generate the electrical current. These internal batteries have finite lives, and require replacement when their power has been completely discharged. According to the manufacturer, the Restore[supreg] Rechargeable Implantable Neurostimulator ``represents the next generation of neurostimulator technology, allowing the physician to set the voltage parameters in such a way that fully meets the patient's requirements to achieve adequate pain relief without fear of premature depletion of the battery.'' The applicant stated that the expected life of the Restore[supreg] rechargeable battery is 9 years, compared to an average life of 3 years for conventional neurostimulator batteries. We approved new technology add-on payments for all rechargeable, implantable neurostimulators for FY 2006 and FY 2007. Cases involving these devices, made by any manufacturer, are identified by the presence of newly created ICD-9-CM code 86.98 (Insertion or replacement of dual array rechargeable neurostimulator pulse generator).

The FDA approved the Restore[supreg] Rechargeable Implantable Neurostimulator in 2005. However, as noted in the FY 2006 IPPS final rule (70 FR 47358), at least one similar product was approved by the FDA as early as April 2004. Because the Restore'' Rechargeable Implantable Neurostimulator will be beyond the 2- to 3-year period during which it can be considered new for FY 2008, we are proposing to discontinue add-on payments for the technology in FY 2008. c. X STOP Interspinous Process Decompression System

St. Francis Medical Technologies submitted an application for new technology add-on payments for the X STOP Interspinous Process Decompression System (X STOP) for FY 2007. Lumbar spinal stenosis describes a condition that occurs when the spaces between bones in the spine become narrowed due to arthritis and other age-related conditions. This narrowing, or stenosis, causes nerves coming from the spinal cord to be compressed, thereby causing symptoms including pain, numbness, and weakness. It particularly causes symptoms when the spine is in extension, when a patient stands fully upright or leans back. The X STOP device is inserted between the spinous processes of adjacent vertebrae in order to provide a minimally invasive alternative to conservative treatment (exercise and physical therapy) and invasive surgery (spinal fusion). It works by limiting the spine's extension that compresses the nerve's roots while still preserving as much motion as possible. The device is inserted in a relatively simple, primarily outpatient procedure using local anesthesia. However, in some circumstances, the physician may prefer to admit the

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patient for an inpatient stay. The manufacturer described the device as providing ``a new minimally invasive, stand-alone alternative treatment for lumbar spinal stenosis.''

The X STOP Interspinous Process Decompression system received pre- market approval from the FDA on November 21, 2005. The device is currently described by ICD-9-CM code 84.58 (Implantation of Interspinous process decompression device) (excluding: Fusion of spine (codes 81.00 through 81.08, and 81.30 through 81.39)). This ICD-9-CM code went into effect on October 1, 2005.

In the FY 2007 final rule, with respect to substantial clinical improvement, we noted our concern that, during the FDA approval process, the Center for Devices and Radiological Health Advisory Panel voted against pre-market approval of X STOP because of concerns about proper patient selection, as well as the lack of objective endpoints. The applicant addressed our concerns by demonstrating that the mechanism of effect on the spine in cadavers with in vivo clinical radiographic data. That is, the applicant was able to show that the X STOP device limits spine extension that compresses the nerve. Thus, we indicated that we believed the technology has promise for providing a less invasive alternative to procedures such as laminectomy or fusion for patients that have failed conservative treatment (exercise, physical therapy and medication). The X STOP system represents a new level of treatment on the continuum of care for patients with lumbar spinal stenosis that previously did not exist.

Accordingly, after consideration of the comments received, we approved the X STOP Interspinous Process Decompression System for new technology add-on payment for FY 2007. Cases involving X STOP are identified by ICD-9-CM code 84.58 (Implantation of interspinous process decompression device). These cases are generally included in CMS-DRG 499 (Back and Neck Procedures Except Spinal Fusion with CC) and CMS-DRG 500 (Back and Neck Procedures Except Spinal Fusion without CC) for FY 2007.

The X STOP Interspinous Process Decompression System is still within the 2- to 3-year period during which it can be considered new for FY 2008. However, we are concerned that it may no longer meet the cost-threshold criterion. In section II.D. of the preamble of this proposed rule, we are proposing to adopt MS-DRGs for FY 2008 and assign cases with procedure codes 84.58 into proposed MS-DRG 490 (Back and Neck Procedures Except Spinal Fusion with CC or MCC or Disc Devices). Proposed MS-DRG 490 includes back and neck procedures except spinal fusion with a CC or MCC. As indicated earlier, we did a comprehensive review of the spinal fusion and nonspinal fusion DRGs. Based on this review, we are proposing to further modify MS-DRG 490 to also include the higher cost of cases where the patient receives a spinal disc device such as an artificial spinal disc prosthesis, or an interspinous process decompression system. Our earlier analysis of the spinal and nonspinal fusion DRGs showed that the average charge per case for cases involving X STOP is $29,162. The average charge per case for MS-DRG 490 is $29,656. Therefore, cases that use X STOP have a lower average charge per case than all cases in MS-DRG 490. The data show that the technology is not inadequately paid under the revised MS-DRGs, and it no longer meets the cost threshold for new technology add-on payment. For this reason, we are proposing to discontinue new technology add-on payments for X STOP in FY 2008 and correlate the payments under MS-DRG 490. The high costs for cases using X STOP that necessitated an add-on payment under the CMS DRGs will no longer be necessary because of the higher payment that would be made under the proposed MS-DRG 490. 4. FY 2008 Application for New Technology Add-On Payments

Boston Scientific submitted an application for the Wingspan[reg] Stent System with Gateway PTA Balloon Catheter (Wingspan[reg]) for new technology add-on payments for FY 2008. The device is designed for the treatment of patients with significant intracranial arterial stenosis who are refractory to medical management. The device consists of the following: a self-expanding nitinol stent; a multilumen over wire delivery catheter; and a Gateway\TM\ PTA Balloon Catheter. The device is used to treat stenoses that occur in the intracranial vessels. Prior to stent placement, the Gateway\TM\ PTA Balloon is inflated to dilate the target lesion, and then the stent is deployed across the lesion to restore and maintain luminal patency. Effective October 1, 2004, two new ICD-9-CM procedure codes were created to code intracranial angioplasty and intracranial stenting procedures: procedure codes 00.62 (Percutaneous angioplasty or atherectomy of intracranial vessels) and 00.65 (Percutaneous insertion of intracranial vascular stents).

On August 3, 2005, the Wingspan[reg] was approved by the FDA as a Humanitarian Device Exemption (HDE). We note that the applicant submitted an application for new technology add-on payments in FY 2006 but was not approved for add-on payments because it had not yet received FDA approval. In November 2006, we issued a national coverage determination (NCD) on intracranial stents. The NCD stated that the treatment of cerebral artery stenosis in patients with intracranial atherosclerotic disease with intracranial percutaneous transluminal angioplasty (PTA) and stenting is reasonable and necessary when furnished in accordance with the FDA-approved protocols governing Category B Investigational Device Exemption (IDE) clinical trials. Currently, there are no clinical trials in place for the Wingspan[reg]. However, because the technology is covered by Medicare, if it is used in the setting of a clinical trial, we will evaluate whether the Wingspan[reg] meets the criteria for an inpatient new technology add-on payment. The Wingspan[reg] has been available on the market since August 3, 2005. Therefore, we believe that the technology meets the newness criterion.

The applicant noted in its application that cases of intracranial angioplasty and stenting cases are currently grouped to CMS DRGs 533 (Extracranial Procedure with CC) and 534 (Extracranial Procedure Without CC). However, the applicant believes these cases should be assigned to CMS DRGs 1 (Craniotomy Age > 17 With CC), 2 (Craniotomy Age > 17 Without CC), and 543 (Craniotomy With Major Device Implant or Acute Complex Central Nervous System Principal Diagnosis) based on resource use and for clinical consistency with other endovascular intracranial procedures assigned to these DRGs. As discussed in section II.D. of the preamble of this proposed rule, we are proposing to move procedure code 00.62 to proposed MS-DRGs 25, 26, and 27 (Craniotomy & Endovascular Intracranial Procedures With MCC, With CC, and Without CC/ MCC, respectively) and proposed MS-DRGs 23 and 24 (Craniotomy With Major Device Implant or Acute Complex Central Nervous System Principal Diagnosis With MCC or Without MCC, respectively) under the proposed MS- DRG system, which are comparable to DRGs 1, 2, and 543 under the current CMS-DRG system.

To demonstrate that the Wingspan[reg] meets the cost threshold, the manufacturer submitted data from MedPAR and non-MedPAR databases. Using the FY 2005 MedPAR data, the applicant identified cases of intracranial angioplasty that had a procedure code of 39.50 (Angioplasty or atherectomy of

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other noncoronary vessels) in combination with one of the following principal diagnosis codes: Any principal diagnosis code that begins with the prefix of 433 (Occlusion and stenosis of precerebral arteries), excluding 433.10 (Cartoid artery without mention of cerebral infarction) and 433.11 (Cartoid artery with cerebral infarction); any principal diagnosis code that begins with the prefix of 434 (Occlusion of cerebral arteries), 437.0 (Cerebral atherosclerosis), 437.1 (Other generalized ischemic cerebrovascular disease), or 437.9 (Unspecified). The applicant noted that procedure code 39.50 is the predecessor code for identifying cases of intracranial angioplasty. The applicant explained that, given the newness of procedure codes 00.62 and 00.65 that were implemented beginning October 1, 2005, it believes there are still cases being coded with the predecessor procedure codes. Using this methodology, the applicant found 577 cases in DRG 533 and 179 cases in DRG 534. The applicant noted that charges in the MedPAR file do not include the total costs of devices, drugs, and medical supplies associated with the Wingspan[reg], so the applicant conducted an estimate of the charges associated with the Wingspan[reg]. The applicant determined that costs associated with the Wingspan[reg] are approximately $10,073. Because we use charges to determine if a technology meets the threshold, it is necessary to inflate the costs to charges. Using the national average CCR of 0.47, the applicant inflated the costs associated with the Wingspan[reg] to $21,432 in charges. After adding the charges associated with the Wingspan[reg], the average standardized charge per case was $76,416 and $51,277 for DRGs 533 and 534, respectively.

We are concerned regarding whether the cases identified by the applicant are a useful proxy to identify cases of intracranial angioplasty. Procedure code 39.50 describes cases of angioplasty in any artery of the body except the heart. Intracranial angioplasty with stenting was not covered by Medicare in any circumstance prior to October 2006. Therefore, the Medicare cases submitted by the applicant under procedure code 39.50 should not involve intracranial angioplasty because they are neither described by the code nor covered by Medicare. Furthermore, procedure code 00.62 is assigned to the Non-Covered Procedure edit of the MCE. The applicant supplied Medicare data from FY 2005 for claims coded with procedure code 00.62. It is unclear to us how these claims were processed despite the Non-Covered Procedure edit. Because these data appear to be based on claims that may not have been coded or processed correctly, we question the reliability and validity of these data. We are concerned that it may not be appropriate to rely on these data for purposes of determining whether the technology meets the cost threshold.

As stated above, the applicant also submitted non-Medicare data. The applicant used the 2005 patient discharge data from California's Office of Statewide Health Planning and Development database for hospitals in California and the 2005 patient data from Florida's Agency for Health Care Administration for hospitals in Florida. Similar to the analysis above, the applicant identified cases of intracranial angioplasty using procedure code 39.50 in combination with the diagnosis codes listed above. The applicant identified 43 cases in DRG 533, and 21 cases in DRG 534. Because these cases already include charges associated with Wingspan[supreg], it was not necessary to include the $21,432 in charges associated with Wingspan[supreg]. The average standardized charge per case was $89,697 and $40,475 for DRGs 533 and 534, respectively. As discussed above, we are concerned about whether these cases actually represent cases of intracranial angioplasty. We also note that we are unable to validate these data because they are non-Medicare data. In addition, similar to the analysis described above, the applicant also identified cases of intracranial angioplasty using procedure code 00.62. The applicant found 30 cases in DRG 533, and 23 cases in DRG 534. The average standardized charge per case was $93,215 and $31,479 for DRGs 533 and 534, respectively. Based on these data, the applicant maintains that the technology meets the cost threshold.

As noted above, the applicant has requested that cases of the Wingspan[supreg] be reassigned to CMS DRGs 1, 2 and 543. In section II.G.2. of the preamble of this proposed rule, we are proposing to assign procedure code 00.62 to proposed MS-DRGs 23, 24, 25, 26 and 27, which replace DRGs 1, 2, and 543 of the current CMS DRGs. The thresholds in Table 10 of the Addendum of the FY 2007 IPPS final rule (as corrected at 71 FR 60040) for DRGs 1, 2 and 543 are $53,969, $37,116 and $64,397, respectively. Analyzing the same Medicare and non- Medicare data that the applicant used to demonstrate that the Wingspan[supreg] exceeds the cost threshold for DRGs 533 and 534, the applicant compared the average standardized charge per case to the thresholds for DRGs 1, 2, and 543. The applicant maintains that the Wingspan[supreg] would still exceed the cost threshold even if it were reassigned to DRGs 1, 2, and 543.

However, for the reasons described above, it is not clear whether Wingspan[supreg] meets the cost threshold for new technology add-on payment. We welcome public comments on this issue.

The applicant also maintains that the technology meets the substantial clinical improvement criterion. In the past there has been no surgical or medical treatment available for recurrent strokes that occur despite optimal medical management. The applicant asserts that the Wingspan[supreg] provides a new treatment option for these patients. The applicant submitted three studies to support this position.

First, the applicant cites data derived from a series of cases of 45 patients who received the Wingspan[supreg] that demonstrate 4.4 percent composite ipsilateral stroke or death at 30 days, 7.0 percent composite ipsilateral stroke or death at 6 months, and 9.3 percent ipsilateral stroke or death at 13 months. The applicant then used patients in the well known Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial as a historical control against which to compare patients who received Wingspan[supreg]. The WASID trial compared the warfarin vs. aspirin therapy in treating symptomatic intracranial arterial stenosis, and it demonstrated a 23 percent stroke/death rate at one year in patients with severe (70 percent or greater) stenosis, and a 21 percent stroke/death rate at 2 years in patients with 50 percent or greater stenosis. The applicant also submitted data from an ongoing Wingspan[supreg] registry of patients that demonstrate a 4.8 percent stroke/death rate at 30 days, and a 9.7 percent stroke/death rate at 3 to 6 month follow up in 72 patients. In addition, the applicant submitted data from a multicenter NIH registry of 131 patients with 70 percent or greater stenosis that demonstrate an 8.4 percent rate of stroke, intracerebral hemorrhage or death at 30 days and a 9.9 percent rate of stroke and death at the mean 3.2 months followup.

While we recognize that Wingspan[supreg] may represent a promising technology in patients with significant intracranial arterial stenosis who are refractory to medical management, we are concerned that, to date, there has been no controlled, randomized trial to demonstrate its clinical efficacy. We are also concerned that the Wingspan[supreg] data did not compare patients over the same followup periods as WASID. In addition, we are concerned over the use

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of WASID patients as a control group against which to compare Wingspan[supreg] patients. The current FDA Humanitarian Device Exemption, in combination with the current CMS NCD, while providing access to this technology for very ill patients with generally poor prognoses who have few other options, also effectively designates the technology as investigational, and in need of further studies to prove its effectiveness. We would prefer that the product's effectiveness be demonstrated before we judge whether the product represents a substantial clinical improvement. For these reasons, we are concerned that there may not be sufficient evidence that Wingspan[supreg] represents an advance that substantially improves the diagnosis or treatment of Medicare beneficiaries. However, we welcome public comments that may pertain to this matter. 5. Technical Correction

Section 1886(d)(5)(K)(i) of the Act requires that the Secretary establish a mechanism to recognize the costs of new medical services and technologies under subsection (d) of section 1886 of the Act. As made clear under section 1886(d)(1)(A) of the Act, subsection (d) provides the methodology for payment with respect to the operating costs of inpatient hospital services. Section 1886(g) of the Act provides for payment of capital costs of inpatient hospital services. Although it has always been our policy that new technology add-on payment is available only with respect to operating costs, Sec. 412.88(a)(2) of our regulations does not specifically refer to operating costs or the operating CCR. Therefore, we are proposing to revise Sec. 412.88(a)(2) to clarify that the new technology add-on payment is available only for operating costs, and that we estimate the costs of a case by applying the hospital's operating CCR to the billed charges. This proposed correction would not have an impact on new technology add-on payments because, to the best of our knowledge, MACs already correctly apply only the operating CCR to calculate new technology add-on payments.

III. Proposed Changes to the Hospital Wage Index

A. Background

Section 1886(d)(3)(E) of the Act requires that, as part of the methodology for determining prospective payments to hospitals, the Secretary must adjust the standardized amounts ``for area differences in hospital wage levels by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the hospital compared to the national average hospital wage level.'' In accordance with the broad discretion conferred under the Act, we currently define hospital labor market areas based on the definitions of statistical areas established by the Office of Management and Budget (OMB). A discussion of the proposed FY 2008 hospital wage index based on the statistical areas, including OMB's revised definitions of Metropolitan Areas, appears under section III.B. of this preamble.

Beginning October 1, 1993, section 1886(d)(3)(E) of the Act requires that we update the wage index annually. 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 must exclude the wages and wage-related costs incurred in furnishing skilled nursing services. This provision also requires us to make any updates or adjustments to the wage index in a manner that ensures that aggregate payments to hospitals are not affected by the change in the wage index. The proposed adjustment for FY 2008 is discussed in section II.B. of the Addendum to this proposed rule.

As discussed below in section III.I. of this preamble, we also take into account the geographic reclassification of hospitals in accordance with sections 1886(d)(8)(B) and 1886(d)(10) of the Act when calculating IPPS payment amounts. Under section 1886(d)(8)(D) of the Act, the Secretary is required to adjust the standardized amounts so as to ensure that aggregate payments under the IPPS 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. The proposed budget neutrality adjustment for FY 2008 is discussed in section II.A.4.b. of the Addendum to this proposed rule.

Section 1886(d)(3)(E) of the Act also provides for the collection of data every 3 years on the occupational mix of employees for short- term, acute care hospitals participating in the Medicare program, in order to construct an occupational mix adjustment to the wage index. A discussion of the occupational mix adjustment that we are proposing to apply beginning October 1, 2007 (the FY 2008 wage index) appears under section III.C. of this preamble.

B. Core-Based Statistical Areas for the Hospital Wage Index

(If you choose to comment on issues in this section, please include the caption ``CBSAs'' at the beginning of your comments.)

The wage index is calculated and assigned to hospitals on the basis of the labor market area in which the hospital is located. In accordance with the broad discretion under section 1886(d)(3)(E) of the Act, beginning with FY 2005, we define hospital labor market areas based on the Core-Based Statistical Areas (CBSAs) established by OMB and announced in December 2003 (69 FR 49027). For a discussion of OMB's revised definitions of CBSAs and our implementation of the CBSA definitions, we refer readers to the preamble of the FY 2005 IPPS final rule (69 FR 49026 through 49032). The revised area designations established by OMB resulted in a higher wage index for some areas and a lower wage index for others. Further, some hospitals that were previously classified as urban became classified as rural. Given the significant payment impacts upon some hospitals because of these changes, we provided a transition period to the new labor market areas in the FY 2005 IPPS final rule. As part of that transition, we allowed urban hospitals that became rural under the new definitions to maintain their assignment to the MSA where they were previously located for the 3-year period of FY 2005, FY 2006, and FY 2007. For a discussion of the transition, we refer readers to the FY 2005 IPPS final rule (69 FR 49032 through 49034).

FY 2007 was the last year of the transition period for urban hospitals that became classified as rural. Therefore, for discharges on or after October 1, 2007 (FY 2008), these hospitals will receive their statewide rural wage index or their FY 2008 MGCRB reclassified age index. (These hospitals were and are eligible to apply for reclassification by the MGCRB both during the transition period and in subsequent years. These hospitals are considered rural for reclassification purposes.)

Consistent with the FY 2005, FY 2006, and FY 2007 IPPS final rules, for FY 2008 we are proposing to provide that hospitals receive 100 percent of their wage index based upon the CBSA configurations. Specifically, for each hospital, we will determine a wage index for FY 2008 employing wage index data from FY 2004 hospital cost reports and using the CBSA labor market definitions. We consider CBSAs that are MSAs to be urban, and CBSAs that are Micropolitan Statistical Areas as well as areas outside of CBSAs to be rural. In addition, where an MSA has been divided into Metropolitan Divisions, we consider the Metropolitan

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Division to comprise the labor market areas for purposes of calculating the wage index (69 FR 49029).

On December 18, 2006, OMB announced the inclusion of two new CBSAs and the revision of designations for six areas (OMB Bulletin No. 07- 01). The new CBSAs are as follows:

Lake Havasu-Kingman, Arizona (CBSA 29420). This CBSA comes from Mohave County, Arizona;

Palm Coast, Florida (CBSA 37380). This CBSA comes from Flager County, Florida;

The revised CBSA designations are as follows:

Mauldin, South Carolina and Easley, South Carolina qualify as new principal cities of the Greenville-Mauldin-Easley, South Carolina CBSA;

Conway, Arkansas qualifies as a new principal city of the Little Rock-North Little Rock-Conway, Arkansas CBSA;

Goleta, California qualifies as a new principal city of the Santa Barbara-Santa Maria-Goleta, California CBSA;

Franklin, Tennessee qualifies as a new principal city of the Nashville-Davidson-Murfreesboro-Franklin, Tennessee CBSA;

Fort Pierce, Florida no longer qualifies as a principal city of the Port St. Lucie-Fort Pierce, Florida CBSA; the new designation is Port St. Lucie, Florida CBSA.

(We note also that OMB renamed the Essex County, Massachusetts Metropolitan Division as the Peabody, Massachusetts Metropolitan Division. OMB also changed the CBSA code from 21604 to 37764.)

The OMB bulletin is available on the OMB Web site at http://www.whitehouse.gov/OMB_go to ``Bulletins'' or ``Statistical Programs

and Standards.'' CMS will apply these changes to the IPPS beginning October 1, 2007.

C. Proposed Occupational Mix Adjustment to the Proposed FY 2008 Wage Index

(If you choose to comment on issues in this section, please include the caption ``Occupational Mix Adjustment'' at the beginning of your comment.)

As stated earlier, section 1886(d)(3)(E) of the Act provides for the collection of data every 3 years on the occupational mix of employees for each short-term, acute care hospital participating in the Medicare program, in order to construct an occupational mix adjustment to the wage index, for application beginning October 1, 2004 (the FY 2005 wage index). The purpose of the occupational mix adjustment is to control for the effect of hospitals' employment choices on the wage index. For example, hospitals may choose to employ different combinations of registered nurses, licensed practical nurses, nursing aides, and medical assistants for the purpose of providing nursing care to their patients. The varying labor costs associated with these choices reflect hospital management decisions rather than geographic differences in the costs of labor.

1. Development of Data for the Proposed FY 2008 Occupational Mix Adjustment

On October 14, 2005, we published a notice in the Federal Register (70 FR 60092) proposing to use a new survey, the 2006 Medicare Wage Index Occupational Mix Survey (the 2006 survey) to apply an occupational mix adjustment to the FY 2008 wage index. In the proposed 2006 survey, we included several modifications based on the comments and recommendations we received on the 2003 survey, including (1) allowing hospitals to report their own average hourly wage rather than using BLS data; (2) extending the prospective survey period; and (3) reducing the number of occupational categories but refining the subcategories for registered nurses.

We made the changes to the occupational categories in response to MedPAC comments to the FY 2005 IPPS final rule (69 FR 49036). Specifically, MedPAC recommended that CMS assess whether including subcategories of registered nurses would result in a more accurate occupational mix adjustment. MedPAC believed that including all registered nurses in a single category may obscure significant wage differences among the subcategories of registered nurses, for example, the wages of surgical registered nurses and floor registered nurses may differ. Also, to offset additional reporting burden for hospitals, MedPAC recommended that CMS should combine the general service categories that account for only a small percentage of a hospital's total hours with the ``all other occupations'' category because most of the occupational mix adjustment is correlated with the nursing general service category.

In addition, in response to the public comments on the October 14, 2005 notice, we modified the 2006 survey. On February 10, 2006, we published a Federal Register notice (71 FR 7047) that solicited comments and announced our intent to seek OMB approval on the revised occupational mix survey (Form CMS-10079 (2006)). OMB approved the survey on April 25, 2006.

The 2006 survey provides for the collection of hospital-specific wages and hours data, a 6-month prospective reporting period (that is, January 1, 2006, through June 30, 2006), the transfer of each general service category that comprised less than 4 percent of total hospital employees in the 2003 survey to the ``all other occupations'' category (the revised survey focuses only on the mix of nursing occupations), additional clarification of the definitions for the occupational categories, an expansion of the registered nurse category to include functional subcategories, and the exclusion of average hourly rate data associated with advance practice nurses.

The 2006 survey included only two general occupational categories: nursing and ``all other occupations.'' The nursing category has four subcategories: registered nurses, licensed practical nurses, aides, orderlies, attendants, and medical assistants. The registered nurse subcategory includes two functional subcategories: Management personnel and staff nurses or clinicians. As indicated above, the 2006 survey provided for a 6-month data collection period, from January 1, 2006 through June 30, 2006. However, we allowed flexibility for the reporting period begin and end dates to accommodate some hospitals' bi- weekly payroll and reporting systems. That is, the 6-month reporting period had to begin on or after December 25, 2005, and end before July 9, 2006.

We are proposing to use the 6-month 2006 survey data to calculate the occupational mix adjustment for the FY 2008 wage index. We used the 1st quarter of 2006 survey data in the FY 2007 wage index to comply with a court decision in Bellevue Hosp. Center v. Leavitt, 443 F.3d 163 (2nd Cir. 2006). For a discussion of our use of the 2006 survey data in the FY 2007 wage index, in compliance with the Bellevue decision, we refer readers to the FY 2007 IPPS final rule (71 FR 48007) as well as the FY 2007 IPPS final notice (71 FR 90886). However, as stated above, we are proposing to use the entire 6-month 2006 survey data (that is, from the period January 1, 2006 through June 30, 2006) to calculate the occupational mix adjustment for the FY 2008 wage index. 2. Timeline for the Collection, Review, and Correction of the Occupational Mix Data

In a Joint-Signature Memorandum that we issued on April 21, 2006 (JSM-06412), and in the FY 2007 IPPS final rule (71 FR 48008), we discussed the schedule for the 1st quarter 2006

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occupational mix survey data that would be used in the FY 2007 wage index. The schedule included deadlines for--

Hospitals to submit 1st quarter occupational mix data. The deadline was June 1, 2006.

MAC review of the submitted 1st quarter data. The deadline was June 22, 2006.

Availability of the submitted first quarter data on the CMS Web site. The deadline was June 29, 2006.

Hospitals to submit requests to their MACs for corrections to their 1st quarter occupational mix data. The deadline was July 13, 2006.

MACs to submit corrected 1st quarter occupational mix survey data to CMS. The deadline was July 27, 2006.

In the Joint-Signature Memorandum, we also indicated that hospitals were to submit their 2nd quarter 2006 occupational mix survey data to their intermediaries (MACs) by August 31, 2006. On October 6, we published on our web site both the audited 1st quarter and unaudited 2nd quarter 2006 occupational survey data and Worksheet S-3 wage data to be used in calculating the FY 2008 wage index. In addition, we sent a letter to hospitals through their MACs (dated October 6, 2006) that discussed the timeframe for reviewing and correcting Worksheet S-3 wage data and the 2nd quarter 2006 survey data, and an opportunity for hospitals to request additional adjustments to their 1st quarter 2006 survey data for the FY 2008 wage index. The revision and correction process for all of the data to be used for computing the FY 2008 wage index is discussed in detail in section III.K. of this preamble. 3. Calculation of the Proposed Occupational Mix Adjustment for FY 2008

For FY 2008 (as we did for FY 2007), we are proposing to calculate the occupational mix adjustment factor using the following steps:

Step 1--For each hospital, determine the percentage of the total nursing category attributable to a nursing subcategory by dividing the nursing subcategory hours by the total nursing category's hours (registered nurse management personnel and registered nurse staff nurses or clinicians are treated as separate nursing subcategories). Repeat this computation for each of the five nursing subcategories: registered nurse management personnel, registered nurse staff nurses or clinicians, licensed practical nurses; nursing aides, orderlies, and attendants; and medical assistants.

Step 2--Determine a national average hourly rate for each nursing subcategory by dividing a subcategory's total salaries for all hospitals in the occupational mix survey database by the subcategory's total hours for all hospitals in the occupational mix survey database.

Step 3--For each hospital, determine an adjusted average hourly rate for each nursing subcategory by multiplying the percentage of the total nursing category (from Step 1) by the national average hourly rate for that nursing subcategory (from Step 2). Repeat this calculation for each of the five nursing subcategories.

Step 4--For each hospital, determine the adjusted average hourly rate for the total nursing category by summing the adjusted average hourly rate (from Step 3) for each of the nursing subcategories.

Step 5--Determine the national average hourly rate for the total nursing category by dividing total nursing category salaries for all hospitals in the occupational mix survey database by total nursing category hours for all hospitals in the occupational mix survey database.

Step 6--For each hospital, compute the occupational mix adjustment factor for the total nursing category by dividing the national average hourly rate for the total nursing category (from Step 5) by the hospital's adjusted average hourly rate for the total nursing category (from Step 4).

If the hospital's adjusted average hourly rate is less than the national average hourly rate (indicating the hospital employs a less costly mix of nursing employees), the occupational mix adjustment factor would be greater than 1.0000. If the hospital's adjusted average hourly rate is greater than the national average hourly rate, the occupational mix adjustment factor would be less than 1.0000.

Step 7--For each hospital, calculate the occupational mix adjusted salaries and wage-related costs for the total nursing category by multiplying the hospital's total salaries and wage-related costs (from Step 5 of the unadjusted wage index calculation in section III.F. of this preamble) by the percentage of the hospital's total workers attributable to the total nursing category (using the occupational mix survey data, this percentage is determined by dividing the hospital's total nursing category salaries by the hospital's total salaries for ``nursing and all other'') and by the total nursing category's occupational mix adjustment factor (from Step 6 above).

The remaining portion of the hospital's total salaries and wage- related costs that is attributable to all other employees of the hospital is not adjusted by the occupational mix. A hospital's all other portion is determined by subtracting the hospital's nursing category percentage from 100 percent.

Step 8--For each hospital, calculate the total occupational mix adjusted salaries and wage-related costs for a hospital by summing the occupational mix adjusted salaries and wage-related costs for the total nursing category (from Step 7) and the portion of the hospital's salaries and wage-related costs for all other employees (from Step 7).

To compute a hospital's occupational mix adjusted average hourly wage, divide the hospital's total occupational mix adjusted salaries and wage-related costs by the hospital's total hours (from Step 4 of the unadjusted wage index calculation in section III.F. of this preamble).

Step 9--To compute the occupational mix adjusted average hourly wage for an urban or rural area, sum the total occupational mix adjusted salaries and wage-related costs for all hospitals in the area, then sum the total hours for all hospitals in the area. Next, divide the area's occupational mix adjusted salaries and wage-related costs by the area's hours.

Step 10--To compute the national occupational mix adjusted average hourly wage, sum the total occupational mix adjusted salaries and wage- related costs for all hospitals in the Nation, then sum the total hours for all hospitals in the Nation. Next, divide the national occupational mix adjusted salaries and wage-related costs by the national hours.

Step 11--To compute the occupational mix adjusted wage index, divide each area's occupational mix adjusted average hourly wage (Step 9) by the national occupational mix adjusted average hourly wage (Step 10).

Step 12--To compute the Puerto Rico specific occupational mix adjusted wage index, follow Steps 1 through 11 above.

The table below is an illustrative example of the proposed occupational mix adjustment. BILLING CODE 4120-01-P

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From the Federal Register Online via GPO Access [wais.access.gpo.gov] ]

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Because the occupational mix adjustment is required by statute, all hospitals that are subject to payments under the IPPS, or any hospital that

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would be subject to the IPPS if not granted a waiver, must complete the occupational mix survey, unless the hospital has no associated cost report wage data that are included in the proposed FY 2008 wage index.

For the FY 2007 wage index, if a hospital did not respond to the occupational mix survey, or if we determined that a hospital's submitted data were too erroneous to include in the wage index, we assigned the hospital the average occupational mix adjustment for the labor market area (71 FR 48013). We believed this method had the least impact on the wage index for other hospitals in the area. For areas where no hospital submitted data for purposes of calculating the occupational mix adjustment, we applied the national occupational mix factor of 1.0000 in calculating the area's FY 2007 occupational mix adjusted wage index. We indicated in the FY 2007 IPPS final rule that we reserve the right to apply a different approach in future years, including potentially penalizing nonresponsive hospitals.

For the FY 2008 wage index, we are proposing to handle the data for hospitals that did not respond to the occupational mix survey (neither the 1st quarter nor 2nd quarter data) in the same manner as discussed above for the FY 2007 wage index. In addition, if a hospital submitted survey data for either the 1st quarter or 2nd quarter, but not for both quarters, we are proposing to use the data the hospital submitted for one quarter to calculate the hospital's FY 2008 occupational mix adjustment factor. Lastly, if a hospital submitted a survey(s), but that survey data could not be used because we determined it to be aberrant, we also assigned the hospital the average occupational mix adjustment for its labor market area. For example, if a hospital's individual nurse category average hourly wages were out of range (that is, unusually high or low), and the hospital did not provide sufficient documentation to explain the aberrancy, or the hospital did not submit any registered nurse staff salaries or hours data, we assigned the hospital the average occupational mix adjustment for the labor market area in which it is located.

In calculating the average occupational mix adjustment factor for a labor market area, we replicated Steps 1 through 6 of the calculation for the occupational mix adjustment. However, instead of performing these steps at the hospital level, we aggregated the data at the labor market area level. In following these steps, for example, for CBSAs that contain providers that did not submit occupational mix survey data, the occupational mix adjustment factor ranged from a low of 0.8972 (CBSA 39820, Redding, CA), to a high of 1.0728 (CBSA 19, Rural Louisiana). Also, in computing a hospital's occupational mix adjusted salaries and wage-related costs for nursing employees (Step 7 of the calculation), in the absence of occupational mix survey data, we multiplied the hospital's total salaries and wage-related costs by the percentage of the area's total workers attributable to the area's total nursing category. For FY 2008, there is one CBSA in which none of the providers submitted the occupational mix survey (CBSA 49740, Yuma, AZ). In the absence of any data in this labor market area, we applied an occupational mix adjustment factor of 1.0 to all provider(s).

In the FY 2007 IPPS final rule, we also indicated that we would give serious consideration to applying a hospital-specific penalty if a hospital does not comply with regulations requiring submission of occupational mix survey data in future years. We stated that we believe that section 1886(d)(5)(I)(i) of the Act provides us with the authority to penalize hospitals that do not submit occupational mix survey data. That section authorizes us to provide for exceptions and adjustments to the payment amounts under IPPS as the Secretary deems appropriate. We also indicated that we would address this issue in the FY 2008 IPPS proposed rule.

We are soliciting comments and suggestions for a hospital-specific penalty for hospitals that do not submit occupational mix survey. In response to the FY 2007 IPPS proposed rule, some commenters suggested a 1-percent to 2-percent reduction in the hospital's wage index value or a set percentage of the standardized amount. Any penalty that we would determine for nonresponsive hospitals would apply to a future wage index, not the FY 2008 wage index. 4. Proposed 2007-2008 Occupational Mix Survey for the FY 2010 Wage Index

As stated earlier, section 304(c) of Pub. L. 106-554 amended section 1886(d)(3)(E) of the Act to require CMS to collect data every 3 years on the occupational mix of employees for each short-term, acute care hospital participating in the Medicare program. We are currently using occupational mix survey data collected in 2006 in the FY 2007 IPPS. Since we implemented the 2006 survey, we received several public comments suggesting further improvements to the occupational mix survey instructions and definitions. Specifically, some commenters recommended that we include certain employees, such as surgical technicians and paramedics in the occupational mix adjustment. The commenters indicated that these occupations perform similar functions, and in some cases, are used as substitutes for nursing staff. Therefore, they recommended that CMS include these occupations with the nursing categories on the survey. (On the 2003 and 2006 surveys, these categories were included in the ``All Other Occupations'' category.) The commenters also recommended that CMS expand the list of cost centers for the survey to include additional cost centers that contain a significant number of nursing personnel.

Some commenters suggested that CMS not collect occupational mix data for the ``Registered Nurse'' subcategories (that is, Management Personnel and Staff Nurse/Clinician). The commenters expressed concern that requiring the subcategories led to errors and inconsistencies in reporting, and added to the hospitals' collection burden. The commenters did not believe that this level of specificity significantly affects the adjustment. Therefore they recommended that CMS eliminate the RN subcategories.

In addition, commenters recommended that CMS provide for a 1-year data collection period rather than a 6-month data collection period for the next survey collection. The commenters suggested that a 1-year data collection period would provide a better representation of a hospital's employment mix, which can vary during different times of the year. The commenters also indicated that a 1-year data collection period would allow hospitals to verify their wages and hours to year-end payroll reports and contractor invoices.

In response to these suggestions we have modified the occupational mix survey. The revised 2007-2008 occupational mix survey will provide for the collection of hospital-specific wages and hours data for a 1- year prospective reporting period from July 1, 2007, through June 30, 2008, additional clarifications to the survey instructions, the elimination of the registered nurse subcategories, some refinements to the definitions of the occupational categories, and the inclusion of additional cost centers that typically provide nursing services. The revised 2007-2008 Medicare occupational mix survey will be applied beginning with the FY 2010 wage index.

On February 2, 2007, we published a notice soliciting comments on the proposed revisions to the occupational mix survey (Form CMS-10079 (2006))

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(72 FR 5055). The comment period for the proposed survey ended on April 3, 2007. A final notice is expected to be published in the Federal Register by July 1, 2007.

D. Worksheet S-3 Wage Data for the Proposed FY 2008 Wage Index

(If you choose to comment on issues in this section, please include the caption ``Wage Data'' at the beginning of your comment.)

The proposed FY 2008 wage index values (to be effective for hospital discharges occurring on or after October 1, 2007, and before October 1, 2008) in section II.B. of the Addendum to this proposed rule are based on the data collected from the Medicare cost reports submitted by hospitals for cost reporting periods beginning in FY 2004 (the FY 2007 wage index was based on FY 2003 wage data). 1. Included Categories of Costs

The proposed FY 2008 wage index includes the following categories of data associated with costs paid under the IPPS (as well as outpatient costs):

Salaries and hours from short-term, acute care hospitals (including paid lunch hours and hours associated with military leave and jury duty).

Home office costs and hours.

Certain contract labor costs and hours (which includes direct patient care, certain top management, pharmacy, laboratory, and nonteaching physician Part A services).

Wage-related costs, including pensions and other deferred compensation costs. 2. Contract Labor for Indirect Patient Care Services

In the FY 2003 IPPS final rule (67 FR 50022), we discussed the inclusion of contract labor cost in calculating the wage index. Our policy has evolved over the years with the increasing role of contract labor in meeting special personnel needs of hospitals. In response to suggestions that we further expand our definition of contract labor for the wage index, we indicated our intent to begin collecting data in future Medicare cost reports on the following overhead services: administrative and general (A&G); housekeeping; and dietary. We selected these three overhead services for consideration because they are provided at all hospitals, either directly or through contracts, and together they comprise about 60 percent of a hospital's overhead hours. Consistent with our consideration of contract A&G services, we also stated that we would begin collecting costs and hours data associated with other contract management services that would not be included on the cost report as overhead A&G and are not top management contracts (that is, the chief executive officer, chief financial officer, chief operating officer, and nurse administrator) that are included on Line 9 of Worksheet S-3, Part II.

We revised the cost report, beginning October 1, 2003 (the FY 2004 cost report), to provide for the collection of cost and hours data for the four identified contract indirect patient care services. We added four new line items to Worksheet S-3, Part II: Line 9.03 (Contract management and administrative services); Line 22.01 (Contract A & G services); Line 26.01 (Contract housekeeping services); and Line 27.01 (Contract dietary services). We stated in the FY 2003 final rule that our decision on whether to include these costs in calculating the wage index would depend on our analyses of the data and public comments. The FY 2008 wage index, which is based on FY 2004 cost report data, is the first year that we can assess the impact of including these costs in the wage index.

As part of the FY 2008 wage index desk review program, we required the fiscal intermediaries (or, if applicable, the MAC) to verify the accuracy of the data reported on the new Lines 9.03, 22.01, 26.01, and 27.01. After the completion of these reviews, some hospitals continued to fail our edits for reasonableness: 12 hospitals (0.3 percent) failed edits for Line 9.03; 130 hospitals (3.6 percent) failed edits for Line 22.01; 56 hospitals (1.6 percent) failed edits for Line 26.01; and 99 hospitals (2.8 percent) failed edits for Line 27.01. Many of these edit failures are for wage data that are not to be included in the wage index and will be excluded through the wage index calculation. That is, as specified in the cost reporting instructions in the Provider Reimbursement Manual, Part II, section 3605.2, if a hospital's ratio of excluded area hours (Lines 8 and 8.0) on Worksheet S-3, Part II to total adjusted hours is less than 15 percent, Lines 21 through 35 of Part II should not be completed by hospitals. In addition, some of the aberrant data will be resolved by the final rule through the correction process described in section III.K. of the preamble of this proposed rule. Nevertheless, we believe that the amount of aberrant data on these new line items is minimal and will have little impact on area wage index values.

In addition, we have simulated the effect of including these wage data for contract indirect patient care services on the wage index. Under this simulation, we found that the resulting average hourly wage would not affect 3,231 hospitals (90.2 percent), would decrease for 121 hospitals (3.4 percent), and would increase for 229 hospitals (6.4 percent). Only one hospital would experience a decrease of greater than 1 percent (3 percent), and 19 hospitals would experience an increase of greater than 1 percent (the largest being 7.8 percent). At the labor market area level, we found that the resulting average hourly wage would not affect 316 areas (72.6 percent), would decrease for 28 areas (6.4 percent), and would increase for 91 areas (20.9 percent). No area, rural or urban, would experience an increase or decrease of greater than 0.6 percent in its wage index. We believe that the combined effect of including these costs in the wage index is negligible because the higher labor costs associated with contract management and A&G services are offset by the lower labor costs associated with contract housekeeping and dietary services.

Public commenters have expressed interest in including in the wage index the costs and hours for contract management, A&G, housekeeping, and dietary services. We also believe that including a more comprehensive measure of area differences in the cost of labor will improve the accuracy of the wage index. For these reasons, we are proposing to include these contract services in the wage index, beginning with FY 2008. Although we invite public comment on whether we should revise a future cost report to collect contract labor data for the remaining indirect patient care cost centers on Worksheet S-3, Part II for possible inclusion in the wage index, we will consider these comments in the context of potential reforms of the IPPS wage index for FY 2009 and subsequent years. As indicated in section III.M. of the preamble of this proposed rule, section 106(b) of the MIEA-TRHCA (Pub. L. 109-432) requires the Secretary to consider a MedPAC study and nine specific aspects of the wage index in making one or more proposals for revisions in FY 2009. 3. Excluded Categories of Costs

Consistent with the wage index methodology for FY 2007, the proposed wage index for FY 2008 also excludes the direct and overhead salaries and hours for services not subject to IPPS payment, such as SNF services, home health services, costs related to GME (teaching physicians and residents) and certified registered nurse anesthetists (CRNAs), and other subprovider components that are not paid under the IPPS. The proposed FY 2008 wage index

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also excludes the salaries, hours, and wage-related costs of hospital- based rural health clinics (RHCs), and Federally qualified health centers (FQHCs) because Medicare pays for these costs outside of the IPPS (68 FR 45395). In addition, salaries, hours, and wage-related costs of CAHs are excluded from the wage index, for the reasons explained in the FY 2004 IPPS final rule (68 FR 45397). 4. Use of Wage Index Data by Providers Other Than Acute Care Hospitals under the IPPS

Data collected for the IPPS wage index are also currently used to calculate wage indices applicable to other providers, such as SNFs, home health agencies, and hospices. In addition, they are used for prospective payments to IRFs, IPFs, and LTCHs, and for hospital outpatient services. We note that, in the IPPS rules, we do not address comments pertaining to the wage indices for non-IPPS providers. Such comments should be made in response to separate proposed rules for those providers.

E. Verification of Worksheet S-3 Wage Data

(If you choose to comment on this section, please include the caption ``Wage Data'' at the beginning of your comment.)

The wage data for the proposed FY 2008 wage index were obtained from Worksheet S-3, Parts II and III of the FY 2004 Medicare cost reports. Instructions for completing the Worksheet S-3, Parts II and III are in the Provider Reimbursement Manual, Part I, sections 3605.2 and 3605.3. The data file used to construct the proposed wage index includes FY 2004 data submitted to us as of February 26, 2007 As in past years, we will perform an intensive review of the wage data, mostly through the use of edits designed to identify aberrant data.

We asked our fiscal intermediaries/MACs to revise or verify data elements that resulted in specific edit failures. We identified and excluded 23 hospitals with data that was too aberrant to include in the proposed wage index, although if these data elements are corrected, we may include some of these providers in the FY 2008 final wage index. However, some unresolved data elements are included in the calculation of the proposed FY 2008 wage index. We instructed fiscal intermediaries/MACs to complete their data verification of questionable data elements and to transmit any changes to the wage data no later than April 13, 2007. We believe all unresolved data elements will be resolved by the date the final rule is issued. The revised data will be reflected in the final rule.

In constructing the proposed FY 2008 wage index, we include the wage data for facilities that were IPPS hospitals in FY 2004, even for those facilities that have since terminated their participation in the program as hospitals, as long as those data do not fail any of our edits for reasonableness. We believe that including the wage data for these hospitals is, in general, appropriate to reflect the economic conditions in the various labor market areas during the relevant past period. However, we exclude the wage data for CAHs as discussed in 68 FR 45397. For this proposed rule, we removed 18 hospitals that converted to CAH status between February 17, 2006, the cut-off date for CAH exclusion from the FY 2007 wage index, and February 16, 2007, the cut-off date for CAH exclusion from the FY 2008 wage index. After removing hospitals with aberrant data and hospitals that converted to CAH status, the proposed FY 2008 wage index is calculated based on 3,581 hospitals.

F. Wage Index for Multicampus Hospitals

(If you choose to comment on issues in this section, please include the caption ``Multicampus Hospitals'' at the beginning of your comment.)

As discussed earlier under section III.B. of this preamble, effective October 1, 2004, for the IPPS, CMS implemented new labor market areas based on the CBSA definitions of MSAs. As a result of the new labor market areas, there are multicampus hospitals previously located in a single MSA that are now located in more than one CBSA. A multicampus hospital is a single integrated institution. For this reason, the multicampus hospital has one provider number and submits a single cost report that combines the total wages and hours of each of its campuses. When campuses of a multicampus hospital are located in the same CBSA, the wages and hours for the entire institution are included in the calculation of the wage index for that labor market area and there is no need to separate the data by campus. However, when a multicampus hospital has campuses located in different labor market areas, wages and hours are reported in a single CBSA even though the hospital's staff is working at campuses in more than one labor market area. The wage data are reported in the labor market area of the hospital campus associated with the provider number. Wages and hours are not reported separately for each campus and no data from the multicampus hospital are used in determining the wage index for the labor market area(s) where the other campus(es) are located. Under Sec. 412.64(b)(5) of our regulations, the wage-adjusted standardized amount is based on geographic location of the hospital facility at which the discharge occurred. Therefore, the wage index for each hospital campus used to make the IPPS payment is based on its geographic location, while the wage data from all of the campuses, including those that may be located in a different geographic area, are applied to one area only. We have received inquiries from several hospitals suggesting that we should adopt a policy that results in an allocation of a multicampus hospital's wages and hours across the different labor market areas where its campuses are located.

The wage index was developed to adjust the IPPS standardized amount to reflect area differences in hospital wage levels in the hospital's geographic area compared to the national hospital wage level as required under section 1886(d)(3)(E) of the Act. Although we acknowledge that reporting the wage data into a single labor market area when individual campuses of a multicampus hospital are located in different labor market areas may not allocate wage data with exact precision, the Medicare cost report, in its current form, does not enable a multicampus hospital to separately report its costs by location. The fact that a multicampus hospital submits a single cost report reflects that it is an integrated institution with one accounting structure. Nevertheless, we agree with the comments brought to our attention that we should consider a policy that allocates a multicampus hospital's wages and hours among the different labor market areas where it is located. That is, rather than giving 100 percent of the hospital's wage data to the labor market area associated with its provider number, we believe that an allocation of its wage data should be made to each campus.

We considered three alternative methods of apportionment: beds, discharges, or FTE staff. A hospital's number of discharges can fluctuate from year to year and may be an unstable data source to use in allocating a hospital's wages and hours among the different campuses. Alternatively, while a hospital's number of beds is a more static number, it likely does not correlate well with how a hospital incurs its wage costs. Furthermore, neither of these numbers is available on a campus-specific basis in Medicare's data systems. (While an individual

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campus of a multicampus hospital located in a different labor market area than the remainder of the institution is required to indicate a suffix on its provider number when submitting a claim in order to receive payment using the wage index for its geographic location, the suffix is only used by the fiscal intermediary (or, if applicable, the MAC) and is not retained in Medicare's historical data files that we use to determine IPPS rates).

Given the unavailability of beds and discharges and their respective drawbacks for allocating wages and hours across multiple campuses, we are proposing to apportion wages and hours for each campus of a multicampus hospital based on FTE staff. For example, a multicampus hospital may have three campuses located in two different labor market areas. Campuses A and B are located in labor market area 1 and have 50 and 25 FTEs, respectively. Campus C is located in labor market area 2 and has an additional 25 FTEs. Therefore, 75 percent of the hospital's FTEs work in labor market 1 and 25 percent in labor market area 2. Under the proposed policy, we would apportion 75 percent of the hospital's occupational mix adjusted total salaries, wage- related costs and hours to labor market 1 and 25 percent to labor market 2. We believe that the number of FTEs will provide the best method of apportioning wages and hours among the different campuses, thereby allowing the apportioned wage data to be included in each geographic area where the hospital has employees working.

This proposed policy requires the identification of all multicampus hospitals located in more than one CBSA, the county, State, and zip code of each campus, and the campus-specific number of FTEs. Based on our comprehensive interactions with our fiscal intermediaries since adopting the revised labor market areas beginning in FY 2005, we are only aware of three multicampus hospitals that are located in more than one labor market area. We are beginning the process to make updates and refinements to the cost report for the future. We are currently planning to add additional lines to Worksheet S-2 of the cost report that will allow a multicampus hospital to report the locations of its different campuses (county, State, and zip code) and number of FTE staff by location so this information would become part of the cost report submission process. The effective date of the revised cost report is not expected until FY 2009. Therefore, we would not have data from multicampus hospitals under our normal wage data collection process to be able to allocate wages to each labor market area by FTEs until at least the FY 2013 wage index. In the interim, we will collect this information from multicampus hospitals on a small survey form through our fiscal intermediaries/MACs as part of the wage index desk review process beginning with the FY 2009 wage index. We will not be able to apply this policy to the FY 2008 wage index unless we have this information from multicampus hospitals prior to the close of the comment period on this proposed rule. Therefore, for the FY 2008 wage index, multicampus hospitals with campuses located in more than one geographic area should submit the information during the comment period on this proposed rule for the county, State, and zip code of its campuses, and the FTE number, including contract labor, per campus along with supporting documentation to: Centers for Medicare & Medicaid Services, Wage Index Team, C4-08-06, 7500 Security Boulevard, Baltimore, Maryland 21244, Attn: Kathy Ellingson.

The hospitals should submit data from their FY 2004 cost reporting period to match the same data that will be used for the FY 2008 wage index. However, if unavailable, the hospital may submit the data for a subsequent cost reporting period that is closest to the FY 2004 reporting period that provides the information in order to apportion the hospital's wage data among its campuses. These data will enable CMS to apportion the wages and hours of the multicampus hospital among its different campuses for use in the FY 2008 wage index calculations should this proposal become final. As stated earlier, we are only aware of three hospitals that would be affected by this proposed information collection request. As stipulated under 5 CFR 1320.3(c)(4), the proposed information collection request is exempt from the Paperwork Reduction Act (PRA) as it does not affect 10 or more persons within a 12-month period. However, if during the IPPS rule comment period, we determine the number of affected persons surpasses the threshold of 10 as specified in 5 CFR 1320.3(c)(4), we will not adopt the policy until FY 2009 in order for us to seek the requisite approval from OMB under the PRA.

G. Computation of the Proposed FY 2008 Unadjusted Wage Index

(If you choose to comment on issues in this section, please include the caption ``Wage Index'' at the beginning of your comment.) 1. Method for Computing the Proposed FY 2008 Unadjusted Wage Index

The method used to compute the proposed FY 2008 wage index without an occupational mix adjustment follows:

Step 1--As noted above, we based the proposed FY 2008 wage index on wage data reported on the FY 2004 Medicare cost reports. We gathered data from each of the non-Federal, short-term, acute care hospitals for which data were reported on the Worksheet S-3, Parts II and III of the Medicare cost report for the hospital's cost reporting period beginning on or after October 1, 2003, and before October 1, 2004. In addition, we include data from some hospitals that had cost reporting periods beginning before October 2003 and reported a cost reporting period covering all of FY 2004. These data are included because no other data from these hospitals would be available for the cost reporting period described above, and because particular labor market areas might be affected due to the omission of these hospitals. However, we generally describe these wage data as FY 2004 data. We note that, if a hospital had more than one cost reporting period beginning during FY 2004 (for example, a hospital had two short cost reporting periods beginning on or after October 1, 2003, and before October 1, 2004), we include wage data from only one of the cost reporting periods, the longer, in the wage index calculation. If there was more than one cost reporting period and the periods were equal in length, we include the wage data from the later period in the wage index calculation.

Step 2--Salaries--The method used to compute a hospital's average hourly wage excludes certain costs that are not paid under the IPPS. In calculating a hospital's average salaries plus wage-related costs, we subtract from Line 1 (total salaries) the GME and CRNA costs reported on Lines 2, 4.01, 6, and 6.01, the Part B salaries reported on Lines 3, 5 and 5.01, home office salaries reported on Line 7, and exclude salaries reported on Lines 8 and 8.01 (that is, direct salaries attributable to SNF services, home health services, and other subprovider components not subject to the IPPS). We also subtract from Line 1 the salaries for which no hours were reported. To determine total salaries plus wage-related costs, we add to the net hospital salaries the costs of contract labor for direct patient care, certain top management, pharmacy, laboratory, and nonteaching physician Part A services (Lines 9 and 10), home office salaries and wage-related costs reported by the

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hospital on Lines 11 and 12, and nonexcluded area wage-related costs (Lines 13, 14, and 18).

We note that contract labor and home office salaries for which no corresponding hours are reported are not included. In addition, wage- related costs for nonteaching physician Part A employees (Line 18) are excluded if no corresponding salaries are reported for those employees on Line 4.

Step 3--Hours--With the exception of wage-related costs, for which there are no associated hours, we compute total hours using the same methods as described for salaries in Step 2.

Step 4--For each hospital reporting both total overhead salaries and total overhead hours greater than zero, we then allocate overhead costs to areas of the hospital excluded from the wage index calculation. First, we determine the ratio of excluded area hours (sum of Lines 8 and 8.01 of Worksheet S-3, Part II) to revised total hours (Line 1 minus the sum of Part II, Lines 2, 3, 4.01, 5, 5.01, 6, 6.01, 7, and Part III, Line 13 of Worksheet S-3). We then compute the amounts of overhead salaries and hours to be allocated to excluded areas by multiplying the above ratio by the total overhead salaries and hours reported on Line 13 of Worksheet S-3, Part III. Next, we compute the amounts of overhead wage-related costs to be allocated to excluded areas using three steps: (1) we determine the ratio of overhead hours (Part III, Line 13) to revised hours (Line 1 minus the sum of Lines 2, 3, 4.01, 5, 5.01, 6, 6.01, 7, 8, and 8.01); (2) we compute overhead wage-related costs by multiplying the overhead hours ratio by wage- related costs reported on Part II, Lines 13, 14, and 18; and (3) we multiply the computed overhead wage-related costs by the above excluded area hours ratio. Finally, we subtract the computed overhead salaries, wage-related costs, and hours associated with excluded areas from the total salaries (plus wage-related costs) and hours derived in Steps 2 and 3.

Step 5--For each hospital, we adjust the total salaries plus wage- related costs to a common period to determine total adjusted salaries plus wage-related costs. To make the wage adjustment, we estimate the percentage change in the employment cost index (ECI) for compensation for each 30-day increment from October 14, 2003, through April 15, 2005, for private industry hospital workers from the BLS' Compensation and Working Conditions. We use the ECI because it reflects the price increase associated with total compensation (salaries plus fringes) rather than just the increase in salaries. In addition, the ECI includes managers as well as other hospital workers. This methodology to compute the monthly update factors uses actual quarterly ECI data and assures that the update factors match the actual quarterly and annual percent changes. We also note that, since April 2006 with the publication of March 2006 data, the BLS' ECI uses a different classification system, the North American Industrial Classification System (NAICS), instead of the Standard Industrial Codes (SICs), which no longer exist. We have consistently used the ECI as the data source for our wages and salaries and other price proxies in the IPPS market basket and are not proposing to make any changes to the usage at this time. However, we are soliciting comments on our continued use of the BLS ECI data in light of the BLS change in system usage to the NAICS- based ECI. The factors used to adjust 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

10/14/2003

11/15/2003

1.05743 11/14/2003

12/15/2003

1.05355 12/14/2003

01/15/2004

1.04964 01/14/2004

02/15/2004

1.04578 02/14/2004

03/15/2004

1.04198 03/14/2004

04/15/2004

1.03830 04/14/2004

05/15/2004

1.03482 05/14/2004

06/15/2004

1.03153 06/14/2004

07/15/2004

1.02821 07/14/2004

08/15/2004

1.02466 08/14/2004

09/15/2004

1.02086 09/14/2004

10/15/2004

1.01705 10/14/2004

11/15/2004

1.01344 11/14/2004

12/15/2004

1.01003 12/14/2004

01/15/2005

1.00671 01/14/2005

02/15/2005

1.00336 02/14/2005

03/15/2005

1.00000 03/14/2005

04/15/2005

0.99663

For example, the midpoint of a cost reporting period beginning January 1, 2004, and ending December 31, 2004, is June 30, 2004. An adjustment factor of 1.02821 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 2004 and covered a period of less than 360 days or more than 370 days, we annualize the data to reflect a 1-year cost report. Dividing the data by the number of days in the cost report and then multiplying the results by 365 accomplishes annualization.

Step 6--Each hospital is assigned to its appropriate urban or rural labor market area before any reclassifications under section 1886(d)(8)(B), section 1886(d)(8)(E), or section 1886(d)(10) of the Act. Within each urban or rural labor market area, we add the total adjusted salaries plus wage-related costs obtained in Step 5 for all hospitals in that area to determine the total adjusted salaries plus wage-related costs for the labor market area.

Step 7--We divide the total adjusted salaries plus wage-related costs obtained under both methods in Step 6 by the sum of the corresponding 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 add the total adjusted salaries plus wage-related costs obtained in Step 5 for all hospitals in the Nation and then divide the sum by the national

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sum of total hours from Step 4 to arrive at a national average hourly wage. Using the data as described above, the proposed national average hourly wage is $30.9298.

Step 9--For each urban or rural labor market area, we calculate the hospital wage index value, unadjusted for occupational mix, by dividing the area average hourly wage obtained in Step 7 by the national average hourly wage computed in Step 8.

Step 10--Following the process set forth above, we develop a separate Puerto Rico-specific wage index for purposes of adjusting the Puerto Rico standardized amounts. (The national Puerto Rico standardized amount is adjusted by a wage index calculated for all Puerto Rico labor market areas based on the national average hourly wage as described above.) We add the total adjusted salaries plus wage- related costs (as calculated in Step 5) for all hospitals in Puerto Rico and divide the sum by the total hours for Puerto Rico (as calculated in Step 4) to arrive at an overall proposed average hourly wage of $13.4729 for Puerto Rico. For each labor market area in Puerto Rico, we calculate the Puerto Rico-specific wage index value by dividing the area average hourly wage (as calculated in Step 7) by the overall Puerto Rico average hourly wage.

Step 11--Section 4410 of Pub. L. 105-33 provides that, for discharges on or after October 1, 1997, the area wage index applicable to any hospital that is located in an urban area of a State may not be less than the area wage index applicable to hospitals located in rural areas in that State. For FY 2008, this change affects 239 hospitals in 65 urban areas. The areas affected by this provision are identified by a footnote in Table 4A in the Addendum of this proposed rule. 2. Expiration of the Imputed Floor

(If you choose to comment on issues in this section, please include the caption ``Imputed Floor'' at the beginning of your comment.)

Section 4410 of Pub. L. 105-33 provides that the area wage index applicable to any hospital that is located in an urban area of a State may not be less than the area wage index applicable to hospitals located in rural areas of that State (``the rural floor''). There are two States that have no rural areas (New Jersey and Rhode Island) and one State that has rural areas but no IPPS hospitals located in the rural areas of the State (Massachusetts). In the FY 2005 IPPS final rule (69 FR 49109), we adopted an ``imputed'' floor measure to address the concern that hospitals in all-urban States were disadvantaged by the absence of rural areas, because there is no floor within the State. We limited application of the policy to FYs 2005, 2006, and 2007 and indicated our intent to make additional changes to the policy or eliminate it for fiscal years after FY 2007.

In FY 2008, the rural floor will apply to 239 hospitals in 25 States. If the imputed rural floor were to continue into FY 2008, it would apply to an additional 28 hospitals in New Jersey. In FY 2007, 40 hospitals in 10 urban areas received higher wage indices due to the imputed floor policy: Massachusetts (10 hospitals in 2 areas); New Jersey (30 hospitals in 8 areas); Rhode Island (no areas and no hospitals). In Massachusetts, the imputed rural floor will no longer apply even if it were to continue because one hospital acquired rural status under Sec. 412.103. We note that if a State has a hospital reclassified as rural under Sec. 412.103, the State will be considered to have IPPS hospitals located in rural areas because, in this case, the reclassified hospital is treated as being located in a rural area in accordance with section 1886(d)(8)(E) of the Act. This policy also accords with how we defined an ``all-urban State'' under Sec. 412.64(h)(5) of the regulations, which specifies that ``A State with rural areas and with hospitals reclassified as rural under Sec. 412.103 is not an all-urban State.'' Therefore, in the case where a State has no hospitals that are geographically located in its rural areas, and one or more hospitals in the State are reclassified as rural under Sec. 412.103, the data for the reclassified rural hospitals will be used to set the rural floor for the State until a new geographically located rural hospital opens and data are available from that hospital (as noted above, 4 years later) to compute the rural floor.

We are proposing to discontinue the imputed floor policy after the FY 2007 wage index. After further considering the issue, we do not believe that it is necessary to have an ``imputed'' rural floor in States that have no rural areas or no rural hospitals. As discussed above, the imputed floor would not apply to two of the three States: it is not necessary for Rhode Island and is no longer necessary for Massachusetts. In addition, the imputed rural floor methodology creates a disadvantage in the application of the wage index to hospitals in States with rural hospitals but no urban hospitals receiving the rural floor. Because the application of a rural floor requires a transfer of payments from hospitals in States with rural hospitals but where the rural floor is not applied to hospitals in States where either a rural or imputed floor is applied, we believe the policy should apply only when required by statute. Thus, only States with both rural areas and hospitals located in such areas (including any hospital reclassified under Sec. 412.103) would benefit from the rural floor, as required by Congress.

For all of the reasons stated above, we are not proposing to continue the imputed rural floor. Nevertheless, we recognize that we would still need a policy for determining the rural wage index when a new IPPS hospital opens in a State that has rural areas, but no IPPS hospitals. There is a lag between the time a hospital opens or becomes an IPPS provider and when the hospital's cost report wage data are available to include in calculating the area wage index. For example, if a hospital files its first Medicare cost report as an IPPS provider with a beginning date of January 1, 2007, and an ending date of December 31, 2007, the hospital's FY 2007 wage data would not be included in the wage index until the FY 2011 IPPS update. Therefore, when a rural IPPS hospital opens in a State that has rural areas, but no wage data are available to calculate a rural wage index, we are proposing to apply a wage index to that hospital using the same methodology that we currently use for home health and other post-acute care providers in rural Massachusetts (71 FR 65906). That is, we would use the unweighted average of the wage indices from all CBSAs that are contiguous to the rural counties of the State. (We define contiguous as sharing a border.)

We would apply the wage index calculated above until the new IPPS hospital files a cost report for the base year that is used in calculating the wage index. (In the above example, the rural hospital's wage index would be calculated for FYs 2008, 2009, and 2010 using urban area data.) Further, under section 4410 of Pub. L. 105-33, the wage index for this rural hospital would become the State's rural floor. As stated above, however, if a State has rural areas, and a hospital is reclassified as rural under Sec. 412.103, then there would be no need to apply the above policy. The reclassified hospital would set the rural floor, and the wage data of the newly opened rural hospitals would be included in the calculation of the wage index of the rural area only once their wage data correlated with the survey year used to establish the wage index (4 years after wage data are reported). 3. CAHs Reverting Back to IPPS Hospitals and Raising the Rural Floor

(If you choose to comment on issues in this section, please include the

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caption ``Rural Floor'' at the beginning of your comment.)

Medicare payments to CAHs are based on 101 percent of reasonable costs and are generally greater than the payments Medicare would make if the same hospitals were paid under the IPPS, which pays hospitals a fixed rate per discharge. Also, as a CAH, a hospital is guaranteed to recover is costs, while under the IPPS, it is not. We are aware of a situation where two rural hospitals in a State are considering converting from CAH status back to IPPS even though they continue to be CAH eligible. The CAHs would convert back to IPPS even though it would not directly benefit them. As IPPS providers, the hospitals' wage data would eventually set the rural floor for the State (that is, in 4 years when the hospitals' first IPPS cost reports would be included in a base year used in calculating the State's rural wage index). In this case, we are concerned that these hospitals are converting solely in order to take advantage of the rural floor provisions for the other hospitals in the State, but not for any reasons that are intrinsic to the two specific hospitals. Because the hospitals' wage levels are higher than most, if not all, of the urban IPPS hospitals in the State, including one hospital in the State that acquired rural status under Sec. 412.103, the wage indices for most, if not all, of the State's urban hospitals would increase as a result of the rural floor provision if the CAHs convert to IPPS status. Such an arrangement would increase payments to the hospitals in the State at the expense of every other IPPS hospital in the nation. The two rural hospitals that are currently CAHs were last paid under the IPPS in FY 2003. We simulated the effect of allowing these two hospitals to set the State's rural floor with the same data used to calculate the FY 2003 wage index as would occur in FY 2011 if these hospitals were to convert to IPPS status in FY 2007 and no other hospitals were to open in the rural area of the State. Based on this simulation, all hospitals except two would be paid using the rural floor, increasing payments in excess of $220 million for a single year. If the average hourly wage for these two hospitals increased faster than the national average, the increase in payments would be even higher. It seems likely that over 5 years, Medicare payments to hospitals in this State would increase by more than $1 billion. Again, these increased payments would be budget neutralized at the expense of all other IPPS hospitals nationwide. Given that the hospitals continue to be eligible for the higher paying CAH status, we are concerned that hospitals are converting to IPPS status solely in order to raise the State's rural floor. We are concerned about the propriety of such an arrangement if the intent is to manipulate the State's area wage index values to receive higher Medicare reimbursement.

Section 1886(d)(5)(I)(i) of the Act allows the Secretary the authority to ``provide by regulation for such other exceptions and adjustments * * * as the Secretary deems appropriate.'' We are soliciting comments regarding whether it would be appropriate for CMS to establish a policy under this authority to preclude the arrangement described above and, if so, how such a policy would be applied. We believe that any policy should only apply to a CAH that continues to meet the CAH certification requirements and should not apply if a CAH no longer met those requirements and converted to an IPPS provider. 4. Application of Rural Floor Budget Neutrality

Section 4410 of the Balanced Budget Act of 1997 (BBA) established the rural floor by requiring that the wage index for a hospital in any urban area cannot be less than the area wage index determined for the State's rural area. Since FY 1998, we have implemented the budget neutrality requirement of this provision by adjusting the standardized amounts. A discussion and illustration of the calculation of the standardized amounts is shown in the Addendum of every year's IPPS rule.\16\

\16\ The BBA was enacted on August 5, 1997, and required application of the rural floor beginning with the FY 1998 IPPS. See the following for a description and calculation of the IPPS standardized amounts since that time: 62 FR 46038-46043, August 29, 1997; 63 FR 41006-41010, July 31, 1998; 64 FR 41544-41549, July 30, 1999; 65 FR 47111-47116, August 1, 2000; 66 FR 39939-39946, August 1, 2001; 67 FR 50120-50126, August 1, 2002; 68 FR 45474-45480, August 1, 2003; 69 FR 49273-49282, August 11, 2004; 70 FR 47491- 47498, August 12, 2005; 71 FR 59889-58980, October 11, 2006.

In this proposed rule, we are proposing a prospective change to how budget neutrality is applied to implement the rural floor for FY 2008 and subsequent years. Section 4410(a) of the BBA indicates that ``the area wage index applicable * * * to any hospital which is not located in a rural area'may not be less than the area wage index applicable * * * to hospitals located in rural areas in the State in which the hospital is located.'' Section 4410(b) of the BBA imposes the budget neutrality requirement and states that the Secretary shall ``adjust the area wage index referred to in subsection (a) for hospitals not described in such subsection.''

One possible interpretation of section 4410(b) of the BBA is that the budget neutrality adjustment would be applied only to those hospitals that do not receive the rural floor. In other words, the wage index of an urban hospital subject to the rural floor would be increased to the level of the rural wage index in the same State, but would not be adjusted for budget neutrality. Thus, urban hospitals receiving the rural floor would receive a higher wage index than the rural hospitals within the same State (because rural floor hospitals would not be subject to budget neutrality, whereas rural hospitals would be). We believe such a reading would not be in accordance with Congressional intent, which was to set a floor for urban hospitals, not to pay urban hospitals a wage index higher than the wage index applicable to rural hospitals.

In order to avoid the apparent contradiction between raising an urban hospital's wage index to the rural floor and not applying budget neutrality to its wage index, we also believe the statute could be read to allow an iterative calculation of budget neutrality and wage indices. Under such iterative calculations (consistent with section 4410(a) of the BBA), we would raise the wage index for urban hospitals to the level of the pre-budget neutrality rural wage index. Consistent with section 4410(b) of the BBA, we would adjust the wage index for all nonrural floor hospitals to achieve budget neutrality. However, such an adjustment would result in an urban hospital that would receive the rural floor having a higher wage index than a rural hospital in the same State. Therefore, we would then decrease wage indices for the rural floor hospitals so they are equal to the adjusted rural wage index in the same State. At this point, payments would be less in the aggregate than they were prior to applying the rural floor. Accordingly, a new budget neutrality adjustment would have to be calculated to raise the wage indices and total payments for rural hospitals and nonrural floor urban hospitals. The rural wage index would now be higher than the wage index for the rural floor hospitals in the same State. Therefore, the wage index for rural floor hospitals would then be increased again to the level of the State's rural wage index, leading to budget neutrality being recalculated again, the wage index reduced for rural floor hospitals, and so forth until the wage index and the budget neutrality adjustment stabilize.

We have determined that the iterative method is substantively equivalent to

[[Page 24788]]

simply adjusting all area wage indices by a uniform percentage. We have performed the iterative calculation using provider-level data based on FY 2007 MedPAR data and the first half of FY 2007 wage index data. Using such data, we determined that the iterative method results in the same final wage indices through four decimal places that would result if a uniform budget neutrality factor were applied to all hospitals' wage indices. Furthermore, an iterative method, which requires adjusting only the wage index values of nonrural floor providers, reassigning the lowered rural floor value to rural floor providers, and reiterating the budget neutrality factor applied to the nonrural floor providers would require an excessive number of iterations and computer processing, which is not necessary if we simply apply a uniform budget neutrality adjustment to all wage index values. The latter method is accomplished more quickly, is less complex, and arrives at the same final wage index values. Because the IPPS schedule is relatively condensed, with a proposed rule issued in April, a 60-day comment period until June, and then only 2 months to analyze comments, respond to them, determine final policies and calculate final rates prior to the August 1 publication, we believe it would not be practical to require such multiple layers of calculations, when a uniform adjustment would produce substantively identical results. Therefore, we are proposing to implement the rural floor budget neutrality requirement by applying a uniform budget neutrality adjustment to all hospital wage indices rather than the more complicated iterative process illustrated below.

The following hypothetical example, which includes a series of nine iterations, illustrates how the iterative process works. The example assumes three IPPS hospitals in one State. Hospital A is rural and Hospitals B and C are urban.

Pre-Floor Wage Index

Hospital A

Hospital B

Hospital C

Total

Wage Index....................... 0.9500............. 1.1700............. 0.8600............. .............. Relative Weights................. 100................ 200................ 150................ .............. Location......................... Rural.............. Urban.............. Urban.............. .............. Standardized Amounts............. $1,000............. $1,000............. $1,000............. .............. Payments......................... $95,000............ $234,000........... $129,000........... $458,000

Note: Hospital C is urban and has a lower wage index than Hospital A which is rural.

Post-Floor Wage Index; Pre-Budget Neutrality

Hospital A

Hospital B

Hospital C

Total

Wage Index....................... 0.9500............. 1.1700............. 0.9500............. .............. Relative Weights................. 100................ 200................ 150................ .............. Location......................... Rural.............. Urban.............. Urban.............. .............. Standardized Amounts............. $1,000............. $1,000............. $1,000............. .............. Payments......................... $95,000............ $234,000........... $142,500........... $471,500

Note: Hospital C's wage index is raised to the same level as Hospital A.

Post Floor--Budget Neutrality Process

Iteration 1:

Step 1: Apply budget neutrality to Hospital A and Hospital B.

Hospital A

Hospital B

Hospital C

Total

Wage Index...................... 0.9110............ 1.1220............ 0.9500............ BN Factor. Relative Weights................ 100............... 200............... 150............... 0.95897. Location........................ Rural............. Urban............. Urban............. Target. Standardized Amounts............ $1,000............ $1,000............ $1,000............ $458,000. Payments........................ $91,102........... $224,398.......... $142,500.......... $458,000.

Step 2: Reduce Hospital C's wage index to Hospital A's level.

Hospital A

Hospital B

Hospital C

Total

Wage Index...................... 0.9110............ 1.1220............ 0.9110............ BN Factor. Relative Weights................ 100............... 200............... 150............... 0.95897. Location........................ Rural............. Urban............. Urban............. Target. Standardized Amounts............ $1,000............ $1,000............ $1,000............ $458,000. Payments........................ $91,102........... $224,398.......... $136,653.......... $452,153.

[[Page 24789]]

Iteration 2:

Step 1: Apply budget neutrality to Hospital A and Hospital B.

Hospital A

Hospital B

Hospital C

Total

Wage Index...................... 0.9279............ 1.1428............ 0.9110............ BN Factor. Relative Weights................ 100............... 200............... 150............... 1.01853. Location........................ Rural............. Urban............. Urban............. Target. Standardized Amounts............ $1,000............ $1,000............ $1,000............ $458,000. Payments........................ $92,790........... $228,557.......... $136,653.......... $458,000.

Step 2: Increase Hospital C's wage index to Hospital A's level.

Hospital A

Hospital B

Hospital C

Total

Wage Index...................... 0.9279............ 1.1428............ 0.9279............ BN Factor. Relative Weights................ 100............... 200............... 150............... 1.01854. Location........................ Rural............. Urban............. Urban............. Target. Standardized Amounts............ $1,000............ $1,000............ $1,000............ $458,000. Payments........................ $92,790........... $228,557.......... $139,185.......... $460,532.

Iteration 3:

Step 1: Apply budget neutrality to Hospital A and Hospital B.

Hospital A

Hospital B

Hospital C

Total

Wage Index...................... 0.9206............ 1.1338............ 0.9279............ BN Factor. Relative Weights................ 100............... 200............... 150............... 0.99212. Location........................ Rural............. Urban............. Urban............. Target. Standardized Amounts............ $1,000............ $1,000............ $1,000............ $458,000. Payments........................ $92,059........... $226,756.......... $139,185.......... $458,000.

Step 2: Reduce Hospital C's wage index to Hospital A's level.

Hospital A

Hospital B

Hospital C

Total

Wage Index...................... 0.9206............ 1.1338............ 0.9206............ BN Factor. Relative Weights................ 100............... 200............... 150............... 0.99212. Location........................ Rural............. Urban............. Urban............. Target. Standardized Amounts............ $1,000............ $1,000............ $1,000............ $458,000. Payments........................ $92,059........... $226,756.......... $138,088.......... $456,903.

Iteration 4:

Step 1: Apply budget neutrality to Hospital A and Hospital B.

Hospital A

Hospital B

Hospital C

Total

Wage Index...................... 0.9238............ 1.1377............ 0.9206............ BN Factor. Relative Weights................ 100............... 200............... 150............... 1.00344. Location........................ Rural............. Urban............. Urban............. Target. Standardized Amounts............ $1,000............ $1,000............ $1,000............ $458,000. Payments........................ $92,376........... $227,536.......... $138,088.......... $458,000.

Step 2: Increase Hospital C's wage index to Hospital A's level.

Hospital A

Hospital B

Hospital C

Total

Wage Index...................... 0.9238............ 1.1377............ 0.9238............ BN Factor. Relative Weights................ 100............... 200............... 150............... 1.00344. Location........................ Rural............. Urban............. Urban............. Target. Standardized Amounts............ $1,000............ $1,000............ $1,000............ $458,000. Payments........................ $92,376........... $227,536.......... $138,563.......... $458,475.

[[Page 24790]]

Iteration 5:

Step 1: Apply budget neutrality to Hospital A and Hospital B.

Hospital A

Hospital B

Hospital C

Total

Wage Index...................... 0.9224............ 1.1360............ 0.9238............ BN Factor. Relative Weights................ 100............... 200............... 150............... 0.99852. Location........................ Rural............. Urban............. Urban............. Target. Standardized Amounts............ $1,000............ $1,000............ $1,000............ $458,000. Payments........................ $92,238........... $227,198.......... $138,563.......... $458,000.

Step 2: Reduce Hospital C's wage index to Hospital A's level.

Hospital A

Hospital B

Hospital C

Total

Wage Index...................... 0.9224............ 1.1360............ 0.9224............ BN Factor. Relative Weights................ 100............... 200............... 150............... 0.99852. Location........................ Rural............. Urban............. Urban............. Target. Standardized Amounts............ $1,000............ $1,000............ $1,000............ $458,000. Payments........................ $92,238........... $227,198.......... $138,358.......... $457,794.

Iteration 6:

Step 1: Apply budget neutrality to Hospital A and Hospital B.

Hospital A

Hospital B

Hospital C

Total

Wage Index...................... 0.9230............ 1.1367............ 0.9224............ BN Factor. Relative Weights................ 100............... 200............... 150............... 1.00064. Location........................ Rural............. Urban............. Urban............. Target. Standardized Amounts............ $1,000............ $1,000............ $1,000............ $458,000. Payments........................ $92,298........... $227,344.......... $138,358.......... $458,000.

Step 2: Increase Hospital C's wage index to Hospital A's level.

Hospital A

Hospital B

Hospital C

Total

Wage Index...................... 0.9230............ 1.1367............ 0.9230............ BN Factor. Relative Weights................ 100............... 200............... 150............... 1.00064. Location........................ Rural............. Urban............. Urban............. Target. Standardized Amounts............ $1,000............ $1,000............ $1,000............ $458,000. Payments........................ $92,298........... $227,344.......... $138,447.......... $458,089.

Iteration 7:

Step 1: Apply budget neutrality to Hospital A and Hospital B.

Hospital A

Hospital B

Hospital C

Total

Wage Index...................... 0.9227............ 1.1364............ 0.9230............ BN Factor. Relative Weights................ 100............... 200............... 150............... 0.99972. Location........................ Rural............. Urban............. Urban............. Target. Standardized Amounts............ $1,000............ $1,000............ $1,000............ $458,000. Payments........................ $92,272........... $227,281.......... $138,447.......... $458,000.

Step 2: Reduce Hospital C's wage index to Hospital A's level.

Hospital A

Hospital B

Hospital C

Total

Wage Index...................... 0.9227............ 1.1364............ 0.9227............ BN Factor. Relative Weights................ 100............... 200............... 150............... 0.99972. Location........................ Rural............. Urban............. Urban............. Target. Standardized Amounts............ $1,000............ $1,000............ $1,000............ $458,000. Payments........................ $92,272........... $227,281.......... $138,408.......... $457,961.

[[Page 24791]]

Iteration 8:

Step 1: Apply budget neutrality to Hospital A and Hospital B.

Hospital A

Hospital B

Hospital C

Total

Wage Index...................... 0.9228............ 1.1365............ 0.9227............ BN Factor. Relative Weights................ 100............... 200............... 150............... 1.00012. Location........................ Rural............. Urban............. Urban............. Target. Standardized Amounts............ $1,000............ $1,000............ $1,000............ $458,000. Payments........................ $92,283........... $227,308.......... $138,408.......... $458,000.

Step 2: Increase Hospital C's wage index to Hospital A's level.

Hospital A

Hospital B

Hospital C

Total

Wage Index...................... 0.9228............ 1.1365............ 0.9228............ BN Factor. Relative Weights................ 100............... 200............... 150............... 1.00012. Location........................ Rural............. Urban............. Urban............. Target. Standardized Amounts............ $1,000............ $1,000............ $1,000............ $458,000. Payments........................ $92,283........... $227,308.......... $138,425.......... $458,016.

Iteration 9:

Step 1: Apply budget neutrality to Hospital A and Hospital B.

Hospital A

Hospital B

Hospital C

Total

Wage Index...................... 0.9228............ 1.1365............ 0.9228............ BN Factor. Relative Weights................ 100............... 200............... 150............... 0.99995. Location........................ Rural............. Urban............. Urban............. Target. Standardized Amounts............ $1,000............ $1,000............ $1,000............ $458,000. Payments........................ $92,279........... $227,297.......... $138,425.......... $458,000.

In the example above, the wage indices are shown only to the 4th decimal place even though they are not rounded. However, the actual wage indices that we calculate for the IPPS are rounded to 4 decimal places. In the 9th and final iteration of the budget neutrality adjustment shown above, there was no change to the wage indices through the 4th decimal place relative to the 8th iteration. Therefore, because the wage indices stopped changing, we could not obtain further precision in the budget neutrality and wage index calculations in the example shown above with further iterations. We note that the example above produces the same result as simply applying a uniform adjustment to hospital wage indices. Using the same data as the above hypothetical example, we show this result below:

Pre-Floor Wage Index

Hospital A

Hospital B

Hospital C

Total

Note: Hospital C is urban and has a lower wage index than Hospital A which is rural.

Post-Floor Wage Index; Pre-Budget Neutrality

Hospital A

Hospital B

Hospital C

Total

Note: Hospital C's wage index is raised to the same level as Hospital A.

[[Page 24792]]

Post Floor--Budget Neutrality

Hospital A

Hospital B

Hospital C

Total

Wage Index....................... 0.9228............. 1.1365............. 0.9228............. BN Factor Relative Weights................. 100................ 200................ 150................

0.971368 Location......................... Rural.............. Urban.............. Urban..............

Target Standardized Amounts............. $1,000............. $1,000............. $1,000.............

$458,000 Payments......................... $92,280............ $227,300........... $138,420...........

$458,000

We note that our proposed change would apply the budget neutrality adjustment to the wage index, and not to the standardized amount. In previous years, we applied a budget neutrality adjustment to the standardized amount to ensure that payments remained constant to payments that would have occurred in the absence of the rural floor requirement in section 4410 of the BBA. We believe such an adjustment is in keeping with the statute, which requires that the rural floor will not result in aggregate payments that are greater or less than those that would have been made in the absence of a rural floor. We believe that an adjustment to the wage index would result in a substantially similar payment as an adjustment to the standardized amount, as both involve multipliers to the standardized amount, and both would be based upon the same modeling parameters. We do note that because hospitals have different labor-related shares (62 percent for hospitals with wage indices less than or equal to 1; 69.7 percent for hospitals with wage indices greater than 1), an adjustment to the wage index would have slightly different effects from an adjustment to the standardized amount, as each wage index would be adjusted by a uniform percentage.

For FY 2008, we are proposing to use FY 2006 discharge data and FY 2008 wage indices to simulate IPPS payments without the rural floor. We would compare these simulated payments to simulated payments using the same data with a rural floor.

We believe that the statute supports either an adjustment to the standardized amount or the wage indices because under either methodology, the rural floor would not result in aggregate payments that were greater or less than those that would have been made in the absence of a rural floor.

H. Analysis and Implementation of the Proposed Occupational Mix Adjustment and the Proposed FY 2008 Occupational Mix Adjusted Wage Index

(If you choose to comment on issues in this section, please include the caption ``Occupational Mix Adjusted Wage Index'' at the beginning of your comment.)

As discussed in section III.C. of this preamble, for FY 2008, we are proposing to apply the occupational mix adjustment to 100 percent of the FY 2008 wage index. We calculated the occupational mix adjustment using data from the 2006 occupational mix survey data, using the methodology described in section III.C.3. of this preamble.

Using the first and second quarter occupational mix survey data and applying the occupational mix adjustment to 100 percent of the FY 2008 wage index results in a proposed national average hourly wage of $30.9074 and a proposed Puerto Rico-specific average hourly wage of $13.4678. After excluding data of hospitals that either submitted aberrant data that failed critical edits, or that do not have FY 2004 Worksheet S-3 cost report data for use in calculating the proposed FY 2008 wage index, we calculated the proposed FY 2008 wage index using the occupational mix survey data from 3,368 hospitals. Using the Worksheet S-3 cost report data of 3,581 hospitals and occupational mix first and/or second quarter survey data from 3,368 hospitals represents a 94.1 percent survey response rate. The proposed FY 2008 national average hourly wages for each occupational mix nursing subcategory as calculated in Step 2 of the occupational mix calculation are as follows:

Average hourly Occupational mix nursing subcategory

wage

National RN Management..................................

$38.6214 National RN Staff.......................................

33.4800 National LPN............................................

19.2485 National Nurse Aides, Orderlies, and Attendants.........

13.7267 National Medical Assistants.............................

15.7936 National Nurse Category.................................

28.7439

The proposed national average hourly wage for the entire nurse category as computed in Step 5 of the occupational mix calculation is $28.7439. Hospitals with a nurse category average hourly wage (as calculated in Step 4) of greater than the national nurse category average hourly wage receive an occupational mix adjustment factor (as calculated in Step 6) of less than 1.0. Hospitals with a nurse category average hourly wage (as calculated in Step 4) of less than the national nurse category average hourly wage receive an occupational mix adjustment factor (as calculated in Step 6) of greater than 1.0.

Based on the January through June 2006 occupational mix survey data, we determined (in Step 7 of the occupational mix calculation) that the proposed national percentage of hospital employees in the Nurse category is 42.9 percent, and the proposed national percentage of hospital employees in the All Other Occupations category is 57.1 percent. At the CBSA level, the percentage of hospital employees in the Nurse category ranged from a low of 27.3 percent in one CBSA, to a high of 85.3 percent in another CBSA.

We compared the final FY 2007 occupational mix adjusted wage indices for each CBSA to the proposed FY 2008 wage indices adjusted for occupational mix. In proposing to implement an occupational mix adjusted wage index based on the above calculation using 6 months of survey data for FY 2008 as opposed to 3 months of survey data used for FY 2007, the final wage index values for 17 rural areas (36.2 percent) and 189 urban areas (48.7 percent) would decrease as a result of the adjustment. Nine rural areas (19.1 percent) and 127 urban areas (32.7 percent) would experience a decrease of 1 percent or greater in their wage index values. The largest negative impacts would be 3.40 percent and 14.82 percent for a rural and urban area, respectively. In addition, 30 rural areas (63.8 percent) and 197 urban areas (50.8 percent) would experience an increase in their wage index values. Twelve rural areas (25.5 percent) and 131 urban areas (33.8 percent) would experience an increase of 1 percent or greater in their wage index values. The largest increase for a rural area would be 10.75 percent and the largest increase for an urban area would be 16.87 percent. Two urban areas would be unaffected. These results indicate that a larger percentage of rural areas benefit from an occupational mix adjustment than do urban areas. However, as was the case with the FY 2007 occupational mix data, approximately a third of rural CBSAs (36.2 percent) continue to experience a decrease in their wage indices as a result of the occupational mix adjustment.

[[Page 24793]]

The proposed wage index values for FY 2008 (except those for hospitals receiving wage index adjustments under section 1886(d)(13) of the Act) are shown in Tables 4A, 4B, 4C, and 4F in the Addendum to this proposed rule.

Tables 3A and 3B in the Addendum to this proposed rule list the 3- year average hourly wage for each labor market area before the redesignation of hospitals based on FYs 2006, 2007, and 2008 cost reporting periods. Table 3A lists these data for urban areas and Table 3B lists these data for rural areas. In addition, Table 2 in the Addendum to this proposed rule includes the adjusted average hourly wage for each hospital from the FY 2002 and FY 2003 cost reporting periods, as well as the FY 2004 period used to calculate the proposed FY 2008 wage index. The 3-year averages are calculated by dividing the sum of the dollars (adjusted to a common reporting period using the method described previously) across all 3 years, by the sum of the hours. If a hospital is missing data for any of the previous years, its average hourly wage for the 3-year period is calculated based on the data available during that period.

The proposed wage index values in Tables 4A, 4B, 4C, and 4F and the average hourly wages in Tables 2, 3A, and 3B in the Addendum to this proposed rule include the proposed occupational mix adjustment as well as the budget neutrality adjustment for the rural floor.

I. Revisions to the Proposed Wage Index Based on Hospital Redesignations

(If you choose to comment on issues in this section, please include the caption ``Hospital Reclassifications and Redesignations'' at the beginning of your comment.) 1. General

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 IPPS. Hospitals must apply to the MGCRB to reclassify by September 1 of the year preceding the year during which reclassification is sought. Generally, hospitals must be proximate to the labor market area to which they are seeking reclassification and must demonstrate characteristics similar to hospitals located in that area. The MGCRB issues its decisions by the end of February for reclassifications that become effective for the following fiscal year (beginning October 1). The regulations applicable to reclassifications by the MGCRB are located in Sec. Sec. 412.230 through 412.280.

Section 1886(d)(10)(D)(v) of the Act provides that, beginning with FY 2001, a MGCRB decision on a hospital reclassification for purposes of the wage index is effective for 3 fiscal years, unless the hospital elects to terminate the reclassification. Section 1886(d)(10)(D)(vi) of the Act provides that the MGCRB must use the 3 most recent years' average hourly wage data in evaluating a hospital's reclassification application for FY 2003 and any succeeding fiscal year.

Section 304(b) of Pub. L. 106-554 provides that the Secretary must establish a mechanism under which a statewide entity may apply to have all of the geographic areas in the State treated as a single geographic area for purposes of computing and applying a single wage index, for reclassifications beginning in FY 2003. The implementing regulations for this provision are located at Sec. 412.235.

Section 1886(d)(8)(B) of the Act requires the Secretary to treat a hospital located in a rural county adjacent to one or more urban areas as being located in the MSA to which the greatest number of workers in the county commute, if the rural county would otherwise be considered part of an urban area under the standards for designating MSAs and if the commuting rates used in determining outlying counties were determined on the basis of the aggregate number of resident workers who commute to (and, if applicable under the standards, from) the central county or counties of all contiguous MSAs. In light of the new CBSA definitions and the Census 2000 data that we implemented for FY 2005 (69 FR 49027), we undertook to identify those counties meeting these criteria. The eligible counties are identified under section III.I.8. of this preamble. 2. Effects of Reclassification/Redesignation

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. These requirements for determining the wage index values for redesignated hospitals is applicable both to the hospitals located in rural counties deemed urban under section 1886(d)(8)(B) of the Act and hospitals that were reclassified as a result of the MGCRB decisions under section 1886(d)(10) of the Act. Therefore, as provided in section 1886(d)(8)(C) of the Act, the wage index values were determined by considering the following:

If including the wage data for the redesignated hospitals would reduce the wage index value for the area to which the hospitals are redesignated by 1 percentage point or less, the area wage index value determined exclusive of the wage data for the redesignated hospitals applies to the redesignated hospitals.

If including the wage data for the redesignated hospitals reduces the wage index value for the area to which the hospitals are redesignated by more than 1 percentage point, the area wage index determined inclusive of the wage data for the redesignated hospitals (the combined wage index value) applies to the redesignated hospitals.

If including the wage data for the redesignated hospitals increases the wage index value for the urban area to which the hospitals are redesignated, both the area and the redesignated hospitals receive the combined wage index value. Otherwise, the hospitals located in the urban area receive a wage index excluding the wage data of hospitals redesignated into the area.

Rural areas whose wage index values would be reduced by excluding the wage data for hospitals that have been redesignated to another area continue to have their wage index values calculated as if no redesignation had occurred (otherwise, redesignated rural hospitals are excluded from the calculation of the rural wage index). The wage index value for a redesignated rural hospital cannot be reduced below the wage index value for the rural areas of the State in which the hospital is located.

CMS has also adopted the following policies by regulation:

The wage data for a reclassified urban hospital is included in both the wage index calculation of the area to which the hospital is reclassified (subject to the rules described above) and the wage index calculation of the urban area where the hospital is physically located.

In cases where urban hospitals have reclassified to rural areas under 42 CFR 412.103, the urban hospital wage data are: (a) Included in the rural wage index calculation, unless doing so would reduce the rural wage index; and (b) included in the urban area where the hospital is physically located. 3. FY 2008 MGCRB Reclassifications

(If you choose to comment on issues in this section, please include the caption ``MGCRB'' at the beginning of your comment.)

Under section 1886(d)(10) of the Act, the MGCRB considers applications by hospitals for geographic reclassification

[[Page 24794]]

for purposes of payment under the IPPS. The specific procedures and rules that apply to the geographic reclassification process are outlined in Sec. 412.230 through Sec. 412.280.

At the time this proposed rule was constructed, the MGCRB had completed its review of FY 2008 reclassification requests. There were 365 hospitals approved for wage index reclassifications by the MGCRB for FY 2008. Because MGCRB wage index reclassifications are effective for 3 years, hospitals reclassified during FY 2006 or FY 2007 are eligible to continue to be reclassified based on prior reclassifications to current MSAs during FY 2008. There were 299 hospitals reclassified for wage index in FY 2006 and 214 hospitals reclassified for wage index in FY 2007. Some of the hospitals that reclassified for FY 2006 and FY 2007 have elected not to continue their reclassifications in FY 2008 because, under the revised labor market area definitions, they are now physically located in the areas to which they previously reclassified. Of all of the hospitals approved for reclassification for FY 2006, FY 2007, and FY 2008, 866 hospitals are in a reclassification status for FY 2008.

Prior to FY 2004, hospitals had been able to apply to be reclassified for purposes of either the wage index or the standardized amount. Section 401 of Pub. L. 108-173 established that all hospitals will be paid on the basis of the large urban standardized amount, beginning with FY 2004. Consequently, all hospitals are paid on the basis of the same standardized amount, which made such reclassifications moot. Although there could still be some benefit in terms of payments for some hospitals under the DSH payment adjustment for operating IPPS, section 402 of Pub. L. 108-173 equalized DSH payment adjustments for rural and urban hospitals, with the exception that the rural DSH adjustment is capped at 12 percent (except that rural referral centers and, effective for discharges occurring on or after October 1, 2006, MDHs have no cap). (A detailed discussion of this application appears in section IV.I. of the preamble of the FY 2005 IPPS final rule (69 FR 49085). The exclusion of MDHs from the 12 percent DSH cap under Pub. L. 109-171 was discussed under section IV.F.4. of the preamble of the FY 2007 IPPS final rule (71 FR 48066.)

Under Sec. 412.273, hospitals that have been reclassified by the MGCRB are permitted to withdraw their applications within 45 days of the publication of a proposed rule. The request for withdrawal of an application for reclassification or termination of an existing 3-year reclassification that would be effective in FY 2008 must be received by the MGCRB within 45 days of the publication of this proposed rule. If a hospital elects to withdraw its wage index application after the MGCRB has issued its decision, but prior to the above date, it may later cancel its withdrawal in a subsequent year and request the MGCRB to reinstate its wage index reclassification for the remaining fiscal year(s) of the 3-year period (Sec. 412.273(b)(2)(i)). The request to cancel a prior withdrawal or termination must be in writing to the MGCRB no later than the deadline for submitting reclassification applications for the following fiscal year (Sec. 412.273(d)). For further information about withdrawing, terminating, or canceling a previous withdrawal or termination of a 3-year reclassification for wage index purposes, we refer the reader to Sec. 412.273, as well as the August 1, 2002, IPPS final rule (67 FR 50065) and the August 1, 2001 IPPS final rule (66 FR 39887).

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. These changes may affect not only the wage index value for specific geographic areas, but also the wage index value redesignated hospitals receive; that is, whether they receive the 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.

Applications for FY 2009 reclassifications are due to the MGCRB by September 4, 2007 (the first working day of September 2007). We note that this is also the deadline for canceling a previous wage index reclassification withdrawal or termination under Sec. 412.273(d). Applications and other information about MGCRB reclassifications may be obtained, beginning in mid-July 2007, via the CMS Internet Web site at: http://cms.hhs.gov/providers/prrb/mgcinfo.asp, or by calling the MGCRB

at (410) 786-1174. The mailing address of the MGCRB is: 2520 Lord Baltimore Drive, Suite L, Baltimore, MD 21244-2670. 4. Hospitals That Applied for Reclassification Effective in FY 2008 and Reinstating Reclassifications in FY 2008

Applications for FY 2008 reclassifications were due to the MGCRB by September 1, 2006. We note that this deadline also applied for canceling a previous wage index reclassification withdrawal or termination under Sec. 412.273(d). The MGCRB, in evaluating a hospital's request for reclassification for FY 2008 for the wage index, utilized the official data used to develop the FY 2007 wage index. The wage data used to support the hospital's wage comparisons were from the CMS hospital wage survey. Generally, the source for these data is the IPPS final rule to be published on or before August 1, 2006. However, the wage tables identifying the 3-year average hourly wage of hospitals were not available in time to include them in the FY 2007 IPPS final rule. Therefore, we made the data available subsequent to the publication of the FY 2007 IPPS final rule.

Section 1886(d)(10)(C)(ii) of the Act indicates that a hospital requesting a change in geographic classification for a fiscal year must submit its application to the MGCRB not later than the first day of the 13-month period ending on September 30 of the preceding fiscal year. Thus, the statute requires that FY 2008 reclassification applications were to be submitted to the MGCRB by no later than September 1, 2006. For this reason, we required hospitals to file an FY 2008 reclassification application by the September 1, 2006 deadline even though the average hourly wage data used to develop the final FY 2007 wage indices were not yet available. However, as outlined in Sec. 412.256(c)(2), we also allowed hospitals with incomplete applications submitted by the deadline to request an extension beyond September 1, 2006, to complete their applications. We also allowed hospitals 30 days from the date the final wage data were posted on the CMS Web site to request to cancel a withdrawal or termination in order to reinstate a reclassification for FY 2008 or FY 2009, or both fiscal years. For a more detailed discussion of the procedures used for the FY 2008 MGCRB applications we refer readers to the FY 2007 IPPS final rule (71 FR 48022-48023). 5. Clarification of Policy on Reinstating Reclassifications

Under Sec. 412.273(a) of our regulations, a hospital or group of hospitals may withdraw its application for reclassification at any time before the

[[Page 24795]]

MGCRB issues its decision or, if after the MGCRB issues its decision, within 45 days after publication of CMS's annual notice of proposed rulemaking for the upcoming fiscal year. In addition, a hospital may terminate a reclassification that is already in effect within 45 days after publication of the notice of proposed rulemaking for the upcoming fiscal year. Once a withdrawal or termination has been made, the hospital or group of hospitals will not be reclassified for purposes of the wage index to the same area for that year. The hospital also will not be reclassified to the withdrawn or terminated reclassification area in subsequent fiscal years unless the hospital subsequently cancels its withdrawal or termination. The procedures for making a withdrawal or termination, as well as for canceling a withdrawal or termination are specified at Sec. 412.273. In the FY 2003 IPPS final rule (67 FR 50065-50066), we clarified our existing policy stating that a previous 3-year reclassification may not be reinstated after a subsequent 3-year reclassification to another area takes effect. Therefore, a hospital can only have one active 3-year reclassification at a time.

We have been asked whether a hospital (or group of hospitals) can reinstate the two remaining years of a previously approved 3-year reclassification to one area, while at the same time the individual hospital (or group) request a new 3-year reclassification from the MGCRB to a different area and be approved for both at the same time. In this case, the hospital or group of hospitals is permitted to apply to a different area than the previously approved reclassification but, as stated in Sec. 412.273(b)(2), once they accept a newly approved reclassification, a previously terminated and reinstated 3-year reclassification would be permanently terminated.

Following the policy set forth at Sec. 412.273(d), a hospital may cancel a previous withdrawal or termination by submitting written notice of its intent to the MGCRB no later than September 1 for reclassifications effective at the start of the second following fiscal year 13 months later. At the same time (because the deadline for geographic reclassification applications for the second following fiscal year 13 months later is also September 1), a hospital or group of hospitals could apply for reclassification to a different area. If the application is denied, the hospital or group of hospitals can select between the reinstated geographic reclassification and the home area wage index for the following fiscal year. The hospital or group of hospitals must file a written request to the MGCRB within 45 days after publication of the notice of proposed rulemaking to terminate the reinstated reclassification and receive the home area wage index. If the hospital or group of hospitals takes no action, the pending geographic reclassification will go into effect. If the new geographic reclassification application is approved, the hospital or group of hospitals will have 45 days from publication of the notice of proposed rulemaking to accept either of the two pending geographic reclassifications or revert to the home area wage index. If the hospital or group of hospitals takes no action, the most recent approved geographic reclassification will go into effect and the prior reclassification will be permanently terminated. Alternatively, the hospital or group of hospitals can withdraw the most recent approved reclassification and accept the previously approved and reinstated reclassification within 45 days of publication of the notice of proposed rulemaking. Such an action will permanently terminate the most recently approved geographic reclassification. Finally, the hospital or group hospitals can write to the MGCRB within 45 days of publication of the notice of proposed rulemaking to withdraw both geographic reclassifications in order to receive the home area wage index. In this case, the hospital or group of hospitals can only reinstate one of the two geographic reclassifications. The other geographic reclassification is permanently terminated. Once a hospital or group of hospitals makes a decision for the following fiscal year within 45 days of publication of the notice of proposed rulemaking, the hospital or group of hospitals cannot change the decision for that fiscal year. It is also important to note that the reinstatement of a reclassification only applies to those withdrawals which were made after the MGCRB issued an approved 3-year decision, not a withdrawal made prior to the MGCRB issuing an approval decision.

For example, a hospital has been reclassified to area ``A'' for FYs 2007 through 2009. The hospital accepts this geographic reclassification for FY 2007. The hospital also applies for reclassification to a different area ``B'' for FYs 2008 through 2010 by September 1, 2006. If reclassification to area ``B'' is denied, the hospital can either withdraw or terminate its reclassification to area ``A'' within 45 days of publication of the proposed rule for FY 2008 and receive the home area wage index for FY 2008 or receive the reclassification to area ``A'' for FY 2008. If the hospital does nothing, it will receive the area ``A'' reclassification. If the hospital's reclassification application to area ``B'' is approved by the MGCRB, the hospital can (1) do nothing (and, therefore, receives the reclassification to area ``B'' for FY 2008, permanently terminating the reclassification to area ``A''); (2) within 45 days of publication of the notice of proposed rulemaking, withdraw the reclassification to area ``B'' and receive the reclassification to area ``A'' for FY 2008 (permanently terminating the reclassification to area ``B''); or (3) withdraw or terminate both the reclassifications to both areas ``A'' and ``B'' and receive the home area wage index for FY 2008). If the latter option is selected, the hospital can only reinstate one of the withdrawn/terminated reclassifications by September 1, 2007 (to take effect for FY 2009). Upon the sunset of the 45-day window, the reclassification selection is final and the hospital will receive that wage index for the fiscal year, in this case for FY 2008. 6. ``Fallback'' Reclassifications

As indicated in section III.I.3. of this preamble, the regulations at Sec. 412.273 provide the process that a hospital wishing to withdraw or terminate a reclassification must follow. If a hospital has an existing reclassification and then applies to the MGCRB to a second area and is approved, it has a choice between two reclassifications and its home area wage index for the following fiscal year. We have been asked a procedural question about how the hospital accepts its previously approved reclassification (its ``fall back'' reclassification) or how it can ``fall back'' to its home area wage index. As the example provided in the section III.I.5. of this preamble illustrates, a hospital will automatically be given its most recently approved reclassification (thereby permanently terminating any previously approved reclassifications) unless it provides written notice to the MGCRB within 45 days of publication of the notice of proposed rulemaking that it wishes to withdraw its most recently approved reclassification and ``fall back'' to either its prior reclassification or its home area wage index for the following fiscal year. If the hospital wishes to accept its home area wage index in preference to its previous ``fall back'' reclassification, the hospital must also state in its request to the MGCRB that it is not only withdrawing its most

[[Page 24796]]

recently approved reclassification but also terminating its previously approved reclassification. 7. Geographic Reclassification Issues for Multicampus Hospitals

(If you choose to comments on issues in this section, please include the caption ``Multicampus Hospitals'' at the beginning of your comment.]

In FY 2005, we modified the reclassification rules at Sec. 412.230(d)(2)(iii) to allow campuses of multicampus hospitals located in separate wage index areas to support a reclassification application to the geographic area in which another campus is located using the average hourly wage data submitted on the cost report for the entire hospital. This special rule applies for applications for reclassifications effective in FYs 2006 through FY 2008. In the FY 2007 IPPS final rule, we decided not to extend this special rule for multicampus hospitals. However, we believe that the proposed change to how we allocate a multicampus hospital's wage data has implications for multicampus hospitals' reclassification requests.

As stated above, we are proposing to allocate the multicampus hospital's wage data across the different labor market areas where the campuses are located based upon FTEs. For this reason, an individual campus located in a geographic area distinct from the geographic area associated with the provider number of the multicampus hospital will now have published, hospital-specific wage data that it may use to support a request for individual reclassification. The campus's wage data will be included in the wage data public use file and also provided to the MGCRB. These data will be considered appropriate wage data under Sec. 412.230, because it will be part of the CMS hospital wage survey used to construct the wage index. We note, that where a multicampus hospital spanning two or more geographic areas does not provide us with appropriate FTE data, its campus-specific data will not be included in the public use files we use to construct the wage index. For this reason, unless a multicampus hospital has provided us with FTE data, we will not have appropriate campus-specific wage data that could be used to support an individual reclassification under Sec. 412.230, and the reclassification request for the individual campus would be denied. In this sense, our policy allowing the allocation of wage data using FTEs is somewhat different from our prior policy on multicampus hospitals.

We note that when a multicampus hospital's wage data are divided by FTEs, the ratio of wages to hours remains constant. Thus, the effect of our policy, in some sense, is that the individual campus of a multicampus hospital effectively uses the average hourly wage of the entire multicampus institution to support its individual reclassification request. However, as stated in the paragraph above, appropriate wage data will exist, only if the hospital has provided FTE data that can be used to allocate institution-wide wages and hours.

Under current policy, an individual campus of a multicampus hospital located in a different area than the one associated with the provider number does not have to provide any official wage index data to join a group reclassification. However, given that we are allocating a portion of the average hourly wage of the hospital's data to the labor market area that includes this campus, we are also proposing that this same data be used as part of a group reclassification application. Again, these data will be published in a public use file and will be considered appropriate wage data under Sec. Sec. 412.232 and 412.234. If a multicampus hospital spanning more than one geographic area has not provided us with FTE data, then, in accordance with our current policies for treating hospitals without official wage data, the individual campus would still be permitted to join the group application (and indeed would be required to join the application since all hospitals in a group must join in the application). In this case, the group application would omit the wage data from the individual campus of a multicampus hospital. 8. Redesignations of Hospitals Under Section 1886(d)(8)(B) of the Act

Beginning October 1, 1988, section 1886 (d)(8)(B) of the Act required us to treat a hospital located in a rural county adjacent to one or more urban areas as being located in the MSA if certain criteria were met. Prior to FY 2005, the rule was that a rural county adjacent to one or more urban areas would be treated as being located in the MSA to which the greatest number of workers in the county commute, if the rural county would otherwise be considered part of an urban area under the standards published in the Federal Register on January 3, 1980 (45 FR 956) for designating MSAs (and New England County Metropolitan Areas (NECMAs)), and if the commuting rates used in determining outlying counties (or, for New England, similar recognized areas) were determined on the basis of the aggregate number of resident workers who commute to (and, if applicable under the standards, from) the central county or counties of all contiguous MSAs (or NECMAs). Hospitals that met the criteria using the January 3, 1980 version of these OMB standards were deemed urban for purposes of the standardized amounts and for purposes of assigning the wage data index.

Effective beginning FY 2005, we use OMB's 2000 CBSA standards and the Census 2000 data to identify counties qualifying for redesignation under section 1886(d)(8)(B) for the purpose of assigning the wage index to the urban area. Hospitals located in these counties have been known as ``Lugar'' hospitals and the counties themselves are often referred to as ``Lugar'' counties. We provide the chart below with the listing of the rural counties designated as urban under section 1886(d)(8)(B) of the Act that we are proposing to use for FY 2008. For discharges occurring on or after October 1, 2007, hospitals located in the first column of this chart will be redesignated for purposes of using the wage index of the urban area listed in the second column.

Rural Counties Redesignated as Urban Under Section 1886(d)(8)(B) of the Act [Based on CBSAs and Census 2000 Data]

Rural county

CBSA

Cherokee, AL........................... Rome, GA. Macon, AL.............................. Auburn-Opelika, AL. Talladega, AL.......................... Anniston-Oxford, AL. Hot Springs, AR........................ Hot Springs, AR. Windham, CT............................ Hartford-West Hartford-East Hartford, CT. Bradford, FL........................... Gainesville, FL. Flagler, FL............................ Deltona-Daytona Beach-Ormond Beach, FL. Hendry, FL............................. West Palm Beach-Boca Raton- Boynton, FL. Levy, FL............................... Gainesville, FL. Walton, FL............................. Fort Walton Beach-Crestview- Destin, FL. Banks, GA.............................. Gainesville, GA. Chattooga, GA.......................... Chattanooga, TN-GA. Jackson, GA............................ Atlanta-Sandy Springs-Marietta, GA. Lumpkin, GA............................ Atlanta-Sandy Springs-Marietta, GA. Morgan, GA............................. Atlanta-Sandy Springs-Marietta, GA. Peach, GA.............................. Macon, GA. Polk, GA............................... Atlanta-Sandy Springs-Marietta, GA. Talbot, GA............................. Columbus, GA-AL. Bingham, ID............................ Idaho Falls, ID. Christian, IL.......................... Springfield, IL. DeWitt, IL............................. Bloomington-Normal, IL. Iroquois, IL........................... Kankakee-Bradley, IL. Logan, IL.............................. Springfield, IL. Mason, IL.............................. Peoria, IL. Ogle, IL............................... Rockford, IL.

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Clinton, IN............................ Lafayette, IN. Henry, IN.............................. Indianapolis-Carmel, IN. Spencer, IN............................ Evansville, IN-KY. Starke, IN............................. Gary, IN. Warren, IN............................. Lafayette, IN. Boone, IA.............................. Ames, IA. Buchanan, IA........................... Waterloo-Cedar Falls, IA. Cedar, IA.............................. Iowa City, IA. Allen, KY.............................. Bowling Green, KY. Assumption Parish, LA.................. Baton Rouge, LA. St. James Parish, LA................... Baton Rouge, LA. Allegan, MI............................ Holland-Grand Haven, MI. Montcalm, MI........................... Grand Rapids-Wyoming, MI. Oceana, MI............................. Muskegon-Norton Shores, MI. Shiawassee, MI......................... Lansing-East Lansing, MI. Tuscola, MI............................ Saginaw-Saginaw Township North, MI. Fillmore, MN........................... Rochester, MN. Dade, MO............................... Springfield, MO. Pearl River, MS........................ Gulfport-Biloxi, MS. Caswell, NC............................ Burlington, NC. Granville, NC.......................... Durham, NC. Harnett, NC............................ Raleigh-Cary, NC. Lincoln, NC............................ Charlotte-Gastonia-Concord, NC- SC. Polk, NC............................... Spartanburg, NC. Los Alamos, NM......................... Santa Fe, NM. Lyon, NV............................... Carson City, NV. Cayuga, NY............................. Syracuse, NY. Columbia, NY........................... Albany-Schenectady-Troy, NY. Genesee, NY............................ Rochester, NY. Greene, NY............................. Albany-Schenectady-Troy, NY. Schuyler, NY........................... Ithaca, NY. Sullivan, NY........................... Poughkeepsie-Newburgh- Middletown, NY. Wyoming, NY............................ Buffalo-Niagara Falls, NY. Ashtabula, OH.......................... Cleveland-Elyria-Mentor, OH. Champaign, OH.......................... Springfield, OH. Columbiana, OH......................... Youngstown-Warren-Boardman, OH- PA. Cotton, OK............................. Lawton, OK. Linn, OR............................... Corvallis, OR. Adams, PA.............................. York-Hanover, PA. Clinton, PA............................ Williamsport, PA. Greene, PA............................. Pittsburgh, PA. Monroe, PA............................. Allentown-Bethlehem-Easton, PA- NJ. Schuylkill, PA......................... Reading, PA. Susquehanna, PA........................ Binghamton, NY. Clarendon, SC.......................... Sumter, SC. Lee, SC................................ Sumter, SC. Oconee, SC............................. Greenville, SC. Union, SC.............................. Spartanburg, SC. Meigs, TN.............................. Cleveland, TN. Bosque, TX............................. Waco, TX. Falls, TX.............................. Waco, TX. Fannin, TX............................. Dallas-Plano-Irving, TX. Grimes, TX............................. College Station-Bryan, TX. Harrison, TX........................... Longview, TX. Henderson, TX.......................... Dallas-Plano-Irving, TX. Milam, TX.............................. Austin-Round Rock, TX. Van Zandt, TX.......................... Dallas-Plano-Irving, TX. Willacy, TX............................ Brownsville-Harlingen, TX. Buckingham, VA......................... Charlottesville, VA. Floyd, VA.............................. Blacksburg-Christiansburg- Radford, VA. Middlesex, VA.......................... Virginia Beach-Norfolk-Newport News, VA. Page, VA............................... Harrisonburg, VA. Shenandoah, VA......................... Winchester, VA-WV. Island, WA............................. Seattle-Bellevue-Everett, WA. Mason, WA.............................. Olympia, WA. Wahkiakum, WA.......................... Longview, WA. Jackson, WV............................ Charleston, WV. Roane, WV.............................. Charleston, WV. Green, WI.............................. Madison, WI. Green Lake, WI......................... Fond du Lac, WI. Jefferson, WI.......................... Milwaukee-Waukesha-West Allis, WI. Walworth, WI........................... Milwaukee-Waukesha-West Allis, WI.

As in the past, hospitals redesignated under section 1886(d)(8)(B) of the Act are also eligible to be reclassified to a different area by the MGCRB. Affected hospitals are permitted to compare the reclassified wage index for the labor market area in Table 4C in the Addendum to this proposed rule into which they have been reclassified by the MGCRB to the wage index for the area to which they are redesignated under section 1886(d)(8)(B) of the Act. Hospitals may withdraw from an MCGRB reclassification within 45 days of the publication of this proposed rule. 9. Reclassifications Under Section 1886(d)(8)(B) of the Act

We have been asked whether Lugar hospitals and counties (discussed above in section III.H.8. of this preamble) are considered urban or rural for MGCRB reclassification purposes. As stated in the regulations at 42 CFR 412.64(b)(3), as well as in section 1886(d)(8)(C) of the Act, Lugar hospitals and counties are deemed to be located in an urban area. Therefore, because they are physically located in a rural area and are deemed urban, they receive the reclassified wage index (Table 4C in the Addendum to this proposed rule) for the urban area to which they have been redesignated. Because Lugar hospitals are treated like reclassified hospitals, when they are seeking reclassification by the MCGRB, they are subject to the rural reclassification rules set forth at Sec. 412.230. The procedural rules set forth at Sec. 412.230 list the criteria which a hospital must meet in order to reclassify as a rural hospital. Lugar hospitals would be subject to the proximity criteria and payment thresholds that apply to rural hospitals. Specifically, the hospital would have to be no more than 35 miles from the area to which it seeks reclassification (Sec. 412.230(b)(1)); the hospital would have to show that its average hourly wage is at least 106 percent of the average hourly wage of all other hospitals in the area in which the hospital is located (Sec. 412.230(d)(1)(iii)(C)); and the hospital would have to demonstrate that its average hourly wage is equal to at least 82 percent of the average hourly wage of hospitals in the area to which it seeks redesignation (Sec. 412.230(d)(1)(iv)(C)).

Hospitals not located in a Lugar county seeking reclassification to the urban area where the Lugar hospitals have been redesignated are not permitted to measure to the Lugar county to demonstrate proximity (no more than 15 miles for an urban hospital, and no more than 35 miles for a rural hospital or the closest urban or rural area for RRCs or SCHs) in order to be reclassified to such urban area. These hospitals must measure to the urban area exclusive of the Lugar County to meet the proximity or nearest urban or rural area requirement. 10. New England Deemed Counties

Our regulations at 42 CFR 412.64(b)(1)(ii)(B) list New England counties that are deemed to be parts of urban areas under section 601(g) of the Social Security Amendments of 1983 (Pub. L. 98-21, 42 U.S.C. 1395ww(note)). These counties include Litchfield County, Connecticut; York County, Maine; Sagadahoc County, Maine; Merrimack County, New Hampshire; and Newport County, Rhode Island. OMB standards designate and define two categories of CBSAs: Metropolitan Statistical Areas (MSAs) and Micropolitan Statistical Areas (65 FR 82235). For our labor market area definitions, we treat micropolitan areas as rural.

Of these five counties, three (York County, Sagadahoc County, and Newport County) are also included in metropolitan areas by OMB, whereas the remaining two, Litchfield County and Merrimack County, are located in micropolitan statistical areas and would

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be treated as rural under our labor market area definitions were they not deemed urban under Sec. 412.64(b)(1)(ii)(B) of the regulations. Litchfield County and Merrimack County have been listed as being part of urban CBSA 25540 Hartford-West Hartford-East Hartford, CT, and urban CBSA 31700 Manchester-Nashua, NH, respectively. Even though hospitals located in Litchfield County and Merrimack County are in micropolitan statistical areas, they have been treated as urban for reclassification purposes. Under our regulations, we have deemed both of these two New England counties and the hospitals within them as urban. Because the counties themselves were deemed urban, the hospitals within them have also been treated as urban for reclassification purposes, even though Litchfield and Merrimack counties are in micropolitan statistical areas. However, upon further consideration of this issue, we believe the hospitals located within these New England counties should be treated the same as Lugar hospitals. That is, the area would be considered rural but the hospitals within them would be deemed to be urban. Therefore, we are proposing to change our policy and consider Litchfield County and Merrimack County as rural but would continue to consider the hospitals within them as being redesignated to urban CBSA 25540 Hartford-West Hartford-East Hartford, CT, and urban CBSA 31700 Manchester-Nashua, NH, respectively. Under our proposal, hospitals located in these counties--like the Lugar hospitals described in section III.I.8. of this preamble--must meet the rural requirements set forth at Sec. 412.230 for individual reclassifications and Sec. 412.232 for group reclassifications. We are proposing to revise Sec. 412.64(b)(1)(ii)(B) accordingly. Hospitals not located inside one of these deemed New England counties are not permitted to measure to these counties to demonstrate close proximity in order to be reclassified to the CBSA(s) to which the hospitals in Litchfield and Merrimack counties are redesignated. We note that Tables 2, 3A, 3B, 4A, and 4B in the Addendum to this proposed rule do not reflect this proposed change; rather, they reflect the wage index based on the current policy. 11. Reclassifications Under Section 508 of Pub. L. 108-173

(If you choose to comment on issues in this section, please include the caption ``508 Reclassifications'' at the beginning of your comment.)

Under section 508 of Pub. L. 108-173, a qualifying hospital could appeal the wage index classification otherwise applicable to the hospital and apply for reclassification to another area of the State in which the hospital is located (or, at the discretion of the Secretary, to an area within a contiguous State). We implemented this process through notices published in the Federal Register on January 6, 2004 (69 FR 661), and February 13, 2004 (69 FR 7340). Such reclassifications were applicable to discharges occurring during the 3-year period beginning April 1, 2004, and ending March 31, 2007. Section 106(a) of the MIEA-TRHCA (Pub. L. 109-432), extended any geographic reclassifications of hospitals that were made under section 508 and that would expire on March 31, 2007, by 6 months until September 30, 2007. On March 23, 2007, we published a notice in the Federal Register (72 FR 13799) that indicated how we are implementing section 106(a) of the MIEA-TRHCA through September 30, 2007. Because the section 508 provision will expire on September 30, 2007, and will not be applicable in FY 2008, in this proposed rule, we are not making any proposals related to the provision. 12. Other Issues

We have been advised of a reclassification scenario of concern to a particular hospital. In this scenario, two hospitals were approved by the Medicare Geographic Classification Review Board (MGCRB) for a 3- year group reclassification. Prior to the second year of the 3-year reclassification, one of the hospitals reclassified individually to another area. Consistent with our policy, the second hospital retained its group geographic reclassification for the two remaining years (see 66 FR 39888, August 1, 2001). However, once the group reclassification expires, the second hospital does not qualify to reclassify individually to another area. We have been asked to consider potential regulatory options that would allow this hospital to either reclassify or receive a declining blend of its home area and reclassified wage index as a transition to its post-reclassified wage index.

There are no options under our current regulations that would allow this hospital to reclassify individually or as a group. The hospital does not meet the well established wage data comparison criteria to reclassify as an individual hospital. In order for a group reclassification to be approved, all hospitals in the county must apply as a group. We have been informed that one hospital will not join the group reclassification because it qualifies individually to reclassify to a different area with a higher wage index than where the group applied.

We considered whether to change our regulations for this type of situation. However, we decided not to propose a change to our regulations given the need to gather additional information and better understand the policy issues in such a case. In this regard, we would be interested in receiving comments on whether such a situation is consistent with the purpose of reclassification. In particular, we would like to receive comments on how a hospital that is applying to reclassify would demonstrate similarity to hospitals in the neighboring area when the hospital would qualify to be part of a group reclassification if all other hospitals in the county the hospital is located agreed to apply.

In addition, we would be interested in comments on how we could make a determination that a hospitals own area wage index is inappropriate when the hospital does not meet the current criteria for reclassification on its own, but would meet the criteria for a group reclassification in the event all hospitals in the county in which the hospital is located would agree to submit a group application. Finally, given that reclassifications are in effect for three years, we request comments on whether or how we could address this situation while simultaneously maintaining the distinction between group and individual reclassifications--particularly the rule that all members of a group must apply for a group reclassification.

For all the above reasons, we decided, as noted, not to propose changes to the regulations to address the situation brought to our attention. Rather, we think it is appropriate to gather additional information and seek comment on this or similar situations. If commenters wish to raise issues with the points described in this section or comment on other issues we did not consider in the questions raised above, we welcome such public comments.

J. Proposed FY 2008 Wage Index Adjustment Based on Commuting Patterns of Hospital Employees

(If you choose to comment on issues in this section, please include the caption ``Out-Migration Adjustment'' at the beginning of your comment.)

In accordance with the broad discretion under section 1886(d)(13) of the Act, as added by section 505 of Pub. L. 108-173, beginning with FY 2005, we established a process to make adjustments to the hospital wage index based on commuting patterns of hospital employees. The process,

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outlined in the FY 2005 IPPS final rule (69 FR 49061), provides for an increase in the wage index for hospitals located in certain counties that have a relatively high percentage of hospital employees who reside in the county but work in a different county (or counties) with a higher wage index. Such adjustments to the wage index are effective for 3 years, unless a hospital requests to waive the application of the adjustment. A county will not lose its status as a qualifying county due to wage index changes during the 3-year period, and counties will receive the same wage index increase for those 3 years. However, a county that qualifies in any given year may no longer qualify after the 3-year period, or it may qualify but receive a different adjustment to the wage index level. Hospitals that receive this adjustment to their wage index are not eligible for reclassification under section 1886(d)(8) or section 1886(d)(10) of the Act. Adjustments under this provision are not subject to the budget neutrality requirements under section 1886(d)(3)(E) of the Act.

Hospitals located in counties that qualify for the wage index adjustment are to receive an increase in the wage index that is equal to the average of the differences between the wage indices of the labor market area(s) with higher wage indices and the wage index of the resident county, weighted by the overall percentage of hospital workers residing in the qualifying county who are employed in any labor market area with a higher wage index. To date, we have used pre-reclassified wage indices when determining the out-migration adjustment. In the FY 2005 IPPS final rule (69 FR 49061 through 49063), we stated that it was reasonable to interpret the term ``wage index'' in section 1886(d)(13)(D) of the Act to mean the pre-reclassified, pre-adjusted wage index. At the time, we stated that it was unclear whether to use the pre- or post-reclassified wage index as the basis for comparison to determine the out-migration adjustment. We also cited complicating factors such as the use of blended wage indices as a result of the labor market area transition as another reason to base the out- migration adjustment on the pre-reclassified wage index. However, we indicated that we will continue to examine the possibility of employing post-reclassification wage indexes as we refine our policy for future adjustments.

We have reconsidered our policy in this proposed rule and are proposing to calculate the out-migration adjustment using the post- reclassified wage index. First, the labor-market area transition has ended and the use of blended wage indexes is no longer a complicating factor in determining whether to use pre- or post-reclassified wage indexes to determine the out-migration adjustment. Second, we are proposing to apply budget neutrality for application of the rural floor to area wage indices rather than to the standardized amount beginning in FY 2008. The budget neutrality adjustment for the rural floor is being applied to the post-reclassification wage indices and is a component of the wage index that is being used to adjust for area differences in wages. Therefore, we believe the out-migration adjustment should be determined using post-reclassified wage index that reflects the budget neutrality adjustment for application of the rural floor.

We are proposing to use the same formula described in the FY 2005 final rule (69 FR 49064), with the addition of now using the post- reclassified wage indices, to calculate the out-migration adjustment. This adjustment is calculated as follows:

Step 1. Subtract the wage index for the qualifying county from the wage index of each of the higher wage area(s) to which hospital workers commute.

Step 2. Divide the number of hospital employees residing in the qualifying county who are employed in such higher wage index area by the total number of hospital employees residing in the qualifying county who are employed in any higher wage index area. For each of the higher wage areas, multiply this result by the result obtaining in Step 1.

Step 3. Sum the products resulting from Step 2 (if the qualifying county has workers commuting to more than one higher wage area).

Step 4. Multiply the result from Step 3 by the percentage of hospital employees who are residing in the qualifying county and who are employed in any higher wage index area.

These adjustments will be effective for each county for a period of 3 fiscal years. Hospitals that received the adjustment in FY 2007 will be eligible to retain that same adjustment for FY 2008. For hospitals in newly qualified counties, adjustments to the wage index are effective for 3 years, beginning with discharges occurring on or after October 1, 2007.

Hospitals receiving the wage index adjustment under section 1886(d)(13)(F) of the Act are not eligible for reclassification under sections 1886(d)(8) or (d)(10) of the Act unless they waive the out- migration adjustment. Consistent with our FY 2005, 2006, and 2007 final rules, we are proposing that hospitals redesignated under section 1886(d)(8) of the Act or reclassified under section 1886(d)(10) of the Act will be deemed to have chosen to retain their redesignation or reclassification. Section 1886(d)(10) hospitals that wish to receive the out-migration adjustment, rather than their reclassification, should follow the termination/withdrawal procedures specified in 42 CFR 412.273 and section III.I.3. of the preamble of this proposed rule. Otherwise, they will be deemed to have waived the out-migration adjustment. Hospitals redesignated under section 1886(d)(8) of the Act will be deemed to have waived the out-migration adjustment, unless they explicitly notify CMS that they elect to receive the out-migration adjustment instead within 45 days from the publication of this proposed rule. These notifications should be sent to the following address: Centers for Medicare and Medicaid Services, Center for Medicare Management, Attention: Wage Index Adjustment Waivers, Division of Acute Care, Room C4-08-06, 7500 Security Boulevard, Baltimore, MD 21244-1850.

Table 4J in the Addendum to this proposed rule lists the proposed out-migration wage index adjustments for FY 2008. Hospitals that are not otherwise reclassified or redesignated under section 1886(d)(8) or section 1886(d)(10) of the Act will automatically receive the listed adjustment. In accordance with the procedures discussed above, redesignated/reclassified hospitals will be deemed to have waived the out-migration adjustment unless CMS is otherwise notified. Hospitals that are eligible to receive the out-migration wage index adjustment and that withdraw their application for reclassification automatically receive the wage index adjustment listed in Table 4J in the Addendum to this proposed rule. Hospitals should carefully review the wage index adjustment that they would receive under this provision (as listed in Table 4J) and the area wage index value as listed in Table 4A (both included in the Addendum to this proposed rule) in comparison to the wage index value that they would receive under the MGCRB reclassification (Table 4C in the Addendum to this proposed rule).

K. Process for Requests for Wage Index Data Corrections

(If you choose to comment on issues in this section, please include the caption ``Wage Index Data Corrections'' at the beginning of your comment.)

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The preliminary Worksheet S-3 wage data and occupational mix survey data files (1st and 2nd quarter 2006) for the FY 2008 wage index were made available on October 6, 2006, through the Internet on the CMS Web site at: http://cms.hhs.gov/AcuteInpatientPPS/. In a memorandum dated

October 6, 2006, we instructed all fiscal intermediaries to inform the IPPS hospitals they service of the availability of the wage index data files and the process and timeframe for requesting revisions (including the specific deadlines listed below). We also instructed the fiscal intermediaries to advise hospitals that these data are also made available directly through their representative hospital organizations.

If a hospital wished to request a change to its data as shown in the October 6, 2006 wage and occupational mix data files, the hospital was to submit corrections along with complete, detailed supporting documentation to its fiscal intermediary by December 4, 2006. Hospitals were notified of this deadline and of all other possible deadlines and requirements, including the requirement to review and verify their data as posted on the preliminary wage index data file on the Internet, through the October 6, 2006 memorandum referenced above.

In the October 6, 2006 memorandum, we also specified that a hospital could request revisions to 1st and/or 2nd quarter occupational mix survey data if they missed the previous deadlines (June 1, 2006, for the 1st quarter data collection and August 31, 2006, for the 2nd quarter collection) for submitting occupational mix survey data to their fiscal intermediaries. A hospital requesting revisions to its 1st and/or 2nd quarter occupational mix survey data was to copy its record(s) from the CY 2006 occupational mix preliminary files posted to our website in October, highlight the revised cells on its spreadsheet, and submit its spreadsheet(s) and complete documentation to its fiscal intermediary no later than December 4, 2006.

The fiscal intermediaries (or, if applicable, the MAC) notified the hospitals by mid-February 2007 of any changes to the wage index data as a result of the desk reviews and the resolution of the hospitals' early-December revision requests. The fiscal intermediaries or MAC also submitted the revised data to CMS by mid-February 2007. CMS published the proposed wage index public use files that included hospitals' revised wage data on February 23, 2007. In a memorandum also dated February 23, 2007, we instructed fiscal intermediaries and the MAC to notify all hospitals regarding the availability of the proposed wage index public use files and the criteria and process for requesting corrections and revisions to the wage index data. Hospitals had until March 12, 2007 to submit requests to the fiscal intermediaries or the MAC for reconsideration of adjustments made by the fiscal intermediaries or the MAC as a result of the desk review, and to correct errors due to CMS's or the fiscal intermediary's (or, if applicable, the MAC's) mishandling of the wage index data. Hospitals were also required to submit sufficient documentation to support their requests.

After reviewing requested changes submitted by hospitals, fiscal intermediaries or the MAC are to transmit any additional revisions resulting from the hospitals' reconsideration requests by April 13, 2007. The deadline for a hospital to request CMS intervention in cases where the hospital disagreed with the fiscal intermediary's (or, if applicable, the MAC's) policy interpretations is April 20, 2007.

Hospitals should also examine Table 2 in the Addendum to this proposed rule. Table 2 of this proposed rule contained each hospital's adjusted average hourly wage used to construct the wage index values for the past 3 years, including the FY 2004 data used to construct the proposed FY 2008 wage index. We note that the hospital average hourly wages shown in Table 2 only reflect changes made to a hospital's data and transmitted to CMS by February 21, 2007.

We will release the final wage index data public use files in early May 2007 on the Internet at http:/www.cms.hhs.gov/AcuteInpatientPPS/.

The May 2007 public use files will be made available solely for the limited purpose of identifying any potential errors made by CMS or the fiscal intermediary or MAC in the entry of the final wage index data that result from the correction process described above (revisions submitted to CMS by the fiscal intermediaries or the MAC by April 13, 2007). If, after reviewing the May 2007 final files, a hospital believes that its wage or occupational mix data are incorrect due to a fiscal intermediary or MAC or CMS error in the entry or tabulation of the final data, the hospital should send a letter to both its fiscal intermediary or MAC and CMS that outlines why the hospital believes an error exists and to provide all supporting information, including relevant dates (for example, when it first became aware of the error). CMS and the fiscal intermediaries (or, if applicable, the MAC) must receive these requests no later than June 08, 2007. Requests mailed to CMS should be sent to: Centers for Medicare & Medicaid Services, Center for Medicare Management, Attention: Wage Index Team, Division of Acute Care, C4-08-06, 7500 Security Boulevard, Baltimore, MD 21244-1850.

Each request also must be sent to the fiscal intermediary or the MAC. The fiscal intermediary or the MAC will review requests upon receipt and contact CMS immediately to discuss its findings.

At this point in the process, that is, after the release of the May 2007 wage index data files, changes to the wage and occupational mix data will only made in those very limited situations involving an error by the fiscal intermediary or the MAC or CMS that the hospital could not have known about before its review of the final wage index data files. Specifically, neither the fiscal intermediary or the MAC nor CMS will approve the following types of requests:

Requests for wage index data corrections that were submitted too late to be included in the data transmitted to CMS by fiscal intermediaries or the MAC on or before April 13, 2007.

Requests for correction of errors that were not, but could have been, identified during the hospital's review of the February 23, 2007 wage index public use files.

Requests to revisit factual determinations or policy interpretations made by the fiscal intermediary or the MAC or CMS during the wage index data correction process.

Verified corrections to the wage index data received timely by CMS and the fiscal intermediaries or the MAC (that is, by June 08, 2007) will be incorporated into the final wage index to be published by August 1, 2007, to be effective October 1, 2007.

We created the processes described above to resolve all substantive wage index data correction disputes before we finalize the wage and occupational mix data for the FY 2008 payment rates. Accordingly, hospitals that do not meet the procedural deadlines set forth above will not be afforded a later opportunity to submit wage index data corrections or to dispute the fiscal intermediary's (or, if applicable the MAC's) decision with respect to requested changes. Specifically, our policy is that hospitals that do not meet the procedural deadlines set forth above will not be permitted to challenge later, before the Provider Reimbursement Review Board, the failure of CMS to make a requested data revision. (See W.A. Foote Memorial

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Hospital v. Shalala, No. 99-CV-75202-DT (E.D. Mich. 2001) and Palisades General Hospital v. Thompson, No. 99-1230 (D.D.C. 2003.) We refer the reader also to the FY 2000 final rule (64 FR 41513) for a discussion of the parameters for appealing to the PRRB for wage index data corrections.

Again, we believe the wage index data correction process described above provides hospitals with sufficient opportunity to bring errors in their wage and occupational mix data to the fiscal intermediary's (or, if applicable, the MAC's) attention. Moreover, because hospitals will have access to the final wage index data by early May 2007, they have the opportunity to detect any data entry or tabulation errors made by the fiscal intermediary or the MAC or CMS before the development and publication of the final FY 2008 wage index by August 1, 2007, and the implementation of the FY 2008 wage index on October 1, 2007. If hospitals avail themselves of the opportunities afforded to provide and make corrections to the wage and occupational mix data, the wage index implemented on October 1 should be accurate. Nevertheless, in the event that errors are identified by hospitals and brought to our attention after June 08, 2007, we retain the right to make midyear changes to the wage index under very limited circumstances.

Specifically, in accordance with Sec. 412.64(k)(1) of our existing regulations, we make midyear corrections to the wage index for an area only if a hospital can show that: (1) The fiscal intermediary or the MAC or CMS made an error in tabulating its data; and (2) the requesting hospital could not have known about the error or did not have an opportunity to correct the error, before the beginning of the fiscal year. For purposes of this provision, ``before the beginning of the fiscal year'' means by the June deadline for making corrections to the wage data for the following fiscal year's wage index. This provision is not available to a hospital seeking to revise another hospital's data that may be affecting the requesting hospital's wage index for the labor market area. As indicated earlier, since CMS makes the wage index data available to hospitals on the CMS Web site prior to publishing both the proposed and final IPPS rules, and the fiscal intermediaries or the MAC notify hospitals directly of any wage index data changes after completing their desk reviews, we do not expect that midyear corrections will be necessary. However, under our current policy, if the correction of a data error changes the wage index value for an area, the revised wage index value will be effective prospectively from the date the correction is made.

In the FY 2006 IPPS final rule (70 FR 47385), we revised Sec. 412.64(k)(2) to specify that, effective on October 1, 2005, that is beginning with the FY 2006 wage index, a change to the wage index can be made retroactive to the beginning of the Federal fiscal year only when: (1) the fiscal intermediary (or, if applicable, the MAC) or CMS made an error in tabulating data used for the wage index calculation; (2) the hospital knew about the error and requested that the fiscal intermediary (or if applicable the MAC) and CMS correct the error using the established process and within the established schedule for requesting corrections to the wage index data, before the beginning of the fiscal year for the applicable IPPS update (that is, by the June 08, 2007 deadline for the FY 2008 wage index); and (3) CMS agreed that the fiscal intermediary (or if applicable, the MAC) or CMS made an error in tabulating the hospital's wage index data and the wage index should be corrected.

In those circumstances where a hospital requests a correction to its wage index data before CMS calculates the final wage index (that is, by the June deadline), and CMS acknowledges that the error in the hospital's wage index data was caused by CMS's or the fiscal intermediary's (or, if applicable, the MAC's) mishandling of the data, we believe that the hospital should not be penalized by our delay in publishing or implementing the correction. As with our current policy, we indicated that the provision is not be available to a hospital seeking to revise another hospital's data. In addition, the provision cannot be used to correct prior years' wage index data; it can only be used for the current Federal fiscal year. In other situations where our policies would allow midyear corrections, we continue to believe that it is appropriate to make prospective-only corrections to the wage index.

We note that, as with prospective changes to the wage index, the final retroactive correction will be made irrespective of whether the change increases or decreases a hospital's payment rate. In addition, we note that the policy of retroactive adjustment will still apply in those instances where a judicial decision reverses a CMS denial of a hospital's wage index data revision request.

L. Labor-Related Share for the Proposed Wage Index for FY 2008

(If you choose to comment on issues in this section, please include the caption ``Labor-Related Share'' at the beginning of your comment.)

Section 1886(d)(3)(E) of the Act directs the Secretary to adjust the proportion of the national prospective payment system base payment rates that are attributable to wages and wage-related costs by a factor that reflects the relative differences in labor costs among geographic areas. It also directs the Secretary to estimate from time to time the proportion of hospital costs that are labor-related: ``The Secretary shall adjust the proportion (as estimated by the Secretary from time to time) of hospitals' costs which are attributable to wages and wage- related costs of the DRG prospective payment rates* * *'' We refer to the portion of hospital costs attributable to wages and wage-related costs as the labor-related share. The labor-related share of the prospective payment rate is adjusted by an index of relative labor costs, which is referred to as the wage index.

Section 403 of Pub. L. 108-173 amended section 1886(d)(3)(E) of the Act to provide that the Secretary must employ 62 percent as the labor- related share unless this ``would result in lower payments to a hospital than would otherwise be made.'' However, this provision of Pub. L. 108-173 did not change the legal requirement that the Secretary estimate ``from time to time'' the proportion of hospitals' costs that are ``attributable to wages and wage-related costs.'' We believe that this reflected Congressional intent that hospitals receive payment based on either a 62-percent labor-related share, or the labor-related share estimated from time to time by the Secretary, depending on which labor-related share resulted in a higher payment.

We have continued our research into the assumptions employed in calculating the labor-related share. Our research involves analyzing the compensation share separately for urban and rural hospitals, using regression analysis to determine the proportion of costs influenced by the area wage index, and exploring alternative methodologies to determine whether all or only a portion of professional fees and nonlabor intensive services should be considered labor-related.

In the FY 2006 IPPS final rule (70 FR 47392), we presented our analysis and conclusions regarding the frequency and methodology for updating the labor-related share for FY 2006. We also recalculated a labor-related share of 69.731 percent, using the FY 2002-based PPS market basket for discharges occurring on or after October 1, 2005. In addition, we implemented this revised and rebased labor-related share in a

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budget neutral manner, but consistent with section 1886(d)(3)(E) of the Act, we did not take into account the additional payments that would be made as a result of hospitals with a wage index less than or equal to 1.0 being paid using a labor-related share lower than the labor-related share of hospitals with a wage index greater than 1.0.

The labor-related share is used to determine the proportion of the national PPS base payment rate to which the area wage index is applied. In this proposed rule, we are not proposing to make any changes to the national average proportion of operating costs that are attributable to wages and salaries, fringe benefits, professional fees, contract labor, and labor intensive services. Therefore, we are proposing to continue to use a labor-related share of 69.731 percent for discharges occurring on or after October 1, 2007. Tables 1A and 1B will reflect this proposed labor-related share. We note that section 403 of Pub. L. 108- 173 amended sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act to provide that the Secretary must employ 62 percent as the labor-related share unless this employment ``would result in lower payments to a hospital than would otherwise be made.''

We also are proposing to continue to use a labor-related share for the Puerto Rico-specific standardized amounts of 58.7 percent for discharges occurring on or after October 1, 2007. Consistent with our methodology for determining the national labor-related share, we added the Puerto Rico-specific relative weights for wages and salaries, fringe benefits, contract labor, nonmedical professional fees, and other labor-intensive services to determine the labor-related share. Puerto Rico hospitals are paid based on 75 percent of the national standardized amounts and 25 percent of the Puerto Rico-specific standardized amounts. For Puerto Rico hospitals, the national labor- related share will always be 62 percent because the wage index for all Puerto Rico hospitals is less than 1.0. A Puerto Rico-specific wage index is applied to the Puerto Rico-specific portion of payments to the hospitals. The labor-related share of a hospital's Puerto Rico-specific rate will be either 62 percent or the Puerto Rico-specific labor- related share depending on which results in higher payments to the hospital. If the hospital has a Puerto Rico-specific wage index of greater than 1.0, we will set the hospital's rates using a labor- related share of 62 percent for the 25 percent portion of the hospital's payment determined by the Puerto Rico standardized amounts because this amount will result in higher payments. Conversely, a hospital with a Puerto Rico-specific wage index of less than 1.0 will be paid using the Puerto Rico-specific labor-related share of 58.7 percent of the Puerto Rico-specific rates because the lower labor- related share will result in higher payments. The Puerto Rico labor- related share of 58.7 percent for FY 2007 is reflected in the Table 1C of the Addendum to this proposed rule.

M. Wage Index Study Required Under Pub. L. 109-432

Section 106(b)(1) of the MIEA-TRHCA (Pub. L. 109-432) requires MedPAC to submit to Congress, not later than June 30, 2007, a report on the Medicare wage index classification system applied under the Medicare Prospective Payment System. Section 106(b) of MIEA-TRHCA requires the report to include any alternatives that MedPAC recommends to the method to compute the wage index under section 1886(d)(3)(E) of the Act.

In addition, section 106(b)(2) of Pub. L. 109-432 instructs the Secretary of Health and Human Services, taking into account MedPAC's recommendations on the Medicare wage index classification system, to include in the FY 2009 IPPS proposed rule one or more proposals to revise the wage index adjustment applied under section 1886(d)(3)(E) of the Act for purposes of the IPPS. The proposal (or proposals) must consider each of the following:

Problems associated with the definition of labor markets for the wage index adjustment;

The modification or elimination of geographic reclassifications and other adjustments;

The use of Bureau of Labor of Statistics data or other data or methodologies to calculate relative wages for each geographic area;

Minimizing variations in wage index adjustments between and within MSAs and statewide rural areas;

The feasibility of applying all components of CMS' proposal to other settings;

Methods to minimize the volatility of wage index adjustments while maintaining the principle of budget neutrality;

The effect that the implementation of the proposal would have on health care providers on each region of the country;

Methods for implementing the proposal(s) including methods to phase in such implementations; and

Issues relating to occupational mix such as staffing practices and any evidence on quality of care and patient safety including any recommendation for alternative calculations to the occupational mix.

We look forward to reviewing the MedPAC report on the wage index later this year. As required by the law, we will consider MedPAC's recommendations and each of the factors specified above in making a proposal (or proposals) in the FY 2009 IPPS proposed rule.

N. Proxy for the Hospital Market Basket

(If you choose to comment on issues in this section, please include the caption ``Hospital Market Basket'' at the beginning of your comment.)

In the FY 2006 IPPS final rule (70 FR 47387), we changed the base year cost structure for the IPPS hospital index for the hospital market basket for operating costs from FY 1997 to FY 2002. As discussed in that final rule, the IPPS hospital index primarily uses the BLS data as price proxies, which are grouped in one of the three BLS categories. The categories are Producer Price Indexes (PPIs), Consumer Price Indexes (CPIs), and Employment Cost Indexes (ECIs), discussed in detail in the FY 2006 IPPS final rule (70 FR 47388 through 47391). We evaluate the price proxies using the criteria of reliability, timeliness, availability, and relevance. The PPIs, CPIs, and ECIs selected by us and used for this proposed rule meet these criteria as described in the FY 2006 IPPS final rule. We believe they continue to be the best measures of price changes for the cost categories.

Beginning April 2006 with the publication of March 2006 data, the BLS' ECI began using a different classification system, the North American Industrial Classification System (NAICS), instead of the Standard Industrial Codes (SIC), which no longer exists. We have consistently used the ECI as the data source for our wages and salaries and other price proxies in the IPPS market basket and are not making any changes to the usage at this time. Thus, we propose to use the BLS- NAICS-based ECIs as price proxies in the market basket.

IV. Other Decisions and Proposed Changes to the IPPS for Operating Costs and GME Costs

A. Reporting of Hospital Quality Data for Annual Hospital Payment Update (Sec. 412.64(d)(2))

(If you choose to comment on issues in this section, please include the caption ``Hospital Quality Data'' at the beginning of your comment.) 1. Background

Section 5001(a) of the Deficit Reduction Act of 2005, Pub. L. 109- 171

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(DRA), set out new requirements for the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program. We established the RHQDAPU program in order to implement section 501(b) of Pub. L. 108-173. It builds on our ongoing voluntary Hospital Quality Initiative which is intended to empower consumers with quality of care information to make more informed decisions about their health care while also encouraging hospitals and clinicians to improve their quality of care.

Section 5001(a) of the DRA revised the mechanism used to update the standardized amount for payment for hospital inpatient operating costs. Specifically, sections 1886(b)(3)(B)(viii)(I) and (II) of the Act provide that the payment update for FY 2007 and each subsequent fiscal year will be reduced by 2.0 percentage points for any ``subsection (d) hospital'' (that is, a hospital paid under the IPPS) that does not submit certain quality data in a form and manner, and at a time, specified by the Secretary.

Sections 1886(b)(3)(B)(viii)(III) and (IV) of the Act required that we expand the ``starter set'' of 10 quality measures established by the Secretary as of November 1, 2003, provided certain requirements were met. In expanding this set of measures, section 1886(b)(3)(B)(viii)(IV) of the Act provides that we must begin to adopt the baseline set of performance measures as set forth in a 2005 report issued by the Institute of Medicine (IOM) of the National Academy of Sciences under section 238(b) of the MMA,\17\ effective for payments beginning with FY 2007.

\17\ Institute of Medicine, ``Performance Measurement: Accelerating Improvement,'' December 1, 2005, available at http://www.iom.edu/CMS/3809/19805/31310.aspx .

The IOM measures include: Hospital Quality Alliance (HQA) quality measures (the HQA is a public-private collaboration to improve the quality of care provided by the nation's hospitals by measuring and publicly reporting on that care), the HCAHPS patient perspective survey, and three structural measures. The structural measures are: (1) Implementation of computerized provider order entry for prescriptions, (2) staffing of intensive care units with intensivists, and (3) evidence-based hospital referrals. These structural measures constitute the Leapfrog Group's original ``three leaps,'' and are part of the National Quality Forum's 30 Safe Practices for Better Healthcare.

Sections 1886(b)(3)(B)(viii)(V) and (VI) of the Act require that, effective for payments beginning with FY 2008, we add other quality measures that reflect consensus among affected parties, and provide the Secretary with the discretion to replace any quality measures or indicators in appropriate cases, such as where all hospitals are effectively in compliance with a measure, or the measures or indicators have been subsequently shown to not represent the best clinical practice. Thus, the Secretary has broad discretion to replace measures on the basis that they are not appropriate.

Section 1886(b)(3)(B)(viii)(VII) of the Act requires that we establish procedures for making quality data available to the public after ensuring that a hospital has the opportunity to review, in advance, its data that are to be made public. In addition, this section requires that we report quality measures of process, structure, outcome, patients' perspective on care, efficiency, and costs of care that relate to services furnished in inpatient settings on the CMS Web site.

Section 1886(b)(3)(B)(viii)(I) of the Act also provides that any reduction in a hospital's payment update will apply only with respect to the fiscal year involved, and will not be taken into account for computing the applicable percentage increase for a subsequent fiscal year.

The starter set of 10 quality measures we established as of November 1, 2003 are as follows:

Heart Attack (Acute Myocardial Infarction or AMI)

Was aspirin given to the patient upon arrival to the hospital?

Was aspirin prescribed when the patient was discharged?

Was a beta-blocker given to the patient upon arrival to the hospital?

Was a beta-blocker prescribed when the patient was discharged?

Was an ACE inhibitor given for the patient with heart failure?

Heart Failure (HF)

Did the patient get an assessment of his or her heart function?

Was an ACE inhibitor given to the patient?

Pneumonia (PNE)

Was an antibiotic given to the patient in a timely way?

Had the patient received a pneumococcal vaccination?

Was the patient's oxygen level assessed?

We adopted these measures after the Secretary of HHS joined in a partnership with several collaborators intended to promote hospital quality improvement and public reporting of hospital quality information. These collaborators included the American Hospital Association, the Federation of American Hospitals, the Association of American Medical Colleges, the Joint Commission on Accreditation of Healthcare Organizations (the Joint Commission), the National Quality Forum (NQF), the American Medical Association, the Consumer-Purchaser Disclosure Project, the AARP, the American Federation of Labor-Congress of Industrial Organizations, the Agency for Healthcare Research and Quality (AHRQ), as well as CMS and others. This collaboration, originally known as the National Voluntary Hospital Reporting Initiative, is now known as the HQA.

This starter set of 10 quality measures was endorsed by the NQF. NQF is a voluntary consensus standard-setting organization established to standardize health care quality measurement and reporting through its consensus development process. In addition, this starter set is a subset of measures currently collected for The Joint Commission as part of its certification program.

We chose these 10 quality measures in order to collect data that will: (1) Provide useful and valid information about hospital quality to the public; (2) provide hospitals with a sense of predictability about public reporting expectations; (3) begin to standardize data and data collection mechanisms; and (4) foster hospital quality improvement.

Hospitals submit quality data through the QualityNet Exchange secure Web site (http://www.qnetexchange.org). We believe that this Web

site meets or exceeds all current Health Insurance Portability and Accountability Act requirements for security of personal health information. Data from this initiative are used to populate the Hospital Compare Web site, http://www.hospitalcompare.hhs.gov. This Web

site assists beneficiaries and the general public by providing information on hospital quality of care for consumers who need to select a hospital. It further serves to encourage consumers to work with their doctors and hospitals to discuss the quality of care they provide to patients, thereby providing an additional incentive to improve their quality of that care.

In the FY 2007 IPPS final rule (71 FR 48137), we amended our regulations at Sec. 412.64(d)(2) to reflect the 2.0 percentage point reduction in the payment update for FY 2007 and subsequent fiscal years for hospitals that do not comply with requirements for reporting quality data as provided for under section 5001(a) of the DRA. We also added 11 additional quality

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measures to the 10 measure starter set to establish an expanded set of 21 quality measures (71 FR 48029 through 48037). These 21 measures are as follows:

Topic

Quality measure

Heart Attack (Acute Myocardial

Aspirin at arrival.* Infarction). Aspirin prescribed at discharge.* ACE inhibitor (ACE-I) or Angiotensin Receptor Blocker (ARBs) for left ventricular systolic dysfunction.* Beta blocker at arrival.* Beta blocker prescribed at discharge.* Thrombolytic agent received within 30 minutes of hospital arrival. Percutaneous Coronary Intervention (PCI) received within 120 minutes of hospital arrival. Adult smoking cessation advice/counseling. Heart Failure (HF)..................... Left ventricular function assessment.* ACE inhibitor (ACE-I) or Angiotensin Receptor Blocker (ARBs) for left ventricular systolic dysfunction.* Discharge instructions. Adult smoking cessation advice/counseling. Pneumonia (PNE)........................ Initial antibiotic received within 4 hours of hospital arrival.* Oxygenation assessment.* Pneumococcal vaccination status.* Blood culture performed before first antibiotic received in hospital. Adult smoking cessation advice/counseling. Appropriate initial antibiotic selection. Influenza vaccination status. Surgical Care Improvement Project

Prophylactic (SCIP)--named SIP for discharges prior antibiotic received within 1 to July 2006 (3Q06).

hour prior to surgical incision. Prophylactic antibiotics discontinued within 24 hours after surgery end time.

*Measure included in 10 measure starter set.

In addition, in the FY 2007 IPPS final rule (71 FR 48031 through 48044), we set out RHQDAPU program procedures for data submission, program withdrawal, data validation, attestation, public display of hospitals' quality data, and reconsiderations. In response to public comments, we required that reporting of the expanded quality measures begin with discharges occurring on or after the third calendar quarter of 2006 (July through September discharges). We also responded to public comments regarding whether we should establish more structured reconsideration procedures for FY 2008 and what such procedures might include.

Under section 1886(b)(3)(B)(viii)(V) of the Act, for payments beginning with FY 2008, we are required to add other measures that reflect consensus among affected parties, and, to the extent feasible and practicable, we must include measures set forth by one or more national consensus building entities. 2. FY 2008 Quality Measures

Commenters on the FY 2007 IPPS proposed rule requested that we notify the public as far in advance as possible of any proposed expansions of the measurement set and program procedures in order to encourage broad collaboration and to give hospitals time to prepare for any anticipated change. Taking these concerns into account, in the CY 2007 OPPS final rule (71 FR 68201), we adopted additional quality measures for the FY 2008 update. The six additional measures we adopted are as follows:

HCAHPS survey SCIP Quality Measures

--SCIP-VTE 1: Venous thromboembolism (VTE) prophylaxis ordered for surgery patient

--SCIP-VTE 2: VTE prophylaxis within 24 hours pre/post surgery

--SCIP Infection 2: Prophylactic antibiotic selection for surgical patients Mortality (Medicare Patients)

--Acute Myocardial Infarction 30-day mortality Medicare patients

--Heart Failure 30-day mortality Medicare patients

For the FY 2008 payment determination, hospitals are required to report the following 27 measures:

Topic

Quality measure

Heart Attack (Acute Myocardial

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Discharge instructions.** Adult smoking cessation advice/counseling.** Pneumonia (PNE)........................ Initial antibiotic received within 4 hours of hospital arrival.* Oxygenation assessment.* Pneumococcal vaccination status.* Blood culture performed before first antibiotic received in hospital.** Adult smoking cessation advice/counseling.** Appropriate initial antibiotic selection.** Influenza vaccination status.** Surgical Care Improvement Project

Prophylactic (SCIP)--named SIP for discharges prior antibiotic received within 1 to July 2006 (3Q06).

hour prior to surgical incision.** Prophylactic antibiotics discontinued within 24 hours after surgery end time.** SCIP-VTE 1: Venous thromboembolism (VTE) prophylaxis ordered for surgery patients.*** SCIP-VTE 2: VTE prophylaxis within 24 hours pre/post surgery.*** SCIP Infection 2: Prophylactic antibiotic selection for surgical patients.*** Mortality Measures (Medicare patients). Acute Myocardial Infarction 30-day mortality Medicare patients.*** Heart Failure 30-day mortality Medicare patients.*** Patients' Experience of Care........... HCAHPS patient survey.***

*Measure included in 10 measure starter set. **Measure included in 21 measure expanded set. *** Measure added in CY 2007 OPPS final rule.

We did not adopt any other new RHQDAPU measures for FY 2008. 3. New Quality Measures and Program Requirements for FY 2009 and Subsequent Years a. Proposed New Quality Measures for FY 2009 and Subsequent Years

We are proposing to add 1 outcome measure and 4 process measures to the existing 27 measure set to establish a new set of 32 quality measures to be used for the FY 2009 annual payment determination. We plan to adopt these measures a year in advance in order to provide additional time for hospitals to prepare for changes related to the RHQDAPU program. We are proposing to add the following quality measures for the FY 2009 RHQDAPU program.

Pneumonia 30-day Mortality (Medicare patients)

SCIP Infection 4: Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose

SCIP Infection 6: Surgery Patients with Appropriate Hair Removal

SCIP Infection 7: Colorectal Patients with Immediate Postoperative Normothermia

SCIP Cardiovascular 2: Surgery Patients on a Beta-Blocker Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period

The above measures reflect our continuing commitment to quality improvement in both clinical care and patient safety. These additional measures also demonstrate our commitment to include in the RHQDAPU program only those quality measures that reflect consensus among the affected parties and that have been reviewed by a consensus building process. The proposed measures have been put forth by the HQA for inclusion in its public reporting set, contingent on endorsement by the NQF. (In the case of SCIP Infection 7, the HQA recently withdrew its previous support unless the measure receives NQF endorsement.) We anticipate that the NQF will endorse these measures prior to the publication of the FY 2008 IPPS final rule. Any measure that has not been endorsed by that time will not be finalized in that rule.

CMS requests public comment on these five measures, as well as whether to add other measures to the RHQDAPU program measure set for FY 2009 and subsequent years. CMS may, based on comments received, include one or more of the measures discussed below in the RHQDAPU program measure set for FY 2009 payments. We will finalize the FY 2009 RHQDAPU measure set in the FY 2008 IPPS final rule.

The following table contains a list of 18 measures and 8 measure sets from which additional quality measures could be selected for inclusion in the RHQDAPU program. It includes measures and measure sets that highlight CMS' interest in improving patient safety and outcomes of care, with a particular focus on the quality of surgical care and patient outcomes. In order to engender a broad review of potential performance measures, the list includes measures that have not yet been considered for approval by the HQA or endorsement by the NQF consensus review process for public reporting. It also includes measures developed by organizations other than CMS as well as measures that are to be derived from administrative data (such as claims) that may need to be modified for specific use by the Medicare program if implemented under the RHQDAPU program.

We hope to receive comment from a broad set of stakeholders on the measures and measure sets that are listed, as well as any critical gaps or ``missing'' measures or measure sets. We specifically requests input concerning the following:

Which of the measures or measure sets should be included in the FY 2009 RHQDAPU program or in subsequent years?

What challenges for data collection and reporting are posed by the identified measures and measure sets? What improvements could be made to data collection or reporting that might offset or otherwise address those challenges?

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Possible Measures and Measure Sets for the RHQDAPU Program for FY 2009 and Subsequent Years

Clinical Measure

condition

Intensive Care Unit (ICU) Critical Care Measures

1........ Stress Ulcer Disease Prophylaxis.......... ICU/critical care. 2........ Urinary Catheter-Associated Urinary Tract ICU/critical Infection For Intensive Care Unit (ICU) care. Patients.

Readmission Measures

3........ Readmission Heart Failure (HF) Within 30 Efficiency/HF. Days Rate--Medicare Only (CMS Methodology). 4........ Readmission (same hospital) Acute

Efficiency/AMI. Myocardial Infarction (AMI) Within 30 Days Rate. 5........ Readmission (same hospital) PNE Within 30 Efficiency/PNE. Days Rate. 6........ Readmission Within 30 Days Of Surgery-- Surgical Care. Medicare Only (SCIP Global-2).

NQF--Nursing Sensitive Condition Set (Outcomes Measures Only)

7........ Failure To Rescue--Nursing Sensitive

Patient centered. Measure. 8........ Pressure Ulcer Prevalence--Nursing

Patient centered. Sensitive Measure. 9........ Patient Falls Prevalence--Nursing

Patient centered. Sensitive Measure. 10....... Patient Falls With Injury--Nursing

Patient centered. Sensitive Measure.

Cancer (Inpatient) Measures

11....... Patients With Early Stage Breast Cancer Cancer--Breast. Who Have Evaluation Of The Axilla. 12....... College Of American Pathologists Breast Cancer--Breast. Cancer Protocol. 13....... Surgical Resection Includes At Least 12 Cancer--Colon. Nodes (ACOS-02). 14....... College Of American Pathologists Colon And Cancer--Colon. Rectum Protocol. 15....... Completeness Of Pathologic Reporting (CCO- Cancer--Colon. 04).

Leapfrog Leaps, identified by IOM and Deficit Reduction Act

16....... Use Of Computerized Physician Order Entry Patient safety. (CPOE) Systems. 17....... Use of Intensivists in ICUs/ICU Physician Patient safety. Staffing (IPS). 18....... Evidence-Based Hospital Referrals......... Patient Safety.

Measure Sets of Potential Interest (Individual measures not specified in this proposed rule) Sets Under Active Review by National Quality Forum (NQF)

1........ Healthcare-Associated Infection measures-- Patient Safety. under consideration by the NQF National Voluntary Consensus Standards for Reporting of Healthcare-associated Infections Data Project. 2........ Readmission Rates by Condition--under Efficiency. consideration by NQF National Voluntary Consensus Standards for Hospital Care: Additional Priorities, 2007 Project. 3........ Average Length of Stay (ALOS) by

Efficiency. Condition--under consideration by NQF National Voluntary Consensus Standards for Hospital Care: Additional Priorities, 2007 Project. 4........ AHRQ Quality Indicators, including Patient Patient Safety, Safety Indicators--under consideration by various NQF National Voluntary Consensus

conditions. Standards for Hospital Care: Additional Priorities, 2007 Project.

Measure Sets/Practices Previously Endorsed by NQF

5........ Safe Practices for Better Healthcare...... Patient Safety. 6........ Serious Reportable Events in Healthcare Patient Safety. (``Never Events'').

Other Hospital Measure Sets

7........ Hospital Emergency Department Measures.... Various. 8........ Vascular Surgery Complications (for

Surgical Care. Carotid Endarterectomy, Lower Extremity Bypass, Open Surgery Abdominal Aortic Aneurysm Repair, Endovascular Abdominal Aortic Aneurysm Repair).

b. Data Submission

In order to be eligible for the full FY 2009 market basket update, we are proposing that hospitals will be required to submit data on 32 measures (the 27 existing measures plus the 5 proposed new measures). The technical specifications for this requirement are published in the CMS/Joint Commission Specifications Manual for National Hospital Quality Measures. This manual can be found on the QualityNet.org Web site.

For the additional SCIP measures that we are proposing to add through this rule, (SCIP Infection 4, 6, and 7 and SCIP-Card-2), hospitals will be required to submit data to the QIO Clinical Warehouse starting with discharges that occur in CY 2008. We are proposing that the deadline for hospitals to submit this data for first calendar quarter of 2008 would be August 15, 2008. Data must be submitted for each subsequent quarter by 4.5 months after the end of the quarter.

We are proposing this time period to allow hospitals sufficient time to prepare for the data collection. The three SCIP Infection measures that we are proposing to include for FY 2009 were added to the Manual in version 2.0, effective with third calendar quarter of 2006 (3Q06) and the proposed SCIP Cardiovascular measure was added in version 2.1d of the Manual, effective with fourth calendar quarter of 2006

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(4Q06). Hospitals may report data on these measures for discharges prior to CY 2008 discharges, if they so choose.

For the proposed Pneumonia 30-day Mortality measure, we are proposing to use claims data that are already being collected for index hospitalizations to calculate the mortality rates. As is the case with the other 30-day mortality (outcome) measures already associated with the RHQDAPU program (AMI, HF), hospitals need not submit additional data. Claims data submitted to CMS for index hospitalizations occurring from July 2006 through June 2007 (3Q06 through 2Q07) will be used to calculate the Pneumonia 30-day mortality rate that will be used for FY 2009 annual payment determination.

All measures that we have previously finalized, and that we finalize in the future through the rulemaking process, will be required for the RHQDAPU program annual payment determination each year until further notice. CMS, working in conjunction with The Joint Commission, maintains the specifications for the set of measures used both for the RHQDAPU program and for reporting under the HQA initiative. The specifications are updated semiannually and changes are made prospectively, except in exceptional circumstances. Revised specifications can be found at http://www.qualitynet.org.

4. Retiring or Replacing RHQDAPU Program Quality Measures

Over time, CMS expects that the set of measures used for the RHQDAPU program will evolve and change. New measures will be added to reflect clinical and other program goals. Measures that are no longer supported by clinical evidence would be modified or dropped. Through its public reporting and RHQDAPU program activities, CMS seeks to balance the competing goals of assuring the development of a comprehensive yet parsimonious set of quality measures while reducing reporting burden on hospitals. Section 1886(b)(3)(B)(viii)(VI) of the Act gives the Secretary authority to replace any measures or indicators in appropriate cases, such as where all hospitals are effectively in compliance or the measures or indicators have been subsequently shown not to represent the best clinical practice. CMS recognizes the need to develop a process related to the retirement and/or replacement of measures that comprise the RHQDAPU program measure set. In this proposed rule, we solicit public comment and suggestions concerning the criteria and mechanism for a process that would identify and, where appropriate, retire or replace measures that comprise the RHQDAPU program measure set. 5. Procedures for the RHQDAPU Program for FY 2008 and FY 2009 a. Procedures for Participating in the RHQDAPU Program

The ``Reporting Hospital Quality Data for Annual Payment Update Reference Checklist'' section of the QualityNet Exchange Web site contains all of the forms to be completed by hospitals participating in the program. In order to participate in the hospital reporting initiative for FY 2008, hospitals must follow these steps:

Identify a QualityNet Exchange Administrator who follows the registration process and submits the information through the QIO Clinical Warehouse. This must be done regardless of whether the hospital uses a vendor for transmission of data.

Complete the revised ``Reporting Hospital Quality Data for Annual Payment Update Notice of Participation'' form. These hospitals must send this form to their QIO, no later than August 15, 2007. In effort to alleviate the burden associated with submitting this form annually, we are proposing that a hospital that submits this form will be considered an active RHQDAPU program participant until such time as the hospital submits a withdrawal form to CMS.

In addition, before participating hospitals initially begin reporting data, they must register with the QualityNet Exchange, regardless of the method used for submitting data.

Collect and report data for 24 of the 27 required measures (listed in Table--under the following headings: Acute Myocardial Infarction, Heart Failure, Pneumonia and SCIP). A hospital must report this data for discharges occurring in or after first quarter CY 2007. Hospitals must submit the data to the QIO Clinical Warehouse either using the CMS Abstraction & Reporting Tool (CART), the JCAHO ORYX[reg] Core Measures Performance Measurement System, or using another third- party vendor tool that has met the measurement specification requirements for data transmission to QualityNet Exchange. All submissions will be executed through QualityNet Exchange. Because the information in the QIO Clinical Warehouse is considered QIO information, it is subject to the stringent QIO confidentiality regulations in 42 CFR part 480. The QIO Clinical Warehouse will submit the data to CMS on behalf of the hospitals.

For each quality measure that requires hospitals to collect and report data, submit complete data regarding the quality measures in accordance with the joint CMS/Joint Commission sampling requirements located on the QualityNet Exchange Web site. These requirements specify that hospitals must submit a random sample or complete population of cases for each of topics covered by the quality measures. Hospitals must meet these sampling requirements for these quality measures for discharges in each quarter.

Submit aggregate population and sample size counts for Medicare and non-Medicare discharges for the four topic areas (AMI, HF, PNE, and SCIP) on a quarterly basis to CMS.

Continuously collect HCAHPS data beginning with July 2007 discharges in accordance with the HCAHPS Quality Assurance Guidelines, Version 2.0, located at http://www.hcahpsonline.org. The CY 2007 OPPS

rule required HCAHPS-eligible hospitals to participate in the March 2007 dry run of the HCAHPS survey, if they have not already participated in a previous dry run. Hospitals must submit HCAHPS dry run data to the QIO Clinical Warehouse by July 13, 2007. As part of the March 2007 dry run, hospitals were required to survey HCAHPS-eligible discharges between 48 hours and 6 weeks following hospital discharge.

For the AMI 30-day and HF 30-day mortality measures, CMS will use Part A and Part B claims for Medicare fee-for-service patients to calculate the mortality measures. For FY 2008, hospital inpatient claims (Part A) from July 1, 2005 to June 30, 2006 will be used to identify the relevant patients and the index hospitalizations. Inpatient claims for the index hospitalization and Part A and Part B claims for all inpatient, outpatient and physician services received one year prior to the index hospitalizations are used to determine patient comorbidity, which is used in the risk adjustment calculation (see http://www.qualitynet.org/dcs/ContentServer?cid=1163010398556&pagename=QnetPublic%2FPage%2FQnetTier2&c=Page ). No other hospital data submission is required to calculate the

mortality rates. b. Procedures for Participating in the RHQDAPU Program for FY 2009

For FY 2009, the requirements for FY 2008 discussed above will apply, except that hospitals will be required to collect and report data on any additional measures that we finalize through the rulemaking process and for which we specify that data submission is required. Mortality measures will be expanded to

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include pneumonia pending final NQF endorsement. c. Chart Validation Requirements (1) FY 2008 Validation Requirements

For the FY 2008 update, and until further notice, we will continue to require that hospitals meet the chart validation requirements that we implemented in the FY 2006 IPPS final rule. There were no chart- audit validation criteria in place for FY 2005. Based upon our experience with the FY 2005 submissions and our requirement for reliable and validated data, in the FY 2006 IPPS final rule we discussed additional requirements that we had established for the data that hospitals were required to submit in order to receive the full FY 2006 payment update (70 FR 47421 and 47422). These requirements, as well as additional information on validation requirements, will continue and are being placed on the QualityNet Exchange Web site.

For the FY 2008 payment update, and until further notice, hospitals must pass our validation requirement of a minimum of 80 percent reliability, based upon our chart-audit validation process, for the first three quarters of data from CY 2006. These data are due to the QIO Clinical Warehouse by August 15, 2006 (first quarter CY 2006 discharges), November 15, 2006 (second quarter CY 2006 discharges), and February 15, 2007 (third quarter CY 2006 discharges).

We use confidence intervals to determine if a hospital has achieved an 80-percent reliability aggregated over the three quarters. The use of confidence intervals allows us to establish an appropriate range below the 80-percent reliability threshold that demonstrates a sufficient level of reliability to allow the data to still be considered validated. We estimate the percent reliability based upon a review of five charts, and then calculate the upper 95-percent confidence limit for that estimate. If this upper limit is above the required 80-percent reliability, the hospital data are considered validated.

We are using the design-specific estimate of the variance for the confidence interval calculation, which, in this case, is a stratified single stage cluster sample, with unequal cluster sizes. (For reference, see Cochran, William G.: Sampling Techniques, John Wiley & Sons, New York, chapter 3, section 3.12 (1977); and Kish, Leslie.: Survey Sampling, John Wiley & Sons, New York, chapter 3, section 3.3 (1964).) Each quarter is treated as a stratum for variance estimation purposes.

We will use a two-step process to determine if a hospital is submitting valid data. In the first step, we calculate the percent agreement for all of the variables submitted in all of the charts. If a hospital falls below the 80-percent cutoff, we proceed to the second step and restrict the comparison to those variables associated with payment. For first and second quarter CY 2006 discharges (1Q06, 2Q06), that means we limit the calculations to the 10-measure starter set. For third quarter CY 2006 discharges (3Q06), we include 21 measures. We recalculate the percent agreement and the estimated 95-percent confidence interval and again compare to the 80-percent cutoff point. If a hospital passes under this restricted set of variables, the hospital is considered to be submitting valid data for purposes of the RHQDAPU program.

Due to time constraints, we will not apply the validation requirement for the FY 2008 update to 3 SCIP measures that are included in the RHQDAPU measure set, Infection 2, VTE 1 and VTE 2.

For HCAHPS, hospitals and survey vendors must participate in a quality oversight process conducted by the HCAHPS project team. Prior to July 2007, the purpose of the oversight activities will be to provide feedback to hospitals and survey vendors on data collection procedures. Starting in July 2007, we may ask hospitals/survey vendors to correct any problems that are found and provide follow-up documentation of corrections for review within a defined time period. If the HCAHPS project team finds that the hospital has not made these corrections, CMS may determine that the hospital is not submitting appropriate HCAHPS data for the RHQDAPU program. As part of these activities, HCAHPS project staff will review and discuss with survey vendors and hospitals self-administering the survey their specific Quality Assurance Plans, survey management procedures, sampling and data collection protocols, and data preparation and submission. This review may take place in-person or through other means of communication. (2) FY 2009 Chart Validation Requirements

For the FY 2009 update, all 2008 requirements apply, except for the following modifications. We will modify the validation requirement to pool the quarterly validation estimates for 4th quarter CY 2006 through 3rd quarter 2007 discharges. We will also expand the list of validated measures in the FY 2009 update to add SCIP Infection-2, SCIP VTE-1, and SCIP VTE-2 starting with 4th quarter CY 2006 discharges. We will also drop the current two-step process to determine if the hospital is submitting valid data. We propose for the FY 2009 update to pool validation estimates covering the 4 quarters (4th quarter CY 2006 discharges through 3rd quarter 2007 discharges) in a similar manner to the current 3 quarter pooled confidence interval. (3) Validation and Submission Requirements

We plan to apply the validation and submission requirements for FY 2008 and FY 2009 payment determination for the quality measures. For the validation and submission requirements for the FY 2008 payment year, we plan to use the following:

The 10 measure starter set for both submission and validation for 1st through 3rd quarters CY 2006 discharges.

The additional 11 measures that make up the expanded measure set for both submission and validation for 3rd quarter CY 2006 discharges.

SCIP VTE 1, 2, and SCIP Infection 2 submission only for 1Q 2007 discharges only.

HCAHPS measures, both submission of dry run data and continuous submission beginning with July 2007 discharges.

AMI and HF 30-day mortality measures as described previously. For FY 2009 payment year, we plan to use the following:

The 21 expanded measure set for submission and validation starting with fourth quarter CY 2006 (4Q06) through third quarter CY 2007 discharges.

SCIP VTE 1, 2, and SCIP Infection 2 submission and validation second quarter CY 2007 and 3rd Quarter CY 2007 discharges.

HCAHPS measures, continuous submission.

AMI, HF, and PN 30-day mortality measures as described previously.

As additional measures are finalized for inclusion in the FY 2009 payment decision, we anticipate making changes to the above plan to incorporate those measures. c. Data Validation and Attestation

For the FY 2008 update and in subsequent years, we will revise and post up-to-date confidence interval information on the QualityNet Exchange Web site explaining the application of the confidence interval to the overall validation results. The data are being validated at several levels. There are consistency and internal edit checks to ensure the integrity of the submitted data; there are external edit checks to

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verify expectations about the volume of the data received.

We will require for FY 2008 and subsequent years that hospitals attest each quarter to the completeness and accuracy of their data, including the volume of data, submitted to the QIO Clinical Warehouse in order to improve aspects of the validation checks. We will provide additional information to explain this attestation requirement, as well as provide the relevant form to be completed on the QualityNet Exchange Web site. d. Public Display

We will continue to display quality information for public viewing as required by section 1886(b)(3)(B)(viii)(VII) of the Act. Before we display this information, hospitals will be permitted to review their information as recorded in the QIO Clinical Warehouse.

Currently, hospitals that share the same Medicare Provider Number (MPN) must combine data collection and submission across their multiple campuses (for both clinical measures and for HCAHPS). These measures are then publicly reported as if they apply to a single hospital. We estimate that approximately 5 to 10 percent of the hospitals reported on the Hospital Compare Web site share MPNs. For FY 2008 and subsequent years, we are proposing to require hospitals to begin to report the name and address of each hospital that shares the same MPN. This information will be gathered through the RHQDAPU program Notice of Participation form, which hospitals will submit to their QIOs by August 15, 2007. To increase transparency in public reporting and improve the usefulness of Hospital Compare, CMS plans to note on the Web site where publicly reported measures combine results from two or more hospitals. e. Reconsideration and Appeal Procedures

If we deny a hospital the full market basket update, the hospital may submit a letter requesting that we reconsider our decision that the hospital did not meet the RHQDAPU program requirements. For FY 2008, a hospital must submit such a request for reconsideration on or before November 1, 2007. We also are establishing additional procedural rules that will govern RHQDAPU program reconsiderations. We will post these rules on the QualityNet Exchange Web site.

If a hospital is dissatisfied with the result of a RHQDAPU program reconsideration, the hospital may file a claim under 42 CFR Part 405, Subpart R (a Provider Reimbursement Review Board (PRRB) appeal).

In this proposed rule we are again soliciting public comment and suggestions related to reconsideration. f. RHQDAPU Program Withdrawal Requirements

For the FY 2008 update, hospitals may withdraw from the RHQDAPU program at any time up to August 15, 2007. If a hospital withdraws from the program, it will receive a 2.0 percentage point reduction in its payment update. 6. Electronic Medical Records

In the FY 2006 IPPS final rule, we encouraged hospitals to take steps toward the adoption of electronic medical records (EMRs) that will allow for reporting of clinical quality data from the EMRs directly to a CMS data repository (70 FR 47420). We intend to begin working toward creating measures specifications and a system or mechanism, or both, that will accept the data directly without requiring the transfer of the raw data into an XML file as is currently done. The Department continues to work cooperatively with other Federal agencies in the development of Federal health architecture data standards. We encouraged hospitals that are developing systems to conform them to both industry standards and, when developed, the Federal Health Architecture Data standards, and to ensure that the data necessary for quality measures are captured. Ideally, such systems will also provide point-of-care decision support that enables high levels of performance on the measures. Hospitals using EMRs to produce data on quality measures will be held to the same performance expectations as hospitals not using EMRs.

Due to the low volume of comments we received on this issue in response to the FY 2006 proposed IPPS rule, in the proposed IPPS rule for FY 2007 (71 FR 24095), we again invited comments on these requirements and options. In the FY 2007 IPPS final rule, we summarized and addressed the additional comments we received. We would welcome additional comments on this issue. 7. New Hospitals

In addition, we are proposing a minor change to our policies regarding new hospitals. In the FY 2006 IPPS final rule, we noted that a new hospital should begin collecting and reporting data immediately and complete the registration requirements for the RHQDAPU. (70 FR 47421 and 47428). We also explained that a new hospital would be held to the same standard as established facilities when determining the expected number of discharges for the calendar quarters covered for each fiscal year. We also stated that fiscal intermediaries would provide information on new hospitals to the QIO in the state in which the hospital has opened for operations as a Medicare provider as soon as possible so that the QIO can enter the provider information into its Program Resource System (PRS) and follow through with ensuring provider participation with the requirements for quality data reporting under this rule.

We believe that some new hospitals have found it difficult to start reporting RHQDAPU measures immediately after signing up to participate in the RHADAPU program. Therefore, we are proposing a modification to our policy to reduce burden on new hospitals. We are proposing that the fiscal intermediary would continue to provide information on the new hospital to the QIO in the state in which the hospital is located as soon as possible so that the QIO could enter the provider information into its PRS and follow through with ensuring provider participation with the requirements for quality data reporting. However, for a new hospital that receives a provider number on or after October 1st of each year (beginning with October 1, 2007), we are proposing that the hospital would be required to report RHQDAPU data beginning with the first day of the quarter following the date the hospital registers to participate in the RHQDAPU program. For example, a hospital that receives its MPN on October 2, 2007 and signs up to participate in RHQDAPU on November 1, 2007 will be expected to meet all data submission requirements for discharges on or after January 1, 2008.

B. Development of the Medicare Hospital Value-Based Purchasing Plan

(If you choose to comment on issues in this section, please include the caption ``Value-Based Purchasing Plan'' at the beginning of your comment.)

Section 5001(b) of the DRA specifies that CMS develop a plan to implement a Value-Based Purchasing (VBP) Program for payments under the Medicare program for subsection (d) hospitals beginning with FY 2009. Congress specified that the ``plan'' include consideration of the following issues:

The ongoing development, selection, and modification process for measures of quality and efficiency in hospital inpatient settings.

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The reporting, collection, and validation of quality data.

The structure of value-based payment adjustments, including the determination of thresholds or improvements in quality that would substantiate a payment adjustment, the size of such payments, and the sources of funding for the value-based payments.

The disclosure of information on hospital performance.

In developing the plan, we must consult with relevant affected parties and consider experience with demonstrations that are relevant to the value-based purchasing program.

We have created an internal Hospital Pay-for-Performance Workgroup that is charged with developing the VBP Plan for Medicare hospital services. The workgroup is organized into four subgroups to address each of the required planning issues: (1) measures; (2) data collection and validation; (3) incentive structure; and (4) public reporting. The workgroup has been charged with preparing a set of design options, narrowing the set of design options to prepare a draft plan, and preparing the final plan for implementing VBP for Medicare hospital services that will be provided to Congress.

CMS is hosting two public ``Listening Sessions'' in early 2007 to solicit comments from relevant affected parties on outstanding design questions associated with development of the final plan. The first listening session was held on January 17, 2007, to consider design questions posed in an issues paper that has been posted since December 22, 2006, on the Medicare Web site, Hospital Center, under Spotlights at: http://www.cms.hhs.gov/center/hospital.asp. An audio download of

the listening session and the PowerPoint slides used during the session are also posted on this Web site.

The second listening session will be held on April 12, 2007, to consider the draft plan, which will be posted on the Medicare Web site, Hospital Center, on March 22, 2007. A notice announcing this listening session was published in the Federal Register on February 23, 2007 (71 FR 8179). It is hoped that hospitals, hospital associations, and other interested parties will attend and make comments on the draft plan in person. It will also be possible to participate by teleconference, and limited time will be allocated for verbal comments by telephone participants. Registration to participate in person or by telephone is open until April 5, 2007. The agenda and PowerPoint slides for the session will be posted by April 9, 2007. An audio download of the second listening session will be posted by April 17, 2007. Written comments are welcomed and will be accepted until 5 PM EDT on April 19, 2007. The perspectives expressed during this session and in writing will assist CMS in making revisions to the draft plan to create the final Medicare Hospital Value-Based Purchasing Plan expected to be completed by June 2007.

While section 5001(b) of the DRA authorized development of this plan, additional legislation will be required to establish and implement the Medicare Hospital Value-Based Purchasing Program. As described in the draft plan, we proposed that the current RHQDAPU Program will provide the foundation for and be incorporated into the new Medicare Hospital Value-Based Purchasing Program.

C. Rural Referral Centers (RRCs) (Sec. 412.96)

(If you choose to comment on issues in this section, please include the caption ``RRCs'' at the beginning of your comment.)

Under the authority of section 1886(d)(5)(C)(i) of the Act, the regulations at Sec. 412.96 set forth the criteria that a hospital must meet in order to qualify under the IPPS as an RRC. For discharges occurring before October 1, 1994, RRCs received the benefit of payment based on the other urban standardized amount rather than the rural standardized amount. Although the other urban and rural standardized amounts are the same for discharges occurring on or after October 1, 1994, RRCs continue to receive special treatment under both the DSH payment adjustment and the criteria for geographic reclassification.

Section 402 of Pub. L. 108-173 raised the DSH adjustment for other rural hospitals with less than 500 beds and RRCs. Other rural hospitals with less than 500 beds are subject to a 12-percent cap on DSH payments. RRCs are not subject to the 12-percent cap on DSH payments that is applicable to other rural hospitals (with the exception of rural hospitals with 500 or more beds). RRCs are not subject to the proximity criteria when applying for geographic reclassification, and they do not have to meet the requirement that a hospital's average hourly wage must exceed 106 percent of the average hourly wage of the labor market area where the hospital is located.

Section 4202(b) of Pub. L. 105-33 states, in part, ``[a]ny hospital classified as an RRC by the Secretary * * * for fiscal year 1991 shall be classified as such an RRC for fiscal year 1998 and each subsequent year.'' In the August 29, 1997 final rule with comment period (62 FR 45999), we also reinstated RRC status for all hospitals that lost the status due to triennial review or MGCRB reclassification, but not to hospitals that lost RRC status because they were now urban for all purposes because of the OMB designation of their geographic area as urban. However, subsequently, in the August 1, 2000 final rule (65 FR 47089), we indicated that we were revisiting that decision. Specifically, we stated that we would permit hospitals that previously qualified as an RRC and lost their status due to OMB redesignation of the county in which they are located from rural to urban to be reinstated as an RRC. Otherwise, a hospital seeking RRC status must satisfy the applicable criteria. We used the definitions of ``urban'' and ``rural'' specified in Subpart D of 42 CFR Part 412.

1. Proposed Annual Update of RRC Status Criteria

One of the criteria under which a hospital may qualify as a RRC is to have 275 or more beds available for use (Sec. 412.96(b)(1)(ii)). A rural hospital that does not meet the bed size requirement can qualify as an RRC if the hospital meets two mandatory prerequisites (a minimum CMI and a minimum number of discharges) and at least one of three optional criteria (relating to specialty composition of medical staff, source of inpatients, or referral volume) (Sec. 412.96(c)(1) through (c)(5)). (See also the September 30, 1988 Federal Register (53 FR 38513).) With respect to the two mandatory prerequisites, a hospital may be classified as an RRC if--

The hospital's CMI is at least equal to the lower of the median CMI for urban hospitals in its census region, excluding hospitals with approved teaching programs, or the median CMI for all urban hospitals nationally; and

The hospital's number of discharges is at least 5,000 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, as specified in section 1886(d)(5)(C)(i) of the Act.) a. Case-Mix Index

Section 412.96(c)(1) provides that CMS will establish updated national and regional CMI values in each year's annual notice of prospective payment rates for purposes of determining RRC status. The methodology we use to determine the national and regional CMI values is set forth in regulations at Sec. 412.96(c)(1)(ii). The proposed national

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median CMI value for FY 2008 includes all urban hospitals nationwide, and the regional values for FY 2008 are the median CMI values of urban hospitals within each census region, excluding those hospitals with approved teaching programs (that is, those hospitals receiving indirect medical education payments as provided in Sec. 412.105(f)). These values are based on discharges occurring during FY 2006 (October 1, 2005 through September 30, 2006) and include bills posted to CMS' records through December 2006.

We are proposing that, in addition to meeting other criteria, if they are to qualify for initial RRC status for cost reporting periods beginning on or after October 1, 2007, rural hospitals with fewer than 275 beds must have a CMI value for FY 2006 that is at least--

1.2258; or

The median CMI value (not transfer-adjusted) for urban hospitals (excluding hospitals with approved teaching programs as identified in Sec. 412.105(f)) calculated by CMS for the census region in which the hospital is located.

The proposed median CMI values by region are set forth in the following table:

Case-mix index Region

value

1. New England (CT, ME, MA, NH, RI, VT)...............

1.2389 2. Middle Atlantic (PA, NJ, NY).......................

1.2675 3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)

1.3524 4. East North Central (IL, IN, MI, OH, WI)............

1.3499 5. East South Central (AL, KY, MS, TN)................

1.2909 6. West North Central (IA, KS, MN, MO, NE, ND, SD)....

1.2780 7. West South Central (AR, LA, OK, TX)................

1.4013 8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)..........

1.4260 9. Pacific (AK, CA, HI, OR, WA).......................

1.3722

The preceding numbers will be revised in the final rule to the extent required to reflect the updated FY 2006 MEDPAR file, which will contain data from additional bills received through March 2007.

Hospitals seeking to qualify as RRCs or those wishing to know how their CMI value compares to the criteria should obtain hospital- specific CMI values (not transfer-adjusted) from their fiscal intermediaries. Data are available on the Provider Statistical and Reimbursement (PS&R) System. In keeping with our policy on discharges, these CMI values are computed based on all Medicare patient discharges subject to the IPPS DRG-based payment. b. Discharges

Section 412.96(c)(2)(i) provides that CMS will set forth the national and regional numbers of discharges in each year's annual notice of prospective payment rates for purposes of determining RRC status. As specified in section 1886(d)(5)(C)(ii) of the Act, the national standard is set at 5,000 discharges. We are proposing to update the regional standards based on discharges for urban hospitals' cost reporting periods that began during FY 2004 (that is, October 1, 2003 through September 30, 2004), which is the latest available cost report data we have at this time.

Therefore, we are proposing that, in addition to meeting other criteria, a hospital, if it is to qualify for initial RRC status for cost reporting periods beginning on or after October 1, 2007, must have as the number of discharges for its cost reporting period that began during FY 2004 a figure that is at least--

5,000 (3,000 for an osteopathic hospital); or

The median number of discharges for urban hospitals in the census region in which the hospital is located, as indicated in the following table:

Number of Region

discharges

1. New England (CT, ME, MA, NH, RI, VT)...............

7,749 2. Middle Atlantic (PA, NJ, NY).......................

10,603 3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)

10,562 4. East North Central (IL, IN, MI, OH, WI)............

9,209 5. East South Central (AL, KY, MS, TN)................

7,596 6. West North Central (IA, KS, MN, MO, NE, ND, SD)....

7,963 7. West South Central (AR, LA, OK, TX)................

7,167 8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)..........

9,116 9. Pacific (AK, CA, HI, OR, WA).......................

8,420

These numbers will be revised in the FY 2008 IPPS final rule based on the latest available cost report data.

We note that the median number of discharges for hospitals in each census region is greater than the national standard of 5,000 discharges. Therefore, 5,000 discharges is the minimum criterion for all hospitals.

We reiterate that if an osteopathic hospital is to qualify for RRC status for cost reporting periods beginning on or after October 1, 2007, the hospital would be required to have at least 3,000 discharges for its cost reporting period that began during FY 2004. 2. Acquired Rural Status and RRCs (Sec. 412.103(g))

With the following exceptions, a hospital must be rural to qualify as an RRC:

Consistent with section 4202(b) of Pub. L. 105-33, any hospital designated as an RRC in FY 1991 retains that status for FY 1998 and each subsequent year.

Hospitals located in a rural county that would have lost their RRC status as a result of an OMB redesignation of the area from rural to urban were permitted to remain as RRCs (69 FR 49056).

Hospitals located in urban areas that apply for reclassification as rural under Sec. 412.103 (that is, the hospital is located in an urban area but it

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``acquires'' rural status under the regulations) also may qualify as RRCs.

Under Sec. 412.103(g), a hospital may cancel its rural reclassification by submitting a written request to the CMS Regional Office no less than 120 days prior to the end of its current cost reporting period. A hospital may choose to cancel its acquired rural status if it determines it may be more financially beneficial to return to urban status and the associated IPPS payments rather than remain rural and receive the special treatments of certain rural providers such as RRCs, SCHs and CAHs. The hospital's acquired rural status is canceled beginning with its next cost reporting period. We have received inquiries asking whether a hospital retains its RRC status once it voluntarily cancels its acquired rural status.

As indicated above, a hospital generally must be rural to be classified as an RRC. However, a hospital may retain its RRC status only in the special circumstances where it would have lost status due to OMB redesignation of its area from rural to urban, or where it was already designated as an RRC in 1991. In these situations, there were either special statutory provisions that require the hospital to retain its RRC status or the hospital's geographic status changed from rural to urban through no action of its own. We do not believe that an urban hospital that acquires rural status under Sec. 412.103 and subsequently is approved as an RRC should be able to retain the benefits of being an RRC when it voluntarily cancels that acquired rural status. For this reason, Medicare's policy has been that a hospital cannot continue to be an RRC once it cancels acquired rural status under Sec. 412.103. It follows from the requirement that an RRC must be located in a rural area that cancellation of acquired rural status negates a hospital's RRC designation.

In this proposed rule, we are clarifying our current policy that a hospital that cancels its acquired rural status, received under Sec. 412.103, would also lose its RRC designation under Sec. 412.96. In this situation, the hospital would lose its RRC designation under Sec. 412.96 as of the date the cancellation of its acquired rural status takes effect. As indicated above, RRCs are not subject to a maximum DSH adjustment of 12 percent that applies to other rural hospitals with less than 500 beds. Further, RRCs are not subject to the proximity criteria when applying for geographic reclassification (Sec. 412.230(a)(3)), and they do not have to meet certain wage comparison tests for reclassification (Sec. 412.230(d)(1)(iii)). A hospital located in an urban area that cancels its acquired rural status under Sec. 412.103 loses its RRC status and would become subject to a 12- percent cap on the DSH adjustment applicable to urban hospitals with less than 100 beds (if the hospital has 100 beds or more, it would not be subject to the cap on the DSH adjustment). Further, the hospital would also have to meet the proximity requirement for geographic reclassification at Sec. 412.230(a)(3).

We note that the hospital would maintain the benefit of being exempt from the average hourly wage criterion for geographic reclassification requiring the comparison of the hospital's wages to the wages of the area in which it is located, as stated in section 1886(d)(10)(D)(iii) of the Act.

We are also proposing to revise the regulations at Sec. 412.103(g) with respect to when cancellation of acquired rural status becomes effective. Currently, Sec. 412.103(g)(2) states ``The hospital's cancellation of the classification is effective beginning with the hospital's next full cost reporting period following the date of its request for cancellation.'' While this policy is appropriate for hospitals paid under reasonable costs, such as CAHs, it is inconsistent with the IPPS that makes changes prospectively on the basis of a Federal fiscal year. In addition, to address concerns that some IPPS hospitals are acquiring rural status solely to benefit from reclassification rules applying to hospitals that were once RRCs and then canceling that rural status within a short period of time, such as a few months, we are proposing to require IPPS hospitals to retain acquired rural status for at least one 12-month cost reporting period. If the hospital chooses to cancel its rural reclassification, the effective date of that cancellation would occur both after at least one 12-month cost reporting period and at the start of the next Federal fiscal year. Thus, for example, if a hospital with a cost reporting period from July 1, 2008, to June 30, 2009, becomes rural on May 30, 2008, its acquired rural status under Sec. 412.103 would remain in effect from May 30, 2008, through at least September 30, 2009 (that is, the date it acquired rural status through the end of the fiscal year containing a full cost reporting period). We believe this policy is reasonable, given that acquired rural status for IPPS hospitals should be a considered decision for hospitals that truly wish to be considered as rural, and not purely as a mechanism for reclassifying. We are not proposing a duration requirement for hospitals paid under cost reimbursement because we are not aware of similar manipulations of rural status in these cases. Therefore, we are proposing to change our current policy by revising Sec. 412.103(g) to specify that a hospital's cancellation of its acquired rural status under Sec. 412.103 is effective for hospitals under reasonable cost reimbursement (such as CAHs) with the hospital's next cost reporting period and for hospitals under the IPPS after at least one 12-month cost reporting period as rural and not until the beginning of a Federal fiscal year following both the request for cancellation and the 12-month cost reporting period. Under the proposed revised regulations, an IPPS hospital (such as an RRC or SCH) that cancels its acquired rural status would continue to be paid as rural until the beginning of the next fiscal year after at least one 12-month cost reporting period as rural. In addition, for these IPPS hospitals, the deadline for seeking cancellation of the acquired rural status would be not less than 120 days before the end of the fiscal year.

D. Indirect Medical Education (IME) Adjustment (Sec. 412.105)

(If you choose to comment on issues in this section, please include the caption ``IME Adjustment'' at the beginning of your comment.) 1. Background

Section 1886(d)(5)(B) of the Act provides that prospective payment hospitals that have residents in an approved graduate medical education (GME) program receive an additional payment to reflect the higher indirect patient care costs of teaching hospitals relative to nonteaching hospitals. The regulations regarding the calculation of this additional payment, known as the indirect medical education (IME) adjustment, are located at Sec. 412.105.

The Balanced Budget Act of 1997 (Pub. L. 105-33) established a limit on the number of allopathic and osteopathic residents that a hospital may include in its full-time equivalent (FTE) resident count for direct GME and IME payment purposes. Under section 1886(h)(4)(F) of the Act, a hospital's unweighted FTE count of residents may not exceed the hospital's unweighted FTE count for its most recent cost reporting period ending on or before December 31, 1996. Under section 1886(d)(5)(B)(v) of the Act, the limit on the FTE resident count for IME purposes is effective for discharges occurring on or after October 1, 1997. A similar limit is effective for direct GME purposes for cost reporting periods beginning on or after October 1, 1997. 2. IME Adjustment Factor for FY 2008

The IME adjustment to the DRG payment is based in part on the

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applicable IME adjustment factor. The IME adjustment factor is calculated using a hospital's ratio of residents to beds, which is represented as r, and a formula multiplier, which is represented as c, in the following equation: c x [{1 + r{time} .405-1]. The formula is traditionally described in terms of a certain percentage increase in payment for every 10-percent increase in the resident-to- bed ratio.

Section 502(a) of Pub. L. 108-173 modified the formula multiplier (c) to be used in the calculation of the IME adjustment. Prior to the enactment of Pub. L. 108-173, the formula multiplier was fixed at 1.35 for discharges occurring during FY 2003 and thereafter. Section 502(a) modified the formula multiplier beginning midway through FY 2004 and provided for a new schedule of formula multipliers for FY 2005 and thereafter. In the FY 2005 IPPS rule, we announced the schedule of formula multipliers to be used in the calculation of the IME adjustment and incorporated the schedule in our regulations at Sec. 412.105(d)(3)(viii) through (d)(3)(xii). In this proposed rule, we are specifying that, for any discharges occurring during FY 2008, the statutorily mandated formula multiplier is 1.35. Previously, for discharges occurring during FY 2007, the mandated formula multiplier was 1.32. We estimate that application of the mandated formula multiplier for FY 2008 will result in an increase of 5.5 percent in IME payment for every approximately 10-percent increase in the resident-to- bed ratio. 3. Time Spent by Residents on Vacation or Sick Leave and in Orientation a. Background

In the FY 2007 IPPS final rule (71 FR 48080), we clarified our policy with respect to the time that residents spend in nonpatient care activities (such as conferences and seminars) as part of approved residency programs. We amended our regulations concerning the FTE resident count at 42 CFR 412.105(f)(1)(iii)(C) to state, ``In order to be counted, a resident must be spending time in patient care activities, as defined in Sec. 413.75(b) * * *'' The regulations at Sec. 413.75(b) define patient care activities as ``the care and treatment of particular patients, including services for which a physician or other practitioner may bill.'' In light of this clarification, during the past year, we have received questions from the teaching hospital community as to whether the time that residents spend on vacation or sick leave, and in orientation activities that typically occur at the beginning of a residency training program, is counted for IME payment purposes.

Historically, time spent by residents on vacation or sick leave and in initial orientation activities has been included in the FTE resident count for IME and direct GME. (The sick leave we are referring to throughout this discussion is sick leave that does not require the resident to make up for his or her absence by adding additional training time at the end of the program.) The practice of allowing vacation and sick leave to be included in the IME count appears to be based on a provision in the Provider Reimbursement Manual, Part I, at section 2405.3.H.2. This manual provision discusses the treatment of residents who are on vacation or sick leave in the context of our prior ``one day count'' policy for counting residents for IME payment. Generally, effective with cost reporting periods beginning on or after October 1, 1984, and before July 1, 1991, residents were counted for IME purposes on a uniform reporting date of September 1. A hospital's FTE residents were counted based on their assignment to that hospital's IPPS or outpatient areas on September 1 of an academic year. Because it was possible that a resident might not actually be present in the hospital on September 1 because he or she was on approved vacation or sick leave, to ensure that the hospital's IME FTE count would not be understated for the entire year, section 2405.3.H.2 of the PRM-I states that ``interns and residents using vacation and sick leave on the day of the count may be included in the count.'' Although the regulations were changed effective for cost reporting periods beginning on or after July 1, 1991 (55 FR 36059) to reflect the current resident-counting methodology (that is, to count the number of FTE residents based on the amount of time required to fill a residency slot as specified at Sec. 412.105(f)(1)(iii)(A)), the fiscal intermediary (or MAC) have continued to include time spent by residents on vacation and sick leave in the FTE resident counts for purposes of both IME and direct GME payments.

Orientation time is time spent by residents in activities that typically take place at the beginning of a resident's training program, and include orientation regarding hospital employment, the hospital's policies and procedures in general, as well as policies and procedures specific to the residency training program. As is the case for vacation and sick leave, time spent by residents in orientation has continued to be included by intermediaries/MACs in the FTE resident counts for purposes of both IME and direct GME.

We understand why we have received numerous questions regarding whether FTE resident time spent on vacation or sick leave, or in orientation activities, should be counted for purposes of IME payment. The time a resident spends on vacation or sick leave is not addressed within the current definition of ``patient care activities'' at Sec. 413.75(b). In fact, time spent on vacation or sick leave would not be spent at the hospital location at all, so no patient care activities would occur during this time. Time spent in orientation might be spent in the hospital complex (or at a nonhospital setting), but would not involve the care and treatment of particular patients. Thus, although time spent by residents on vacation or sick leave or in orientation has historically been included in the IME and direct GME FTE counts, it seems apparent that this time should be carefully considered in light of our clarified policy and current regulations. We believe these types of activities (vacation time, sick leave, and orientation) are inherently different from the types of ``patient care activities'' and ``nonpatient care activities'' we have discussed in depth in previous rules, and most recently in the FY 2007 IPPS final rule. We believe the aforementioned activities should be distinguished from other activities, patient care or otherwise, in which the resident participates as part of the approved program. b. Vacation and Sick Leave Time

We believe that approved vacation time and sick leave are not appropriately categorized as patient care activities, or as didactic, research, or other nonpatient care activities. In addition, although the Accreditation Council for Graduate Medical Education (ACGME) has some rules regarding resident duty hours and work environment, the ACGME is not explicit regarding resident vacation and sick leave policies. Rather, vacation and sick leave policies are determined by the resident's employer and can vary by residency training program. Consequently, although vacation and sick leave are fringe benefits to which every employee, hospital or otherwise, is typically entitled, vacation and sick leave are not, in fact, part of the training time spent by residents in an approved program. Therefore, we believe vacation and sick leave are not properly considered as either patient care time or nonpatient care time, but are within a distinct third category of time. As we noted above, it has been our policy to include the time spent by residents on

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vacation or sick leave in the FTE resident count for IME and direct GME. However, we do not believe the continuation of this policy is appropriate in light of our current policy as clarified in the FY 2007 IPPS final rule and expressed in revised regulations that permit only time spent by residents in patient care activities to be counted for purposes of IME. We initially considered proposing a policy to no longer count the time spent by residents on vacation or sick leave for purposes of IME on the ground that this time is not spent in patient care activities in accordance with our regulations. However, we do not believe such a policy would have recognized the unique character of vacation and sick time as time that is not spent in any aspect of residency training--patient care or nonpatient care. Because we believe time spent by residents on vacation and sick leave is not properly considered patient care time or nonpatient care time, but fit within a distinct third category of time that is neither patient care nor nonpatient care, we believe it would be more appropriate to remove the time altogether from the FTE calculation for each resident for both IME and direct GME payment purposes. Accordingly, we are proposing to remove vacation and sick leave from the total time considered to constitute an FTE resident for purposes of IME payment effective for cost reporting periods beginning on or after October 1, 2007. Further, in order to have a consistent conception of an FTE resident for purposes of IME and direct GME payment, we are proposing to remove vacation and sick leave from the total FTE resident time for purposes of direct GME payment as well effective for cost reporting periods beginning on or after October 1, 2007. We acknowledge that removing vacation and sick leave time from the denominator of the FTE count for both IME and direct GME could have some impact on the FTE count, but the impact is fact-specific. In some cases, it would result in a lower FTE count, and in some cases, it would result in a higher FTE count. In addition, we note that under our current policy, residents who are on maternity leave or other approved sick leave of extended duration that prolongs the total time a resident is participating in the approved program beyond the normal duration of the program are not counted while they are out on extended sick or maternity leave. This is because the FTE time spent by such residents is counted in accordance with our FTE counting policies during the training time they spend to make up for their absence. For example, a resident in an internal medicine program who takes 3 months of approved maternity leave and, therefore, must stay an additional 3 months beyond the normal 3 years to complete her training, would not be counted while she is on maternity leave for IME and direct GME payment purposes. Rather, time spent during the additional 3 months of training in which she must participate to make up for her 3 month absence will be counted in accordance with our FTE- counting policies for IME and direct GME. We are not proposing to change our policy with respect to time spent by residents on maternity leave or other approved sick leave of extended duration. c. Orientation Activities

As discussed above, we believe that orientation activities in which residents participate, often prior to the start of their residency training program, are also distinct from the typical ``patient care'' and ``nonpatient care'' activities in which residents participate as part of their training program. For example, before residents begin training in an approved residency program, the hospital (or in many cases, the medical school as the employer of the residents) is required to provide orientation for their residents. Most of these orientation activities involve neither patient care nor the typical didactic or research activities that comprise the residency training program. Instead, such orientation consists of basic informational sessions in which all new employees, residents and other staff, must participate at the beginning of employment. There could also be other orientation activities designed specifically to prepare residents to furnish patient care in a particular setting or to participate in a particular approved residency training program. We recognize that certain portions of orientation activities are specific to residents in particular approved programs and are required by the accrediting organizations. Other components of orientation relate to employment and are common to all employees. Still other components of orientation may involve training regarding particular hospital policies and procedures, some of which would relate to patient care and safety. In many ways, these orientation activities resemble ``didactic'' activities. However, we believe there are important differences between the ``didactic'' activities that are part of orientation and the other conferences and seminars in which the residents engage throughout the course of their training. That is, we do not envision orientation activities as including scholarly didactic activities such as conferences or seminars that may occur throughout a residency training program. Rather, we believe orientation activities would occur either at the beginning of a particular specialty program, or when a resident goes to another facility for training. In orientation sessions, much of the information being imparted to the residents is essential knowledge for the residents in order to furnish patient care services in a particular hospital facility or approved program. Thus, the information furnished during orientation is not information that merely enhances the resident's patient care delivery knowledge and skills during the residency program, but it is a necessary prerequisite for the residents as they commence (or continue) their training program and is often required as a term of employment. Because we recognize the distinct character of orientation activities as essential to the provision of patient care by residents, and the fundamental differences between orientation and the typical didactic activities in which a resident may participate throughout a residency training program, we are proposing to continue to count the time spent by residents in orientation activities, whether they occur in the hospital or nonhospital setting, and are proposing to amend our regulations accordingly. (We note that orientation activities in the hospital setting have historically been counted for direct GME payment purposes in accordance with the regulations at Sec. 413.78(a) which state ``Residents in an approved program working in all areas of the hospital complex may be counted.'') We are proposing to amend Sec. 413.75(b) to add a definition of the term ``orientation activities,'' to mean ``activities that are principally designed to prepare an individual for employment as a resident in a particular setting, or for participation in a particular specialty program and patient care activities associated with that particular specialty program.'' We understand that orientation activities typically occur at the beginning of a resident's first program year. However, we are interested in hearing from commenters on whether orientation activities typically occur during other times during an approved residency training program. We are proposing to amend the definition of ``patient care activities'' at Sec. 413.75(b) as follows: ``the care and treatment of particular patients, including services for which a physician or other practitioner may bill, and

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orientation activities as defined at Sec. 413.75(b).'' In addition, we are proposing to amend the regulations at Sec. Sec. 412.105(f)(1)(iii)(A) and 413.78(b) to specify that ``Vacation and sick leave are not included in the determination of full-time equivalency.'' d. Proposed Regulation Changes

In summary, we are proposing, for cost reporting periods beginning on or after October, 1, 2007, for direct GME and IME, that time spent by residents on vacation or sick leave would not be included in the determination of what constitutes an FTE resident (or would be removed from both the numerator and denominator of the FTE count) for both IME and direct GME payment purposes. In addition, we are proposing to continue to count time spent by residents in orientation activities for both IME and direct GME payment purposes. We are proposing to amend the regulations at Sec. Sec. 412.105(f)(1)(iii)(A) and 413.78(b). Lastly, we are proposing to amend Sec. 413.75(b) to include the definition of the term ``orientation activities'' and to amend the definition of ``patient care activities'' to add ``orientation activities.''

E. Hospital Emergency Services Under EMTALA (Sec. 489.24)

(If you choose to comment on issues in this section, please include the caption ``EMTALA'' at the beginning of your comments.) 1. Background

Sections 1866(a)(1)(I), 1866(a)(1)(N), and 1867 of the Act impose specific obligations on certain Medicare-participating hospitals and CAHs. (Throughout this section of this proposed rule, when we reference the obligation of a ``hospital'' under these sections of the Act and in our regulations, we mean to include CAHs as well.) These obligations concern individuals who come to a hospital emergency department and request examination or treatment for medical conditions, and apply to all of these individuals, regardless of whether they are beneficiaries of any program under the Act.

The statutory provisions cited above are frequently referred to as the Emergency Medical Treatment and Labor Act (EMTALA), also known as the patient antidumping statute. EMTALA was passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), Pub. L. 99-272. Congress enacted these antidumping provisions in the Social Security Act to ensure that individuals with emergency medical conditions are not denied essential lifesaving services because of a perceived inability to pay.

Under section 1866(a)(1)(I)(i) of the Act, a hospital that fails to fulfill its EMTALA obligations under these provisions may be liable for termination of its Medicare provider agreement, which would result in loss of all Medicare and Medicaid payments.

Section 1867 of the Act sets forth requirements for medical screening examinations for individuals who come to the hospital and request examination or treatment for a medical condition. The section further provides that if a hospital finds that such an individual has an emergency condition, it is obligated to provide that individual with either necessary stabilizing treatment or an appropriate transfer to another medical facility where stabilization can occur.

The EMTALA statute also outlines the obligation of hospitals to receive appropriate transfers from other hospitals. Section 1867(g) of the Act states that a participating hospital that has specialized capabilities or facilities (such as burn units, shock-trauma units, neonatal intensive care units or (with respect to rural areas) regional referral centers as identified by the Secretary in regulation) shall not refuse to accept an appropriate transfer of an individual who requires these specialized capabilities or facilities if the hospital has the capacity to treat the individual.

The regulations implementing section 1867 of the Act are found at 42 CFR 489.24. 2. Recent Legislation Affecting EMTALA Implementation a. Secretary's Authority To Waive Requirements During National Emergencies

Section 1135 of the Act authorizes the Secretary to temporarily waive or modify the application of several requirements of titles XVIII, XIX, or XXI of the Act (the Medicare, Medicaid, and State Children's Health Insurance Program provisions) and their implementing regulations in an emergency area during an emergency period. Section 1135(g)(1) of the Act defines an ``emergency area'' as the geographical area in which there exists an emergency or disaster declared by the President pursuant to the National Emergencies Act or the Robert T. Stafford Disaster Relief and Emergency Assistance Act (subsection A) and a public health emergency declared by the Secretary pursuant to section 247d of Title 42 of the United States Code. Section 1135(g)(1) of the Act also defines an ``emergency period'' as the period during which such a disaster exists.

Section 1135(b) of the Act lists the actions for which the otherwise applicable statutory provisions and implementing regulations may be waived. Included among these actions are, in subparagraph (b)(3)(A), a transfer of an individual who has not been stabilized in violation of the EMTALA requirements restricting transfer until an individual has been stabilized (section 1867(c) of the Act) and, in subparagraph (b)(3)(B), the direction or relocation of an individual to receive medical screening in an alternate location, in accordance with an appropriate State emergency preparedness plan.

Section 1135(b) of the Act further states that a waiver or modification provided for under section 1135(b)(3) of the Act shall be limited to a 72-hour period beginning upon implementation of a hospital disaster protocol. All other waivers arising out of section 1135(b) of the Act (except for section 1135(b)(7)) ordinarily may continue in effect for the duration of the declaration of emergency or disaster, or the declaration of a public health emergency, or for 60-day periods as described in section 1135(e)(1) of the Act.

To take into account the effect of section 1135 waivers on the EMTALA requirements, Sec. 489.24(a)(2) of our regulations specifies that sanctions under the EMTALA regulations for inappropriate transfer during a national emergency do not apply to a hospital with a dedicated emergency department located in an emergency area, as specified in section 1135(g)(1) of the Act.

For further information about section 1135 of the Act and its applicability, we refer readers to the CMS Web site: http://www.cms.hhs.gov/Emergency/02_Hurricanes.asp .

b. Provisions of the Pandemic and All-Hazards Preparedness Act

As noted above, section 1135(b)(3) of the Act authorizes the Secretary to waive sanctions for either the transfer of an unstabilized individual in violation of the requirements of section 1867(c) of the Act where such transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period or the direction or relocation of an individual to receive medical screening in an

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alternate location in accordance with an appropriate State emergency preparedness plan. Section 302(b)(1)(A) of Pub. L. 109-417 amended section 1135(b)(3)(B) of the Act to state that sanctions for the direction or relocation of an individual for screening may be waived where, in the case of a public health emergency that involves a pandemic infectious disease, that direction or relocation occurs pursuant to a State pandemic preparedness plan or to an appropriate State emergency preparedness plan. In addition, sections 302(b)(1)(B) and (b)(1)(C) of Pub. L. 109-417 amended section 1135(b) of the Act to state that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the duration of a waiver or modification for such emergency shall be determined in accordance with section 1135(e) of the Act as that subsection applies to public health emergencies. The amendments to section 1135(b) of the Act made by section 302(b) of Pub. L. 109-417 are effective as of the date of enactment of that legislation (December 19, 2006) and apply to public health emergencies declared pursuant to section 247(d) of Title 42 of the United States Code. c. Proposed Revisions to the EMTALA Regulations

Currently, the EMTALA regulation at 42 CFR 489.24(a)(2) specifies that sanctions under this section (Sec. 489.24) for inappropriate transfer during a national emergency do not apply to a hospital with a dedicated emergency department located in an emergency area, as specified in section 1135(g)(1) of the Act. To implement the changes made by section 302(b) of Pub. L. 109-417 and to ensure that our regulations accurately reflect section 1135 of the Act, we are proposing to make two changes to paragraph (a)(2) of Sec. 489.24. First, we would specify that the sanctions that do not apply are those for either the inappropriate transfer of an individual who has not been stabilized or those for the direction or relocation of an individual to receive medical screening at an alternate location. We also are proposing to revise Sec. 489.24 by adding a second sentence to paragraph (a)(2) to state that a waiver of these sanctions for EMTALA violations is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the duration of the waiver will be determined in accordance with subsection (e) of section 1135 of the Act as that subsection applies to public health emergencies. This proposed change would clarify that, in the case of public health emergencies involving pandemic infectious diseases, the waiver of EMTALA sanctions is not limited to 72 hours, but will remain in effect until the termination of the applicable declaration of a public health emergency as described in section 1135(e)(1)(B) of the Act.

F. Disclosure of Physician Ownership in Hospitals and Patient Safety Measures

1. Disclosure of Physician Ownership in Hospitals

(If you choose to comment on issues in this section, please include the caption ``Physician Ownership in Hospitals'' at the beginning of your comment.)

Section 1866 of the Act states that any provider of services (except a fund designated for purposes of section 1814(g) and section 1835(e) of the Act) shall be qualified to participate in the Medicare program and shall be eligible for Medicare payments if it files a Medicare provider agreement and abides by the requirements applicable to Medicare provider agreements. These requirements are incorporated into our regulations in 42 CFR part 489, subparts A and B (Provider Agreements and Supplier Approval). Section 1861(e) of the Act defines the term ``hospital.'' Section 1861(e)(9) of the Act defines a hospital and authorizes the Secretary to establish requirements as he finds necessary in the interest of patient health and safety. Section 1820(e)(3) of the Act authorizes the Secretary to establish criteria necessary for an institution to be certified as a critical access hospital.

Section 5006 of Pub. L. 109-171 (DRA) required the Secretary to develop a ``strategic and implementing plan'' to address certain issues related to physician investment in ``specialty hospitals.'' In the strategic and implementing plan included in our ``Final Report to the Congress and Strategic and Implementing Plan Required under Section 5006 of the Deficit Reduction Act of 2005'' issued on August 8, 2006 (page 69), available on our Web site at: http://www.cms.hhs.gov/PhysicianSelfReferral/06a_DRA_Reports.asp (hereinafter referred to as

the ``DRA Report to Congress''), we stated that our plan for addressing issues related to physician investment in specialty hospitals involved promoting transparency of investment. Consistent with that approach, we stated that we would adopt a disclosure requirement that would require hospitals to disclose to patients whether they are physician-owned, and if so, disclose the names of the physician owners. Accordingly, we are proposing changes to regulations governing Medicare provider agreements to effectuate this change, under our authority at sections 1861(e)(9), 1820(e) and 1866 of the Act and under our rulemaking authority at sections 1871 and 1102 of the Act. We are seeking comment as to whether these changes best effectuated through changes to the Medicare provider agreement regulations or whether it would be more appropriate to include these changes in the conditions of participation requirements applicable to hospitals and critical access hospitals.

Specifically, we are proposing to amend Sec. 489.3 to define a ``physician-owned hospital'' as any participating hospital (as defined in Sec. 489.24) in which a physician or physicians have an ownership or investment interest. We solicit comments on whether, for purposes of the ownership disclosure requirements only, the definition of ``physician-owned hospital'' should exclude certain physician ownership or investment interests based on the nature of the interest or the relative size of the interest or the entity's assets (for example, whether the interest would satisfy the exception at Sec. 4111.356(a) for physician ownership or investment interest in public-traded securities and mutual funds).

We are proposing to add a new provision at Sec. 489.20(u)(1) to require that patients be given written notice that a hospital is physician-owned and that the list of physician owners is available upon request. We are proposing to require that the notice, in a manner reasonably designed to be understood by all patients, disclose the fact that the hospital meets the Federal definition of a ``physician-owned hospital'' and that patients will be provided the list of the hospital's physician owners upon request. In addition, we are proposing to add a new provision at Sec. 489.20(u)(2) which will require hospitals to require that all physician owners who are also members of the hospital's medical staff disclose, in writing, their ownership interest in the hospital to all patients they refer to the hospital, as a condition of continued medical staff membership. Patient disclosure would be required at the time a physician makes a referral. We believe that these provisions are in the interest of the health and safety of individuals who are furnished services in these institutions. This notice requirement will permit individuals to make more informed decisions regarding their treatment and to

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evaluate whether the existence of a financial relationship, in the form of an ownership interest, suggests a conflict of interest that is not in their best interest.

In order to enforce these proposed requirements, we are proposing to amend Sec. 489.12 to deny a provider agreement to a hospital that does not have procedures in place to notify patients of physician ownership in the hospital. In addition, we are proposing to amend Sec. 489.53 to permit CMS to terminate a provider agreement with a physician-owned hospital if the hospital fails to comply with the requirements of Sec. 489.20(u). 2. Patient Safety Measures

(If you choose to comment on issues in this section, please include the caption ``Patient Safety Measures'' at the beginning of your comment.)

In the DRA Report to Congress (page 67), we stated that it was appropriate to issue further guidance on what we expect of all hospitals with respect to the appraisal, initial treatment, and referral, when appropriate, of patients with medical emergencies. The Medicare hospital conditions of participation regulations at 42 CFR part 482 impose requirements on hospitals that have emergency departments, as well as requirements on hospitals without emergency departments. We believe that hospitals should be required to disclose to patients at the time of inpatient admission or registration for an outpatient service information concerning whether a physician is available on the premises 24 hours a days, 7 days a week. Under the authority at sections 1861(e)(9), 1820(e)(3), 1866, 1871, and 1102 of the Act (described previously), we are proposing to add a new provision at Sec. 489.20(v)(1) to require that hospitals furnish all patients notice at the beginning of their hospital stay or outpatient service if a doctor of medicine or a doctor of osteopathy is not present in the hospital 24 hours per day, 7 days a week, and to describe how the hospital will meet the medical needs of any patient who develops an emergency medical condition, at a time when no physician is present in the hospital. We are seeking comment as to whether this change best effectuated through changes to the Medicare provider agreement regulations or whether it would be more appropriate to include this change in the conditions of participation requirements applicable to hospitals and critical access hospitals.

It has also come to our attention that some hospitals have called 9-1-1 when a patient has gone into respiratory arrest, a physician has not been on the premises, and the onsite clinical personnel have lacked the requisite equipment or training to provide the required assessment, initial treatment, and referral that are required of all hospitals. In some cases, required interventions to initiate emergency treatment may be outside the scope of practice of the clinical personnel onsite. This has occurred even in hospitals that operate emergency departments. Therefore, in this proposed rule, we are soliciting comments on whether current requirements for emergency service capability in hospitals with or without emergency departments should be strengthened in certain areas. Specifically, we are seeking feedback on whether present regulatory provisions should be expanded with respect to the type of clinical personnel that must be present at all times in hospitals with and without emergency departments; the competencies that such personnel must demonstrate, such as training in Advanced Cardiac Life Support, or successful completion of specified professional training programs; the type of emergency response equipment that must be available and the manner in which it must be available, such as in each emergency department, or inpatient unit, among others; and whether emergency departments must be operated 24 hours/day, 7 days a week. After evaluating the comments we receive, we will consider whether we should amend the Medicare hospital conditions of participation related to provision of emergency services in hospitals with and without emergency departments.

G. Rural Community Hospital Demonstration Program

(If you choose to comment on issues in this section, please include the caption ``Rural Community Hospital Demonstration'' at the beginning of your comments.)

In accordance with the requirements of section 410A(a) of Pub. L. 108-173, the Secretary has established a 5-year demonstration program (beginning with selected hospitals' first cost reporting period beginning on or after October 1, 2004) to test the feasibility and advisability of establishing ``rural community hospitals'' for Medicare payment purposes for covered inpatient hospital services furnished to Medicare beneficiaries. A rural community hospital, as defined in section 410A(f)(1), is a hospital that--

Is located in a rural area (as defined in section 1886(d)(2)(D) of the Act) or is treated as being located in a rural area under section 1886(d)(8)(E) of the Act;

Has fewer than 51 beds (excluding beds in a distinct part psychiatric or rehabilitation unit) as reported in its most recent cost report;

Provides 24-hour emergency care services; and

Is not designated or eligible for designation as a CAH.

As we indicated in the FY 2005 IPPS final rule (69 FR 49078), in accordance with sections 410A(a)(2) and (a)(4) of Pub. L. 108-173 and using 2002 data from the U.S. Census Bureau, we identified 10 States with the lowest population density from which to select hospitals: Alaska, Idaho, Montana, Nebraska, Nevada, New Mexico, North Dakota, South Dakota, Utah, and Wyoming (Source: U.S. Census Bureau Statistical Abstract of the United States: 2003). Nine rural community hospitals located within these States are currently participating in the demonstration program for FY 2008. (Of the 13 hospitals that participated in the first 2 years of the demonstration program, 4 hospitals located in Nebraska have withdrawn from the program; they have become CAHs.)

Under the demonstration program, participating hospitals are paid the reasonable costs of providing covered inpatient hospital services (other than services furnished by a psychiatric or rehabilitation unit of a hospital that is a distinct part), applicable for discharges occurring in the first cost reporting period beginning on or after the October 1, 2004, implementation date of the demonstration program. Payments to the participating hospitals will be the lesser amount of the reasonable cost or a target amount in subsequent cost reporting periods. The target amount in the second cost reporting period is defined as the reasonable costs of providing covered inpatient hospital services in the first cost reporting period, increased by the inpatient prospective payment update factor (as defined in section 1886(b)(3)(B) of the Act) for that particular cost reporting period. The target amount in subsequent cost reporting periods is defined as the preceding cost reporting period's target amount, increased by the inpatient prospective payment update factor (as defined in section 1886(b)(3)(B) of the Act) for that particular cost reporting period.

Covered inpatient hospital services are inpatient hospital services (defined in section 1861(b) of the Act), and include extended care services furnished under an agreement under section 1883 of the Act.

Section 410A of Pub. L. 108-173 requires that ``in conducting the

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demonstration program under this section, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration program under this section was not implemented.'' Generally, when CMS implements a demonstration program on a budget neutral basis, the demonstration program is budget neutral in its own terms; in other words, the aggregate payments to the participating providers do not exceed the amount that would be paid to those same providers in the absence of the demonstration program. This form of budget neutrality is viable when, by changing payments or aligning incentives to improve overall efficiency, or both, a demonstration program may reduce the use of some services or eliminate the need for others, resulting in reduced expenditures for the demonstration program's participants. These reduced expenditures offset increased payments elsewhere under the demonstration program, thus ensuring that the demonstration program as a whole is budget neutral or yields savings. However, the small scale of this demonstration program, in conjunction with the payment methodology, makes it extremely unlikely that this demonstration program could be viable under the usual form of budget neutrality. Specifically, cost-based payments to the nine participating small rural hospitals are likely to increase Medicare outlays without producing any offsetting reduction in Medicare expenditures elsewhere. Therefore, a rural community hospital's participation in this demonstration program is unlikely to yield benefits to the participant if budget neutrality were to be implemented by reducing other payments for these providers.

In order to achieve budget neutrality for this demonstration program for FY 2008, we are proposing to adjust the national inpatient PPS rates by an amount sufficient to account for the added costs of this demonstration program. We are proposing to apply budget neutrality across the payment system as a whole rather than merely across the participants in this demonstration program. As we discussed in the FY 2005, FY 2006, and FY 2007 IPPS final rules (69 FR 49183; 70 FR 47462; and 71 FR 48100), we believe that the language of the statutory budget neutrality requirements permits the agency to implement the budget neutrality provision in this manner. For FY 2008, using cost report data for FY 2003, adjusted to account for the increased estimated costs for the remaining nine participating hospitals, we estimate that the adjusted amount would be $9,681,893. This proposed estimated adjusted amount reflects the estimated difference between the participating hospitals' costs and the IPPS payment based on data from the hospitals' cost reports. We discuss the proposed payment rate adjustment that would be required to ensure the budget neutrality of the demonstration program for FY 2008 in section II.A.4. of the Addendum to this proposed rule.

V. Proposed Changes to the IPPS for Capital-Related Costs

(If you choose to comment on issues in this section, please include the caption ``Capital IPPS'' at the beginning of your comment.)

A. Background

Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of inpatient acute hospital services ``in accordance with a prospective payment system established by the Secretary.'' Under the statute, the Secretary has broad authority in establishing and implementing the IPPS for acute care hospital inpatient capital-related costs. We initially implemented the IPPS for capital-related costs in the August 30, 1991 IPPS final rule (56 FR 43358), in which we established a 10-year transition period to change the payment methodology for Medicare hospital inpatient capital-related costs from a reasonable cost-based methodology to a prospective methodology (based fully on the Federal rate).

Federal fiscal year (FFY) 2001 was the last year of the 10-year transition period established to phase in the IPPS for hospital inpatient capital-related costs. For cost reporting periods beginning in FY 2002, capital IPPS payments are based solely on the Federal rate for most acute care hospitals (other than certain new hospitals and hospitals receiving certain exception payments). The basic methodology for determining capital prospective payments using the Federal rate is set forth in Sec. 412.312. For the purpose of calculating payments for each discharge, the standard Federal rate is adjusted as follows:

(Standard Federal Rate) x (DRG Weight) x (Geographic Adjustment Factor (GAF)) x (Large Urban Add-on, if applicable) x (COLA for hospitals located in Alaska and Hawaii) x (1 + Capital DSH Adjustment Factor + Capital IME Adjustment Factor, if applicable).

Hospitals also may receive outlier payments for those cases that qualify under the threshold established for each fiscal year as specified in Sec. 412.312(c) of the regulations.

The regulations at Sec. 412.348(f) provide that a hospital may request an additional payment if the hospital incurs unanticipated capital expenditures in excess of $5 million due to extraordinary circumstances beyond the hospital's control. This policy was originally established for hospitals during the 10-year transition period, but as we discussed in the August 1, 2002 IPPS final rule (67 FR 50102), we revised the regulations at Sec. 412.312 to specify that payments for extraordinary circumstances are also made for cost reporting periods after the transition period (that is, cost reporting periods beginning on or after October 1, 2001). Additional information on the exception payment for extraordinary circumstances in Sec. 412.348(f) can be found in the FY 2005 IPPS final rule (69 FR 49185 and 49186).

During the transition period, under Sec. Sec. 412.348(b) through (e), eligible hospitals could receive regular exception payments. These exception payments guaranteed a hospital a minimum payment percentage of its Medicare allowable capital-related costs depending on the class of hospital (Sec. 412.348(c)), but were available only during the 10- year transition period. After the end of the transition period, eligible hospitals can no longer receive this exception payment. However, even after the transition period, eligible hospitals receive additional payments under the special exceptions provisions at Sec. 412.348(g), which guarantees all eligible hospitals a minimum payment of 70 percent of its Medicare allowable capital-related costs provided that special exceptions payments do not exceed 10 percent of total capital IPPS payments. Special exceptions payments may be made only for the 10 years from the cost reporting year in which the hospital completes its qualifying project, and the hospital must have completed the project no later than the hospital's cost reporting period beginning before October 1, 2001. Thus, an eligible hospital may receive special exceptions payments for up to 10 years beyond the end of the capital IPPS transition period. Hospitals eligible for special exceptions payments were required to submit documentation to the intermediary indicating the completion date of their project. (For more detailed information regarding the special exceptions policy under Sec. 412.348(g), refer to the August 1, 2001 IPPS final rule (66 FR 39911 through 39914) and the August 1, 2002 IPPS final rule (67 FR 50102).)

[[Page 24819]]

Under the IPPS for capital-related costs, Sec. 412.300(b) of the regulations defines a new hospital as a hospital that has operated (under current or previous ownership) for less than 2 years. (For more detailed information, we refer readers to the August 30, 1991 final rule (56 FR 43418).) During the 10-year transition period, a new hospital was exempt from the capital IPPS for its first 2 years of operation and was paid 85 percent of its reasonable costs during that period. Originally, this provision was effective only through the transition period and, therefore, ended with cost reporting periods beginning in FY 2002. Because we believe that special protection to new hospitals is also appropriate even after the transition period, as discussed in the August 1, 2002 IPPS final rule (67 FR 50101), we revised the regulations at Sec. 412.304(c)(2) to provide that, for cost reporting periods beginning on or after October 1, 2002, a new hospital (defined under Sec. 412.300(b)) is paid 85 percent of its Medicare allowable capital-related costs through its first 2 years of operation, unless the new hospital elects to receive fully prospective payment based on 100 percent of the Federal rate. (We refer readers to the August 1, 2001 IPPS final rule (66 FR 39910) for a detailed discussion of the statutory basis for the system, the development and evolution of the system, the methodology used to determine capital- related payments to hospitals both during and after the transition period, and the policy for providing exception payments.)

Section 412.374 provides for the use of a blended payment amount for prospective payments for capital-related costs to hospitals located in Puerto Rico. Accordingly, under the capital IPPS, we compute a separate payment rate specific to Puerto Rico hospitals using the same methodology used to compute the national Federal rate for capital- related costs. In general, hospitals located in Puerto Rico are paid a blend of the applicable capital IPPS Puerto Rico rate and the applicable capital IPPS Federal rate.

Prior to FY 1998, hospitals in Puerto Rico were paid a blended capital IPPS rate that consisted of 75 percent of the capital IPPS Puerto Rico specific rate and 25 percent of the capital IPPS Federal rate. However, effective October 1, 1997 (FY 1998), in conjunction with the change to the operating IPPS blend percentage for Puerto Rico hospitals required by section 4406 of Pub. L. 105-33, we revised the methodology for computing capital IPPS payments to hospitals in Puerto Rico to be based on a blend of 50 percent of the capital IPPS Puerto Rico rate and 50 percent of the capital IPPS Federal rate. Similarly, in conjunction with the change in operating IPPS payments to hospitals in Puerto Rico for FY 2005 required by section 504 of Pub. L. 108-173, we again revised the methodology for computing capital IPPS payments to hospitals in Puerto Rico to be based on a blend of 25 percent of the capital IPPS Puerto Rico rate and 75 percent of the capital IPPS Federal rate effective for discharges occurring on or after October 1, 2004.

B. Proposed Policy Change

As we have noted above, the Secretary has broad authority under the statute in establishing and implementing the IPPS for hospital inpatient capital-related costs. We initially exercised that authority in the August 30, 1991 IPPS final rule (56 FR 43358). Among other provisions of that rule, we established the 10-year transition period to change the payment methodology for Medicare hospital inpatient capital-related costs from a reasonable cost-based methodology to a prospective methodology (based fully on the Federal rate). The purpose of that lengthy transition was to allow hospitals sufficient time to adjust to payment under a fully prospective system based on a uniform national rate. In that rule, we also established the initial standard Federal payment rate for capital-related costs, as well as the mechanism for updating that rate in subsequent years. For FY 1992, we computed the standard Federal payment rate for capital-related costs under the IPPS 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 capital standard Federal rate, as provided at Sec. 412.308(c)(1), to account for capital input price increases and other factors. The regulations at Sec. 412.308(c)(2) provide that the capital Federal rate is adjusted annually by a factor equal to the estimated proportion of outlier payments under the capital Federal rate to total capital payments under the capital Federal rate. In addition, Sec. 412.308(c)(3) requires that the capital Federal rate be reduced by an adjustment factor equal to the estimated proportion of payments for (regular and special) exceptions under Sec. 412.348. Section 412.308(c)(4)(ii) requires that the capital standard Federal rate be adjusted so that the effects of the annual DRG reclassification and the recalibration of DRG weights and changes in the geographic adjustment factor are budget neutral.

Since the implementation of the IPPS for hospital inpatient capital-related costs, we have carefully monitored the adequacy of the standard Federal payment rate for capital-related costs and the updates provided under the existing regulations. On several occasions, the standard Federal payment rate has been adjusted. Section 1886(g)(1)(A) of the Act required a 7.4 percent reduction to the capital rate for discharges occurring after September 30, 1993. (We implemented that reduction to the rate in Sec. 412.308(b)(2) of our regulations, effective in FY 1994.) Section 412.308(b)(3) of the regulations describes the 0.28 percent reduction to the capital rate made in FY 1996 as a result of the revised policy of paying for transfers. In FY 1998, we implemented section 4402 of Pub. L. 105-33, which required that, for discharges occurring on or after October 1, 1997, and before October 1, 2002, the unadjusted capital standard Federal rate be reduced by 17.78 percent (above the previous statutory reduction of 7.4 percent). (As a result of that reduction, the FY 1998 standard Federal payment rate for capital-related costs was $371.51, compared to $438.92 in FY 1997.) As we discussed in the FY 2003 IPPS final rule (67 FR 50102) and implemented in Sec. 412.308(b)(6), a small part of that reduction was restored effective October 1, 2002.

In general, under a PPS, standard payment rates should reflect the costs that an average, efficient provider would bear to provide the services required for quality patient care. Payment rate updates should also account for the changes necessary to continue providing such services. Updates should reflect, for example, the increased costs that are necessary to provide for the introduction of new technology that improves patient care. Updates should also take into account the productivity gains that, over time, allow providers to realize the same, or even improved, quality outcomes with reduced inputs and lower costs. Hospital margins, the difference between the costs of actually providing services and the payments received under a particular system, thus provide some evidence concerning whether payment rates have been established and updated at an appropriate level over time for efficient providers to provide necessary services. All other factors being equal, sustained substantial positive margins may suggest that payment rates and updates have exceeded what is required to provide those services. It is to be expected, under a PPS, that highly efficient providers might regularly realize positive margins, while less efficient providers might regularly

[[Page 24820]]

realize negative margins. However, a PPS that is correctly calibrated should not necessarily experience sustained periods in which providers generally realize substantial positive Medicare margins.

Under the capital IPPS in particular, it seems especially appropriate that there should not be sustained significant positive margins across the system as a whole. Prior to the implementation of the capital IPPS, Congress mandated that the Medicare program pay only 85 percent of hospitals' inpatient Medicare capital costs. During the first 5 years of the capital IPPS, Congress also mandated a budget neutrality adjustment, under which the standard Federal capital rate was set each year so that payments under the system as a whole equaled 90 percent of estimated hospitals' inpatient Medicare capital costs for the year. Finally, as we discussed above, Congress has twice adjusted the standard Federal capital rate (a 7.4 percent reduction beginning in FY 1994, followed by a 17.78 percent reduction beginning in FY 1998). On the second occasion in particular, the specific congressional mandate was ``to apply the budget neutrality factor used to determine the Federal capital payment rate in effect on September 30, 1995 * * * to the unadjusted standard Federal capital payment rate'' for FY 1998 and beyond. (The designated budget neutrality factor constituted a 17.78 percent reduction.) This statutory language indicates that Congress considered the payment levels in effect during FYs 1992 through 1995, established under the budget neutrality provision to pay 90 percent of hospitals' inpatient Medicare capital costs in the aggregate, appropriate for the capital IPPS. The statutory history of the capital IPPS thus suggests that the system in the aggregate should not provide for continuous, large positive margins.

In analyzing the adequacy of the existing capital IPPS rates, we recently conducted a comprehensive review of hospital experience under the IPPS for hospital inpatient capital-related costs, with particular attention to the relationship between acute care hospital capital Medicare costs and payments under the capital IPPS. Specifically, we examined the relationship between the Medicare inpatient capital costs of hospitals that are paid under the IPPS for hospital inpatient capital-related costs and their payments under that system over a number of years. We derived both cost and revenue data from the Medicare cost report. Specifically, cost data were derived from Worksheet D, Part I, columns 10 and 12 and Part II, columns 6 and 8, and revenue data from Worksheet E, Part A, Lines 9 and 10. We began our analysis with FY 1996, the year in which the statutory budget neutrality provision expired. (As we have discussed, for FYs 1992 through 1995, section 1886(g)(1)(A) of the Act required that the capital Federal rate also be adjusted by a budget neutrality factor so that aggregate payments for inpatient hospital capital costs were projected to equal 90 percent of the payments that would have been made for capital-related costs on a reasonable cost basis during the fiscal year. As discussed in section III. of the Addendum to this proposed rule, we employed an actuarial capital cost model (described in Appendix B of the FY 2002 IPPS final rule (66 FR 40099)) to estimate the aggregate payments that would have been made on the basis of reasonable cost in order to determine the required budget neutrality adjustment. As a result of the expiration of the budget neutrality provision, the standard Federal payment rate for capital-related costs increased to $461.96 in FY 1996 from $376.83 in FY 1995.) Our analysis extended through FY 2004, the most recent year for which we have relatively complete cost report information. We examined data across all hospitals subject to the capital IPPS and across the categories of hospitals (for example, urban and rural, and teaching and nonteaching) that we normally employ in conducting impact analyses. Specifically, we looked at the difference between aggregate hospital revenues from the capital IPPS and hospitals' aggregate Medicare inpatient capital costs. We determined the inpatient hospital Medicare capital margins for each year of the period from FY 1996 through FY 2004. (A margin is calculated as the difference between payments and costs, divided by payments.) We similarly calculated the aggregate margins for the period (the aggregate difference between payments and costs over the period, divided by total payments over the period). We also calculated aggregate margins for the period FY 1998 through FY 2004 (excluding FY 1996 and 1997). As a result of the expiration of the statutory budget neutrality provision, the capital standard Federal rate increased to $461.96 in FY 1996 from $376.83 in FY 1995. The capital standard Federal rate was $438.92 in FY 1997, before it was reduced to $371.51 in FY 1998 under section 4402 of Pub. L. 105-33, which required that the unadjusted capital standard Federal rate be reduced by 17.78 percent. The capital standard Federal rates for FYs 1996 and 1997 were thus substantially higher than the rates for the periods immediately preceding those years, and in the subsequent years (FY 1998 and beyond). The margins for those years are correspondingly higher than the margins for the other years in the period, and thus it could be argued that the margins for FYs 1996 and 1997 are unrepresentative. The table below summarizes the findings of this analysis.

Hospital Inpatient Medicare Capital Margins

1996 1997 1998 1999 2000 2001 2002 2003 2004 1996-2004 1998-2004*

U.S................................................... 17.5 13.4 7.0 6.8 7.3 7.9 8.7 7.7 5.1

9.0

7.2

URBAN............................................. 17.6 13.8 7.8 7.4 8.3 8.9 10.3 9.1 6.3

9.9

8.3

RURAL............................................. 17.2 11.1 2.0 2.7 1.3 1.5 -1.7 -1.2 -2.9

3.4

0.26 No DSH Payments....................................... 16.2 11.8 4.4 4.4 5.6 5.6 5.0 4.8 -0.9

6.9

4.2 Has DSH Payments...................................... 18.3 14.4 8.5 8.1 8.2 8.7 9.9 8.6 6.7

9.9

8.4

$1-$249,999....................................... 14.5 12.9 -0.4 3.1 1.6 4.2 2.5 0.6 -3.5

3.3

1.8

$250,000-$999,999................................. 15.5 9.3 2.2 1.5 3.0 2.5 -1.2 0.2 -3.8

2.9

0.5

$1,000,000-$2,999,999............................. 16.8 12.8 8.5 9.2 8.6 7.2 9.0 4.6 3.0

8.7

7.1

$3,000,000 or more................................ 20.1 16.6 10.4 9.1 9.7 11.6 13.4 12.5 10.1

12.4

11.1 TEACHING.............................................. 19.4 15.7 9.8 9.7 11.1 11.7 13.9 13.2 11.3

12.9

11.6 NON-TEACHING.......................................... 15.3 10.5 3.3 2.9 2.2 2.8 1.6 0.2 -3.2

3.9

1.3 Census Division:

New England (1)................................... 26.9 25.8 17.0 15.1 18.2 20.5 21.3 21.2 20.5

20.9

19.3

Middle Atlantic (2)............................... 19.1 15.5 11.0 11.5 13.8 16.3 18.4 17.9 15.0

15.5

15.0

South Atlantic (3)................................ 17.9 13.9 5.8 3.9 5.9 5.2 6.3 7.5 4.9

7.9

5.7

East North Central (4)............................ 18.2 12.7 6.2 7.2 8.8 8.6 6.3 8.1 7.1

9.2

7.5

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East South Central (5)............................ 14.8 11.1 3.3 4.1 3.4 2.9 3.0 -1.8 -4.2

3.9

1.4

West North Central (6)............................ 14.2 6.9 0.0 -0.4 -1.6 1.9 2.6 3.3 1.1

3.2

1.1

West South Central (7)............................ 13.3 8.3 3.4 3.1 0.6 0.1 1.4 -1.2 -4.2

2.5

0.3

Mountain (8)...................................... 17.3 14.8 8.4 7.6 7.4 6.4 3.2 3.1 0.7

7.2

4.9

Pacific (9)....................................... 20.5 16.1 12.4 11.3 11.5 12.8 15.5 12.8 9.2

13.5

12.2

Code 99........................................... 24.1 26.1 14.9 16.7 20.0 20.9 20.6 25.2 22.3

21.4

20.3 Bed Size:

= 1000 beds...................................... 8.2 13.8 2.1 0.2 -6.6 -3.5 8.7 6.3 1.4

3.1

1.8

Notes: * Excluding 1996 and 1997. Based on Medicare Cost Report hospital data updated as of the 4th quarter of 2006. Revenue are from Worksheet E, Part A, Lines 9 and 10. Expenses are from Worksheet D, Part I, columns 10 and 12 and Part II, columns 6 and 8. We apply the outlier trimming methodology developed by MedPAC.

As the table shows, hospital inpatient Medicare capital margins have been very high across all hospitals during the period from FY 1996 through FY 2004. The margin for the entire period was 9.0 percent (7.2 percent, excluding FYs 1996 and 1997). For particular years, margins across all hospitals ranged from a high of 17.5 percent in FY 1996 to a low 5.1 percent in FY 2004. While the margins fell after a high in FY 1996 of 17.5 to 6.8 percent in FY 1999, they rose again to 8.7 percent in FY 2002 before declining modestly to 5.1 percent in FY 2004.

There are similar results among most types of hospitals and groupings of hospitals by geographic region. For example, teaching hospitals have realized margins of 12.9 percent (11.6 percent, excluding FYs 1996 and 1997) during the period from FY 1996 through FY 2004, with a high margin of 19.4 percent in FY 1996 and a low margin of 9.7 percent in FY 1999. Urban hospitals realized margins of 9.9 percent during the period from FY 1996 through FY 2004 (8.3 percent, excluding FYs 1996 and 1997). DSH hospitals realized margins of 9.9 percent over the period (8.4 percent, excluding FYs 1996 and 1997), while non-DSH had aggregate margins of 6.9 percent (4.2 percent, excluding FYs 1996 and 1997).

During the period from FY 1996 through FY 2004, every type of hospital and geographic grouping of hospitals has realized a positive aggregate margin from their capital IPPS payments. Of course, the aggregate capital margins for some types of hospitals have been lower than the margins for others. In particular, inpatient hospital Medicare capital margins for rural hospitals have lagged considerably behind the margins for urban hospitals. The aggregate margin for rural hospitals during the period from FY 1996 through FY 2004 was 3.4 percent (0.2 percent, excluding FYs 1996 and 1997), compared to 9.9 percent for urban hospitals and 9.0 percent for all hospitals. Rural hospitals have even experienced negative margins during several years of the period (- 1.7 percent in FY 2002, -1.2 percent in FY 2003, and -2.9 percent in FY 2004). Similarly, nonteaching hospitals have experienced lower margins than teaching hospitals. Teaching hospitals have experienced an aggregate margin of 12.9 percent during the period from FY 1996 through FY 2004 (11.6 percent, excluding FYs 1996 and 1997). However, nonteaching hospitals have experienced an aggregate margin of 3.9 percent during that period (1.3 percent, excluding FYs 1996 and 1997).

There may be various factors reflected in these margins. For example, one factor in the lower margins experienced by rural hospitals may be the transition of many rural hospitals to CAHs that are paid outside the IPPS. The number of rural hospitals in our analysis fell from 2,243 in FY 1996 to 1,211 in FY 2004, as the inpatient Medicare capital margins realized by rural hospitals fell from 17.2 percent to - 2.9 percent. This suggests that more rural hospitals with relatively higher inpatient Medicare capital margins have made the transition to CAH status. However, it remains to be seen whether this trend in inpatient Medicare capital margins will continue as the relative numbers of CAHs and rural hospitals subject to the IPPS stabilize. The low aggregate for nonteaching hospitals is largely a function of the effect of the low, and for some years even negative, margin of the rural hospitals, as discussed earlier.

We believe that there could be a number of reasons for the relatively high margins that most IPPS hospitals have realized under the capital IPPS. One possibility is that the updates to the capital IPPS rates have been higher than the actual increases in Medicare inpatient capital costs that hospitals have experienced in recent years. As we discuss in section III. of the Addendum to this proposed rule, we update the capital standard Federal rate on the basis of an analytical framework that takes into account changes in a capital input price index (CIPI) and several other 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. Under the framework that we have been using, the update factor for FY 2008 would be 0.8 percent, based on the best data available at this time. That update factor is derived from a projected 1.2 percent increase in the CIPI, a 0.0 percent adjustment for intensity, a 0.0 percent adjustment for case-mix, a -0.4 percent adjustment for the FY 2005 DRG reclassification and recalibration, and a forecast error correction of 0.0 percent. We discuss this update framework, and the computation of the policy adjustment factors, in section III. of the Addendum to this proposed rule.

We believe that the CIPI is the most appropriate input price index for capital costs to measure capital price changes in a given year. We also believe that the update framework successfully captures several factors that should be taken into account in determining appropriate updates for hospitals subject to the capital IPPS. However, there may be factors affecting the rate-of-increase in

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capital costs that are not yet captured in our analytical framework. For example, hospitals may be experiencing productivity gains in their use of capital equipment. As productivity increases, hospitals would be able to reduce the number of inputs required to produce a unit of service. MedPAC has taken the position that payment ``rate for health care providers should be set so that the Federal Government benefits from providers' productivity gains, just as private purchasers of goods in competitive markets benefit from the productivity gains of their suppliers.'' MedPAC has, therefore, included a productivity improvement target in its framework for updating Medicare hospital payments on the grounds that ``as a prudent purchaser, Medicare should also require some productivity gains each year from its providers.'' (MedPAC, Report to Congress, March 2006, p. 66) While we have not as yet included a specific productivity factor, such as MedPAC's productivity improvement target, in our analytical frameworks for updating the IPPS payment rates, we will continue to study the appropriateness of adopting such a measure.

Another possible reason for the relatively high margins of most capital IPPS hospitals may be that the payment adjustments provided under the system are too high, or perhaps even unnecessary. Specifically, the adjustments for teaching hospitals, disproportionate share hospitals, and large urban hospitals appear to be contributing to excessive payment levels for these classes of hospitals. Since the inception of the capital IPPS in FY 1992, the system has provided adjustments for teaching hospitals (the IME adjustment factor, under Sec. 412.322 of the regulations), disproportionate share hospitals (the DHS adjustment factor, under Sec. 412.320), and large urban hospitals (the large urban location adjustment factor, under Sec. 412.316((b)). The classes of hospitals eligible for these adjustments have been realizing much higher margins than other hospitals under the system. Specifically, teaching hospitals (11.6 percent for FYs 1998 through 2004), urban hospitals (8.3 percent), and disproportionate share hospitals (8.4 percent) have significant positive margins. Other classes of hospitals have experienced much lower margins, especially rural hospitals (0.2 percent for FYs 1998 through 2004) and nonteaching hospitals (1.3 percent). The three groups of hospitals that have been realizing especially high margins under the capital IPPS are, therefore, classes of hospitals that are eligible to receive one or more specific payment adjustments under the system. We believe that the evidence indicates that these adjustments have been contributing to the significantly large positive margins experienced by the classes of hospitals eligible for these adjustments.

We believe that the data on inpatient hospital Medicare capital margins, as discussed above, provide sufficient evidence that some adjustment of the updates under the capital IPPS is warranted at this time. In light of the significant disparities in the margin performances of different classes of hospitals, we do not believe that an adjustment to the updates for FYs 2008 and 2009 should apply equally to all hospitals that are paid under the capital IPPS. In particular, an adjustment to the updates should take into account the much lower margins of rural hospitals (0.2 percent for the period from FY 1998 through FY 2004) compared to urban hospitals (8.3 percent during that period). We also believe that any initial adjustment to the rate should be relatively modest. One reason is that any adjustment should avoid unwarranted disruption to hospital finances: because of the nature of capital spending, long periods of time can be necessary for hospitals to adjust adequately to significant changes in payment. Therefore, for FYs 2008 and 2009, we are proposing that the update to the capital standard Federal rate for urban hospitals will be 0.0 percent, in place of the 0.8 percent update that would otherwise be provided in FY 2008 under the update framework that we have been employing. (We have not yet determined the update that would be provided for FY 2009 under the framework.) However, in light of the margin analysis, we are also proposing to give rural hospitals the full 0.8 percent update determined by the update framework in FY 2008. We anticipate that we will provide the full update to rural hospitals in FY 2009 as well, once we have determined what the update would be under the update framework. We are proposing to revise Sec. 412.308(c)(1) of the regulations accordingly. For purposes of the update in FYs 2008 and 2009, an urban hospital is any hospital located in an area that meets the definitions under Sec. 412.64(b)(1)(ii)(A) or (b)(1)(ii)(B), or Sec. 412.64(b)(3). A rural hospital is any hospital that does not meet those definitions, or that is reclassified as rural under Sec. 412.103. For subsequent years, we will continue to analyze the data concerning the adequacy of payments under the capital IPPS, and we may propose additional adjustments, positive or negative, as they are warranted. We will also continue to study our update framework and will consider whether adoption of additional or revised adjustments to account for other factors affecting capital cost changes may be warranted.

In addition, we are also proposing to eliminate, for FYs 2008 and beyond, one of the payment adjustments that has been provided under the capital IPPS. Specifically, we are proposing to discontinue the 3.0 percent additional payment that has been provided to hospitals located in large urban areas. The consistent and significant positive margin of hospitals located in urban areas is strong evidence that it is not necessary to continue this adjustment. Therefore, we are proposing to amend Sec. 412.316(b) of the regulations to provide that, effective for discharges on or after October 1, 2007, there will no longer be any additional payment for hospitals located in large urban areas, as currently provided under that section. When the payment adjustments were instituted at the inception of the program, the initial standard Federal payment rate was adjusted in a budget-neutral fashion to account for the expenditures that would be required by these adjustments. However, in light of the strong overall positive margins across the system, we are proposing not to increase the standard capital rate to account for expenditures otherwise payable due to this adjustment (approximately $147 million). Rather, in light of the excessive capital IPPS payments over the period of FYs 1996 through 2004, we believe that it is appropriate for the program to realize savings from this proposal.

We will also continue to study the adequacy of payments under the capital IPPS, and will consider whether it is appropriate to make further adjustments to the standard Federal capital rate and updates of the rate. While we are formally proposing an update of 0.0 percent for urban hospitals, an update of 0.8 percent for rural hospitals in FY 2008, and elimination of the large urban add-on, we are also soliciting comment on additional adjustments to the capital payment structure. As we have noted above, the margin analysis indicates that several classes of hospitals have continuous, significant positive margins. The analysis indicates that the existing payment adjustments for teaching hospitals and disproportionate share hospitals are contributing to excessive payment levels for these classes of hospitals. Therefore, it may be appropriate to reduce these adjustments significantly, or even to eliminate them altogether, within the capital IPPS.

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These payment adjustments, unlike the parallel adjustments under the operating IPPS, were not mandated by the Act. Rather, they were included within the original design of the capital IPPS under the Secretary's broad authority under sections 1886(g)(1)(A) and (g)(1)(B) of the Act to include appropriate adjustments and exceptions within a capital IPPS. Therefore, we are considering whether it may be appropriate to develop a proposal to reduce or to terminate these payment adjustments in the near future. It is difficult to justify indefinite continuation of these adjustments in the light of the continuous, substantial positive margins realized by the classes of hospitals that qualify for them. When the payment adjustments were instituted at the inception of the program, the initial standard Federal payment rate was adjusted in a budget-neutral fashion to account for the expenditures that would be required by these adjustments. Therefore, if we decide to propose to reduce or eliminate these adjustments, we will also consider whether we should similarly adjust the Federal capital payment rate to account for all or a portion of these adjustments, effectively increasing the base payment rate for all hospitals (including rural, nonteaching, and non-DSH hospitals that do not benefit from these adjustments), while removing these special adjustments for the hospitals that have been eligible to receive them. We are also considering whether, in light of the substantial positive margins experienced by these teaching and DSH hospitals, the discontinuation of these adjustments should not result in a change to the standard capital rate and should instead result in savings to the program. We welcome comments on these potential proposals and on other means of appropriately adjusting and targeting payments under the capital IPPS, as well as on the proposals that we are formally making in this proposed rule.

VI. Proposed Changes for Hospitals and Hospital Units Excluded From the IPPS

(If you choose to comment on the issues in this section, please include the caption ``Excluded Hospitals and Hospital Units'' at the beginning of your comment.)

A. Payments to Existing and New Excluded Hospitals and Hospital Units

Historically, hospitals and hospital units excluded from the prospective payment system received payment for inpatient hospital services they furnished on the basis of reasonable costs, subject to a rate-of-increase ceiling. An annual per discharge limit (the target amount as defined in Sec. 413.40(a)) was set for each hospital or hospital unit based on the hospital's own cost experience in its base year. The target amount was multiplied by the Medicare discharges and applied as an aggregate upper limit (the ceiling as defined in Sec. 413.40(a)) on total inpatient operating costs for a hospital's cost reporting period. Prior to October 1, 1997, these payment provisions applied consistently to all categories of excluded providers (rehabilitation hospitals and units (now referred to as IRFs), psychiatric hospitals and units (now referred to as IPFs), LTCHs, children's hospitals, and cancer hospitals).

Payment for children's hospitals and cancer hospitals that are excluded from the IPPS continues to be subject to the rate-of-increase ceiling based on the hospital's own historical cost experience. (We note that, in accordance with Sec. 403.752(a) of the regulations, RNHCIs are also subject to the rate-of-increase limits established under Sec. 413.40 of the regulations. IRFs, IPFs, and LTCHs were paid previously under the reasonable cost methodology. However, the statute was amended to provide for the implementation of prospective payment systems for IRFs, IPFs, and LTCHs. In general, the prospective payment systems for IRFs, IPFs, and LTCHs provide(d) transition periods of varying lengths during which time a portion of the prospective payment is (was) based on cost-based reimbursement rules under Part 413 (certain providers do not receive a transition period or may elect to bypass the transition as applicable under Subparts N, O, and P). We note that the various transition periods provided for under the IRF PPS, IPF PPS, and LTCH PPS have ended or will soon end.)

For cost reporting periods beginning on or after October 1, 2002, all IRFs are paid 100 percent of the adjusted Federal rate under the IRF PPS. Therefore, for cost reporting periods beginning on or after October 1, 2002, no portion of an IRF PPS payment is subject to Part 413. Similarly, for cost reporting periods beginning on or after October 1, 2006, all LTCHs are paid 100 percent of the adjusted Federal rate under the LTCH PPS. Therefore, for cost reporting periods beginning on or after October 1, 2006, no portion of the LTCH PPS payment is subject to 42 CFR part 413. However, except as provided in Sec. 412.426(c), IPFs remain under a blend methodology for cost reporting periods beginning on or after January 1, 2005, and before January 1, 2008.

For IPFs paid under the blend methodology, the portion of the IPF PPS payment that is based on reasonable cost principles is subject to the rules of 42 CFR part 413. In order to calculate the portion of the PPS payment that is based on reasonable cost principles, it is necessary to determine whether the IPF would be considered ``existing'' for purposes of section 1886(b)(3)(H) of the Act or ``new'' for purposes of section 1886(b)(7) of the Act. We note that readers should not confuse an IPF that is considered ``new'' for purposes of section 1886(b)(7) of the Act and Sec. 413.40(f)(2)(ii) of the regulations with an IPF that is considered ``new'' under Sec. 412.426(c) of the reguations. Any IPF that, under present or previous ownership or both, has its first cost reporting period as an IPF beginning on or after January 1, 2005, is considered ``new'' for purposes of Sec. 412.426(c). An IPF that is considered ``new'' under Sec. 412.426(c) is paid based on 100 percent of the Federal per diem payment amount. Consequently, only those IPFs considered ``new'' under section 1886(b)(7) of the Act, but not ``new'' under Sec. 412.426(c) of the regulations will be paid under a PPS blended payment methodology. An IPF considered ``new'' for purposes of Sec. 413.40(f)(2)(ii) would have its ``reasonable cost-based'' portion of its prospective payment subject to Sec. 413.40(f)(2)(ii) and Sec. 413.40(c)(4)(v), as applicable. An IPF considered ``new'' for purposes of section 1886(b)(7) of the Act has the target amount for its third cost reporting period determined in accordance with sections 1886(b)(7)(A)(ii) and 1886(b)(3)(A)(ii) of the Act. For the fourth and subsequent cost reporting periods, the target amount is calculated in accordance with section 1886(b)(3)(A)(ii) of the Act. An IPF that would be considered ``existing'' for purposes of section 1886(b)(3)(H) of the Act has the target amount for the ``reasonable cost-based'' portion of its prospective payment determined in accordance with section 1886(b)(3)(A)(ii) of the Act and the regulations at Sec. 413.40(c)(4)(ii).

We are proposing that the applicable percentage increase to update the target amount for the reasonable cost-based portion of the PPS payment of an IPF that is considered existing under section 1886(b)(3)(H) of the Act or new under section 1886(b)(7) of the Act, but not new under Sec. 412.426(c), is 3.4 percent. (However, if more current data become available prior to publication of the final rule, we will use those data for updating the market basket.)

B. Separate PPS for IRFs

Section 1886(j) of the Act, as added by section 4421(a) of Pub. L. 105-33,

[[Page 24824]]

provided for a phase-in of a case-mix adjusted PPS for inpatient hospital services furnished by IRFs for cost reporting periods beginning on or after October 1, 2000, and before October 1, 2002, with payments based entirely on the adjusted Federal prospective payment for cost reporting periods beginning on or after October 1, 2002. Section 1886(j) of the Act was amended by section 125 of Pub. L. 106-113 to require the Secretary to use a discharge as the payment unit under the PPS for inpatient hospital services furnished by IRFs and to establish classes of patient discharges by functional-related groups. Section 305 of Pub. L. 106-554 further amended section 1886(j) of the Act to allow IRFs, subject to the blend methodology, to elect to be paid the full Federal prospective payment rather than the transitional period payments specified in the Act.

On August 7, 2001, we issued a final rule in the Federal Register (66 FR 41316) establishing the PPS for IRFs, effective for cost reporting periods beginning on or after January 1, 2002. There was a transition period for cost reporting periods beginning on or after January 1, 2002, and ending before October 1, 2002. For cost reporting periods beginning on or after October 1, 2002, payments are based entirely on the adjusted Federal prospective payment rate determined under the IRF PPS.

C. Separate PPS for LTCHs

On August 30, 2002, we issued a final rule in the Federal Register (67 FR 55954) establishing the PPS for LTCHs, effective for cost reporting periods beginning on or after October 1, 2002. Except for a LTCH that made an election under Sec. 412.533(c) or a LTCH that is defined as new under Sec. 412.23(e)(4), there was a transition period for cost reporting periods beginning on or after October 1, 2002, and ending before October 1, 2007. For cost reporting periods beginning on or after October 1, 2006, total LTCH PPS payments are based on 100 percent of the Federal rate.

D. Separate PPS for IPFs

In accordance with section 124 of Pub. L. 106-113 and section 405(g)(2) of Pub. L. 108-173, we established a PPS for inpatient hospital services furnished in IPFs. On November 15, 2004, we issued in the Federal Register a final rule (69 FR 66922) that established the IPF PPS, effective for IPF cost reporting periods beginning on or after January 1, 2005. Under the final rule, we compute a Federal per diem base rate to be paid to all IPFs for inpatient psychiatric services based on the sum of the average routine operating, ancillary, and capital costs for each patient day of psychiatric care in an IPF, adjusted for budget neutrality. The Federal per diem base rate is adjusted to reflect certain patient characteristics, including age, specified DRGs, selected high-cost comorbidities, days of the stay, and certain facility characteristics, including a wage index adjustment, rural location, indirect teaching costs, the presence of a full-service emergency department, and COLAs for IPFs located in Alaska and Hawaii. We have established a 3-year transition period during which IPFs whose first cost reporting periods began before January 1, 2005, will be paid based on a blend of reasonable cost-based payment and IPF PPS payments. For cost reporting periods beginning on or after January 1, 2008, all IPFs will be paid 100 percent of the Federal per diem payment amount.

E. Determining Proposed LTCH Cost-to-Charge Ratios (CCRs) Under the LTCH PPS

(If you choose to comment on the issues in this section, please include the caption ``LTCH PPS CCRs and Outlier Payments'' at the beginning of your comment.)

In determining both high-cost outlier and short-stay outlier payments under the LTCH PPS (at Sec. 412.525(a) and Sec. 412.529, respectively), we calculate the estimated cost of the case by multiplying the LTCH's overall CCR by the Medicare allowable charges for the case. Under the LTCH PPS, a single prospective payment per discharge is made for both inpatient operating and capital-related costs, and, therefore, we compute a single ``overall'' or ``total'' LTCH-specific CCR based on the sum of LTCH operating and capital costs (as described in Chapter 3, section 150.24, of the Medicare Claims Processing Manual (CMS Pub. 100-4)) as compared to total charges. Specifically, a LTCH's CCR is calculated by dividing a LTCH's total Medicare costs (that is, the sum of its operating and capital inpatient routine and ancillary costs) by its total Medicare charges (that is, the sum of its operating and capital inpatient routine and ancillary charges) (72 FR 48117).

In the June 9, 2003 IPPS high-cost outlier final rule (68 FR 34498), we made revisions to our policies concerning the determination of LTCHs' CCRs and the reconciliation of high-cost outlier and short- stay outlier payments under the LTCH PPS. As we stated in that final rule (68 FR 34507), because the LTCH PPS high-cost outlier and short- stay outlier policies are modeled after the IPPS outlier policy, we believe they are susceptible to the same payment vulnerabilities.

In the FY 2007 IPPS final rule (71 FR 48115 through 48122), we amended our regulations and, for discharges occurring on or after October 1, 2006, refined the methodology for determining the annual CCR ceiling and statewide average CCRs. We also codified, with modifications and editorial clarifications, our policy for the reconciliation of high-cost outlier and short-stay outlier payments under the LTCH PPS. We indicated that because, historically, updates to the LTCH PPS CCR ceiling and statewide average CCRs have been effective on October 1, we would make these updates (and include relevant impact data) as a part of the IPPS rulemaking cycle.

Specifically, in the FY 2007 IPPS final rule (71 FR 48117 through 48121), under the broad authority of section 123 of Pub. L. 106-113 and section 307(b)(1) of Pub. L. 106-554, we established under the LTCH PPS high-cost outlier policy at Sec. 412.525(a)(4)(iv)(C) and the LTCH PPS short-stay outlier policy at Sec. 412.529(c)(3)(iv)(C), for discharges occurring on or after October 1, 2006, that the fiscal intermediary (or currently the MAC, if applicable) may use a statewide average CCR, which is established annually by CMS, if it is unable to determine an accurate CCR for a LTCH in one of the following three circumstances: (1) new LTCHs that have not yet submitted their first Medicare cost report (for this purpose, a new LTCH is defined as an entity that has not accepted assignment of an existing hospital's provider agreement in accordance with Sec. 489.18); (2) LTCHs whose CCR is in excess of the LTCH CCR ceiling; and (3) other LTCHs for whom data with which to calculate a CCR are not available (for example, missing or faulty data). (Other sources of data that the fiscal intermediary (or, if applicable, the MAC) may consider in determining a LTCH's CCR include data from a different cost reporting period for the LTCH, data from the cost reporting period preceding the period in which the hospital began to be paid as a LTCH (that is, the period of at least 6 months that it was paid as a short-term acute care hospital), or data from other comparable LTCHs, such as LTCHs in the same chain or in the same region.)

As noted above, a LTCH is assigned the applicable statewide average CCR if, among other things, a LTCH's CCR is found to be in excess of the applicable maximum CCR threshold (that is, the LTCH CCR ceiling). As we explained in the FY 2007 IPPS final rule (71 FR 48117), CCRs above this threshold are

[[Page 24825]]

most likely due to faulty data reporting or entry, and, therefore, these CCRs should not be used to identify and make payments for outlier cases. Such data are clearly errors and should not be relied upon. Thus, under our established policy, if a LTCH's calculated CCR is above the applicable ceiling, the applicable LTCH PPS statewide average CCR is assigned to the LTCH instead of the CCR computed from its most recent (settled or tentatively settled) cost report data.

We revised our methodology for determining the annual CCR ceiling and statewide average CCRs under the LTCH PPS effective October 1, 2006, as we explained in the FY 2007 IPPS final rule (71 FR 48117 through 48121), because we believe that those changes are consistent with the LTCH PPS single payment rate for inpatient operating and capital costs. Therefore, under the broad authority of section 123 of Pub. L. 106-113 and section 307(b)(1) of Pub. L. 106-554, in that same final rule, we revised our methodology used to determine the LTCH CCR ceiling. For discharges occurring on or after October 1, 2006, we established that the LTCH CCR ceiling specified under Sec. 412.525(a)(4)(iv)(C)(2) for high-cost outliers and under Sec. 412.529(c)(3)(iv)(C)(2) for short-stay outliers is calculated as 3 standard deviations above the corresponding national geometric mean total CCR (established and published annually by CMS). (The fiscal intermediary (or, if applicable, the MAC) may use a statewide average CCR if, among other things, a LTCH's CCR is in excess of the LTCH CCR ceiling.) The LTCH total CCR ceiling is determined based on IPPS CCR data, by first calculating the ``total'' (that is, operating and capital) IPPS CCR for each hospital and then determining the average ``total'' IPPS CCR for all IPPS hospitals. (Our rationale for using IPPS hospital data is discussed in the FY 2007 IPPS final rule (71 FR 48117).) The LTCH CCR ceiling is then established at 3 standard deviations from the corresponding national geometric mean total CCR. (For further detail on our methodology for annually determining the LTCH CCR ceiling, we refer readers to the FY 2007 IPPS final rule (71 FR 48117 through 48119).)

We also established that the LTCH ``total'' CCR ceiling used under the LTCH PPS will continue to be published annually in the IPPS proposed and final rules, and the public should continue to consult the annual IPPS proposed and final rules for changes to the LTCH total CCR ceiling that would be effective for discharges occurring on or after October 1 of each year. Accordingly, in the FY 2007 IPPS final rule (71 FR 48119), we established a FY 2007 LTCH PPS total CCR ceiling of 1.321, effective for discharges occurring on or after October 1, 2006.

In this proposed rule, in accordance with Sec. 412.525(a)(4)(iv)(C)(2) for high-cost outliers and Sec. 412.529(c)(3)(iv)(C)(2) for short-stay outliers, using our established methodology for determining the LTCH total CCR ceiling (described above), based on IPPS total CCR data from the December 2006 update to the Provider-Specific File, we are proposing a total CCR ceiling of 1.273 under the LTCH PPS that would be effective October 1, 2007. Furthermore, we are proposing that, if more recent data are available, we will use such data to determine the final total CCR ceiling under the LTCH PPS for FY 2008 using our established methodology described above.

In addition, under the broad authority of section 123 of Pub. L. 106-113 and section 307(b)(1) of Pub. L. 106-554, in the FY 2007 IPPS final rule (71 FR 48120), we revised our methodology to determine the statewide average CCRs under Sec. 412.525(a)(4)(iv)(C) for high-cost outliers and under Sec. 412.529(c)(3)(iv)(C) for short-stay outliers for use under the LTCH PPS in a manner similar to the way we compute the ``total'' CCR ceiling using IPPS CCR data. Specifically, we first calculate the total (that is, operating and capital) CCR for each IPPS hospital. We then calculate the weighted average ``total'' CCR for all IPPS hospitals in the rural areas of the State and the weighted average ``total'' CCR for all IPPS hospitals in the urban areas of the State. (For further detail on our methodology for annually determining the LTCH urban and rural statewide average CCRs, we refer readers to the FY 2007 IPPS final rule (71 FR 48119 through 48121).) We also established that the applicable statewide average ``total'' (operating and capital) CCRs used under the LTCH PPS will continue to be published annually in the IPPS proposed and final rules, and the public should continue to consult the annual IPPS proposed and final rules for changes to the applicable statewide average total CCRs that would be effective for discharges occurring on or after October 1 each year. Accordingly, in the FY 2007 IPPS final rule (71 FR 48122), the FY 2007 LTCH PPS statewide average total CCRs for urban and rural hospitals, effective for discharges occurring on or after October 1, 2006, were presented in Table 8C of the Addendum of that final rule (71 FR 48303).

In this proposed rule, in accordance with Sec. 412.525(a)(4)(iv)(C) for high-cost outliers and Sec. 412.529(c)(3)(iv)(C) for short-stay outliers, using our established methodology for determining the LTCH statewide average CCRs (described above), based on the most recent complete IPPS total CCR data from the December 2006 update of the Provider-Specific File, the proposed LTCH PPS statewide average total CCRs for urban and rural hospitals that would be effective October 1, 2007, are presented in Table 8C of the Addendum to this proposed rule. Furthermore, we are proposing that, if more recent data are available, we would use such data to determine the final statewide average total CCRs for urban and rural hospitals under the LTCH PPS for FY 2008 using our established methodology described above.

We note that, for this proposed rule, as we established when we revised our methodology for determining the applicable LTCH statewide average CCRs in the FY 2007 IPPS final rule (71 FR 48119 through 48121), and as is the case under the IPPS, all areas in the District of Columbia, New Jersey, Puerto Rico, and Rhode Island are classified as urban, and therefore there are no proposed rural statewide average total CCRs listed for those jurisdictions in Table 8C of the Addendum to this proposed rule. In addition, as we established when we revised our methodology for determining the applicable LTCH statewide average CCRs in that same final rule, and as is the case under the IPPS, although Massachusetts has areas that are designated as rural, there are no short-term acute care IPPS hospitals or LTCHs located in those areas as of December 2006. Therefore, there is no proposed rural statewide average total CCR listed for rural Massachusetts in Table 8C of the Addendum of this proposed rule. As we also established when we revised our methodology for determining the applicable LTCH statewide average CCRs in the FY 2007 IPPS final rule (71 FR 48120 through 48121), in determining the urban and rural statewide average total CCRs for Maryland LTCHs paid under the LTCH PPS, we used, as a proxy, the national average total CCR for urban IPPS hospitals and the national average total CCR for rural IPPS hospitals, respectively. We use this proxy because we believe that the CCR data on the Provider-Specific File for Maryland hospitals may not be accurate (as discussed in greater detail in that same final rule (71 FR 48120)).

VII. Services Furnished to Beneficiaries in Custody of Penal Authorities

(If you choose to comment on issues in this section, please include the

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caption ``Beneficiaries in Custody'' at the beginning of your comment.)

Section 1862(a)(2) of the Act prohibits payment under Medicare Part A or Part B for any items or services for which the beneficiary has no legal obligation to pay, and which no other person or organization (such as a prepayment plan of which the beneficiary is a member) has a legal obligation to provide or pay for the service. Our current regulations at Sec. 411.4(b) specify the special conditions when Medicare payment may be made for services furnished to individuals in custody of penal authorities. These regulatory conditions include: (1) State or local law requires those individuals or groups of individuals to repay the cost of medical services they receive while in custody; and (2) the State or local government entity enforces the requirement to pay by billing all such individuals, whether or not covered by Medicare or any other health insurance, and by pursuing collection of the amounts they owe in the same way and with the same vigor that it pursues the collection of other debts.

However, Sec. 411.4(b) does not define ``custody'' and does not clearly state that CMS will not defer to a particular State or local government's definition (or interpretation) of what constitutes ``custody.'' In this proposed rule, we are proposing to specify that, for purposes of Medicare payment, individuals who are in ``custody'' include, but are not limited to, individuals who are under arrest, incarcerated, imprisoned, escaped from confinement, under supervised release, required to reside in mental health facilities, required to reside in halfway houses, required to live under home detention, or confined completely or partially in any way under a penal statute or rule. We believe that this proposed definition of ``custody'' is in accordance with how custody has been defined by Federal courts for purposes of the habeas corpus protections of the Constitution. For example, the term ``custody'' is not limited solely to physical confinement. (Sanders v. Freeman, 221 F.3d 846, 850-51 (6th Cir. 2000).) Individuals on parole, probation, bail, or supervised release may be ``in custody.''

VIII. MedPAC Recommendations

(If you choose to comment on issues in this section, please include the caption ``MedPAC Update Recommendation'' at the beginning of your comment.)

We are required by section 1886(e)(4)(B) of the Act to respond to MedPAC's IPPS recommendations in our annual proposed IPPS rule. We have reviewed MedPAC's March 2007 ``Report to the Congress: Medicare Payment Policy'' and have given it careful consideration in conjunction with the proposed policies set forth in this document. MedPAC's Recommendation 2A-1 states that, ``The Congress should increase payment rates for the acute inpatient and outpatient prospective payment systems in 2008 by the projected rate of increase in the hospital market basket index, concurrent with implementation of a quality incentive payment program.'' This recommendation is discussed in Appendix B to this proposed rule.

Recommendation 2A-2: MedPAC recommended that, ``Concurrent with implementation of severity adjustment to Medicare's diagnosis related group payments, the Congress should reduce the indirect medical education adjustment in fiscal year 2008 by 1 percentage point to 4.5 percent per 10 percent increment in the resident-to-bed ratio. The funds obtained from reducing the indirect medical education adjustment should be used to fund a quality incentive payment system.'' MedPAC further states that the IME adjustment is ``set above the empirical level which contributes to the large differences between teaching and nonteaching hospitals in financial performance under Medicare.'' MedPAC asserts that since there is no accountability for how IME funds are used, and teaching hospitals will benefit from implementation of the severity adjusted DRGs the IME adjustment should be reduced in FY 2008.

Response: We note that, MedPAC stated in its March 2007 Report that Congress made a conscious decision to fund the IME adjustment above the empirical level due to the concern for how teaching hospitals would fare under the PPS. Because the IME adjustment is set by Congress, as cited in section 1886(d)(5)(B) of the Act, any change to the IME adjustment, whether it is a 1 percentage point reduction or reduction of the IME adjustment to its empirical level, would require a statutory change. Therefore, absent a change to the IME provision in the Medicare statute for FY 2008, the IME adjustment will remain at the current level required by the statute, as specified in section IV.D. of this preamble.

Recommendation 2A-3: MedPAC recommended that, ``The Secretary should improve the form and accompanying instructions for collecting data on uncompensated care in the Medicare cost report and require hospitals to report using the revised form as soon as possible.'' MedPAC indicated that ``accurate data on hospitals'' charity care and bad debts are crucial to any effort to help develop a federal payment mechanism to help hospitals with their uncompensated care.''

Response: MedPAC convened an ``Expert Panel on Measuring Uncompensated Care'' on May 5, 2005, to address concerns raised by stakeholders on the usefulness of the S-10 Worksheet data. CMS' representatives participated in the discussions on this expert panel, and listened carefully to the concerns of MedPAC and the stakeholders about the S-10 Worksheet. MedPAC is recommending that we adopt the list of recommended changes to the S-10 Worksheet that resulted from the panel's discussion. CMS is currently undertaking a major update of the hospital cost report and will be making changes to the S-10 Worksheet form and accompanying instructions based on the panel's discussions with MedPAC.

In sections II.C. through E. of the preamble of this proposed rule, we further address the recommendations included in Recommendation 1 and Recommendation 3 in the March 2005 Report to Congress on Physician- Owned Specialty Hospitals. Recommendation 1 relates to refining the DRGs used under the IPPS to more fully capture differences in severity of illness among patients; basing the DRG relative weights on the estimated cost of providing care rather than on charges; and basing the weights on the national average of hospitals' relative values in each DRG. Recommendation 3 recommended that the Secretary implement MedPAC's recommended policies over a transition period.

For further information relating specifically to the MedPAC reports or to obtain a copy of the reports, contact MedPAC at (202) 653-7220, or visit MedPAC's website at: http://www.medpac.gov.

IX. Other Required Information

A. Requests for Data from the Public

In order to respond promptly to public requests for data related to the prospective payment system, we have established a process under which commenters can gain access to raw data on an expedited basis. Generally, the data are available in computer tape or cartridge format; however, some files are available on diskette as well as on the Internet at: http://www.cms.hhs.gov/providers/hipps. Data files and the

cost for each file, if applicable, are listed below. Anyone wishing to purchase

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data tapes, cartridges, or diskettes should submit a written request along with a company check or money order (payable to CMS-PUF) to cover the cost to the following address: Centers for Medicare & Medicaid Services, Public Use Files, Accounting Division, P.O. Box 7520, Baltimore, MD 21207-0520, (410) 786-3691. Files on the Internet may be downloaded without charge. 1. CMS Wage Data Public Use File

This file contains the hospital hours and salaries from Worksheet S-3, Parts II and Parts III from FY 2004 cost reports used to create the proposed FY 2008 IPPS wage index. The file is typically available by the end of February each year for the NPRM and will be available by the beginning of May for the final rule.

PPS Processing year

Wage data fiscal year year

2007.............................................. 2004 2008 2006.............................................. 2003 2007 2005.............................................. 2002 2006

Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage .

Periods Available: FY 2006 through 2008 IPPS Updates. 2. CMS Occupational Mix Data Public Use File

This file contains the occupational mix survey data to be used to compute the occupational mix adjusted wage indexes. The file is typically available by the end of February each year for the NPRM and will be available by the beginning of May for the final rule.

Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage .

Periods Available: FY 2008 PPS Update. 3. Final AHWs for FY 2007 and Proposed AHWs for FY 2008 by CBSA Public Use File

This file includes CBSAs, and the AHWs by CBSA for FY 2007 (final data) and FY 2008 (proposed data). This file is typically available by the end of February each year for the NPRM.

Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage .

Periods Available: FY 2008 IPPS Proposed Rule Update. 4. FY 2008 Occupational Mix Adjusted and Unadjusted AHWs by Provider

This file is available after publication of each IPPS NPRM and final rule, and includes provider number, CBSA, the provider's unadjusted and occupational mix adjusted AHW, and the percent difference between the two.

Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage .

Periods Available: FY 2008 IPPS Update. 5. FY 2008 Occupational Mix Adjusted and Unadjusted AHWs and Pre- Reclass Wage Indexes by CBSA

This file is available after publication of each IPPS NPRM and final rule, and is organized by CBSA, and contains total CBSA occupational mix wages, total CBSA hours, CBSA occupational mix adjusted AHWs, CBSA occupational mix adjusted pre-reclass wage indexes, total CBS unadjusted wages, CBSA unadjusted AHWs, and unadjusted pre- reclass wage indexes.

Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage .

Periods Available: FY 2008 IPPS Update. 6. FY 2008 Occupational Mix Factor by Provider Public Use File

This file is available after publication of each IPPS NPRM and final rule, and is organized by provider, and includes occupational mix adjusted and unadjusted wages, occupational mix adjusted and unadjusted AHWs, the nurse occupational mix adjustment factor, and the CBSA nurse occupational mix adjustment factor.

Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage .

Periods Available: FY 2008 IPPS Update. 7. FY 2008 Average Hourly Wage by Provider and CBSA Public Use File

This file is available after publication of each IPPS NPRM and final rule, and includes occupational mix adjusted wages, hours, occupational mix adjusted AHWs, and pre-reclass occupational mix adjusted wage indexes, by provider and CBSA.

Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage .

Periods Available: FY 2008 IPPS Update. 8. IPPS SSA/FIPS CBSA State and County Crosswalk

This file contains a crosswalk of State and county codes used by the Social Security Administration (SSA) and the Federal Information Processing Standards (FIPS), county name, Core Based Statistical Area (CBSA), and the historical list of Metropolitan Statistical Areas (MSAs).

Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/FFD/list.asp#TopOfPage .

Periods Available: FY 2008 IPPS Update. 9. FY 2008 Proposed Rule AHW by Provider Area Listing

This file contains a spreadsheet with two tabs: One for providers that are geographically located in an area, and one for providers that are reclassifying. The first tab includes the pre-reclass occupational mix adjusted total wages and AHWs by provider and CBSA, and the second tab lists the providers that are reclassifying and their post-reclass occupational mix adjusted total wages and AHWs by provider and CBSA. This file is typically posted after publication of the IPPS NPRM each year.

Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage .

Periods Available: FY 2008 IPPS Proposed Rule Update. 10. PPS-IV to PPS-XII Minimum Data Set

The Minimum Data Set contains cost, statistical, financial, and other information from Medicare hospital cost reports. The data set includes only the most current cost report (as submitted, final settled, or reopened) submitted for a Medicare participating hospital by the Medicare fiscal intermediary to CMS. This data set is updated at the end of each calendar quarter and is available on the last day of the following month.

Media: Compact Disc (CD).

File Cost: $100.00 per year.

Periods beginning and before on or after

PPS-IV........................................ 10/01/86 10/01/87 PPS-V......................................... 10/01/87 10/01/88 PPS-VI........................................ 10/01/88 10/01/89 PPS-VII....................................... 10/01/89 10/01/90 PPS-VIII...................................... 10/01/90 10/01/91 PPS-IX........................................ 10/01/91 10/01/92 PPS-X......................................... 10/01/92 10/01/93 PPS-XI........................................ 10/01/93 10/01/94 PPS-XII....................................... 10/01/94 10/01/95

(Note: The PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-XVIII, PPS- XIX PPS-XX, PPS-XXI, and PPS-XX-II Minimum Data Sets are part of the PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-XVIII, PPS-XIX, PPS- XX, PPS-XXI, and PPS-XXII Hospital Data Set Files (refer to item 10 below).)

11. PPS-XIII to PPS-XXII Hospital Data Set

The file contains cost, statistical, financial, and other data from the Medicare Hospital Cost Report. The data set includes only the most current cost

[[Page 24828]]

report (as submitted, final settled, or reopened) submitted for a Medicare-certified hospital by the Medicare fiscal intermediary to CMS. The data set is updated at the end of each calendar quarter and is available on the last day of the following month.

Media: Compact Disc (CD).

File Cost: $100.00.

Periods beginning and before on or after

PPS-XIII...................................... 10/01/95 10/01/96 PPS-XIV....................................... 10/01/96 10/01/97 PPS-XV........................................ 10/01/97 10/01/98 PPS-XVI....................................... 10/01/98 10/01/99 PPS-XVII...................................... 10/01/99 10/01/00 PPS-XVIII..................................... 10/01/00 10/01/01 PPS-XIX....................................... 10/01/01 10/01/02 PPS-XX........................................ 10/01/02 10/01/03 PPS-XXI....................................... 10/01/03 10/01/04 PPS-XXII...................................... 10/01/04 10/01/05

12. 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: Internet at http://www.cms.hhs.gov/ProspMedicareFeeSvcPmtGen/Downloads/INP_psf0107.zip .

Periods Available: FY 2008 PPS Update. 13. CMS Medicare Case-Mix Index File

The Medicare case-mix indexes by provider number are published in table 2 of 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.

Final rule published in the Federal Register.

Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage .

Periods Available: FY 2006 through FY 2008. 14. DRG Relative Weights (Table 5 DRG)

This file contains a listing of DRGs, DRG narrative descriptions, relative weights, and geometric and arithmetic mean lengths of stay as published in the Federal Register. There are two versions of this file as published in the Federal Register:

NPRM.

Final rule.

Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/FFD/list.asp#TopOfPage .

Periods Available: FY 2006 through FY 2008 PPS Update. 15. 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.

Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/FFD/list.asp#TopOfPage and http://www.cms.hhs.gov/AcuteInpatientPPS/HIF/

ttp:// ">http://www.cms.hhs.gov/AcuteInpatientPPS/HIF/S/HIF/

Periods Available: FY 1994 through FY 2008 PPS Update 16. 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 refer 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.

Final rule published in the Federal Register.

Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/FFD/list.asp#TopOfPage .

Periods Available: FY 2008 PPS Update. 17. Prospective Payment System (PPS) Standardizing File

This file contains information that standardizes the charges used to calculate relative weights to determine payments under the prospective payment system. Variables include wage index, cost-of- living adjustment (COLA), case-mix index, disproportionate share, and the Metropolitan Statistical Area (MSA). The file supports the following:

NPRM published in the Federal Register.

Final rule published in the Federal Register.

Media: Internet.

Periods Available: FY 2008 PPS Update.

For further information concerning these data tapes, contact the CMS Public Use Files Hotline at (410) 786-3691.

Commenters interested in obtaining or discussing any other data used in constructing this proposed rule should contact Mark Hartstein at (410) 786-4548.

B. Collection of Information Requirements

Under the Paperwork Reduction Act of 1995 (PRA), we are required to provide 60-day notice in the Federal Register and solicit public comment before 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 PRA requires that we solicit comment on the following issues:

The need for the information collection and its usefulness in carrying out the proper functions of our agency.

The accuracy of our estimate of the information collection burden.

The quality, utility, and clarity of the information to be collected.

Recommendations to minimize the information collection burden on the affected public, including automated collection techniques.

We are soliciting public comment on each of these issues for the following sections of this document that contain information collection requirements.

Section 412.103 Special Treatment: Hospitals Located in Urban Areas and That Apply for Reclassifications as Rural

Section 412.103(g)(1) states that (1) for a hospital paid on the basis of reasonable costs, the hospital may cancel its rural reclassification by submitting a written request to the CMS Regional Office not less than 120 days prior to the end of its current cost reporting period, and (2) for a hospital paid under the hospital inpatient prospective payment system, the hospital may cancel its rural reclassification by submitting a written request to the CMS Regional Office not less than 120 days prior to the end of a Federal fiscal year and after being paid as rural for at least one 12-month cost reporting period.

[[Continued on page 24829]]

From the Federal Register Online via GPO Access [wais.access.gpo.gov] ]

[[pp. 24829-24878]] Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates

[[Continued from page 24828]]

[[Page 24829]]

The burden associated with these requirements is the time and effort required for a hospital to develop, draft, and submit its written request for the cancellation of its rural reclassification. While these requirements are subject to the PRA, we believe the burden is exempt under 5 CFR 1320.3(c)(4). We believe that the information collection requirements in Sec. 412.103(g)(1) and Sec. 421.103(g)(2), respectively, will impact less than 10 entities. The notices will be submitted by individual hospitals and will be reviewed on a case-by- case basis.

Section 489.20 Basic Commitments

Proposed Sec. 489.20(u)(1) would require physician-owned hospitals, as defined in Sec. 489.3, to furnish notice to all patients that the hospital is a physician-owned hospital. The notice must be furnished at the beginning of their hospital stay or outpatient visit. The burden associated with the aforementioned requirements is the time and effort associated with a physician-owned hospital developing a generic notice and providing notice to the patients. Approximately 175 physician-owned hospitals must comply with this requirement. We estimate that it will require a hospital's general counsel 4 hours to develop a standard notice to be furnished to all patients upon admission as an inpatient or an outpatient.

In addition, we estimate that it will take 30 seconds to provide the notice to a patient and it will take another 30 seconds to maintain a copy of the disclosure in the patient's medical record. On average, each hospital will be required to make 1,092 disclosures per year. The total burden associated with the requirements in Sec. 489.20(u)(1) is 3,885 annual burden hours.

Proposed Sec. 489.20(v) would require all hospitals, as defined in Sec. 489.24(b), to furnish all patients notice, in accordance with Sec. 482.13(b)(2), at the beginning of their hospital stay or outpatient visit if a doctor of medicine or a doctor of osteopathy is not present in the hospital 24 hours per day, 7 days per week. The notice must indicate how the hospital will meet the medical needs of any inpatient who develops an emergency medical condition, as defined in Sec. 489.24(b), at a time when there is no physician present in the hospital. The burden associated with this requirement is the time and effort necessary for each hospital to develop a standard notice to furnish to its patients. We believe 2,504 hospitals will be required to comply with this requirement. Complying with the requirement will require a hospital's general counsel 4 hours to develop a standard notice. In addition, we estimate that it will take 30 seconds to provide the notice to a patient, and it will take another 30 seconds to maintain a copy of the disclosure in the patient's medical record. On average, each hospital will be required to make 1,092 disclosures per year. The total burden associated with the requirements in Sec. 489.20(v)(1) is 55,588 annual burden hours.

Estimated Annual Reporting and Recordkeeping Burden

Total Burden per annual Requirements

OMB control number Respondents Responses response burden (hours) (hours)

Sec. 489.20(u)(1).............. 0938-New...........

175

700 ...................

175

191,100 .016667

3,185 Sec. 489.20(v)(1).............. 0938-New...........

2,504

4 10,016 ...................

2,504 2,734,368 .016667 45,572

Total........................ ................... .............. .............. ........... 59,473

This proposed rule imposes collection of information requirements as outlined in the regulation text and specified above. However, this proposed rule also makes reference to several associated information collections that are not discussed in the regulation text. The following is a discussion of these collections, which have already received the Office of Management and Budget's (OMB) approval.

Proposed Add-on Payments for New Services and Technologies

Section II.I.1 of the preamble of this proposed rule discusses proposed add-on payments for new services and technologies. Specifically, this section states that applicants for add-on payments for new medical services or technologies for FY 2009 must submit a formal request. A formal request includes a full description of the clinical applications of the medical service or technology and the results of any clinical evaluations demonstrating that the new medical service or technology represents a substantial clinical improvement. In addition, the request must contain a significant sample of the data to demonstrate that the medical service or technology meets the high-cost threshold.

We also detailed the burden associated with this requirement in a final rule published in the Federal Register on September 7, 2001 (66 FR 46902). As stated in that final rule, we believe the associated burden is exempt from the PRA as stipulated under 5 CFR 1320.3(h)(6). Collection of the information for this requirement will be conducted on individual case-by-case basis.

Occupational Mix Adjustment to the FY 2008 Index (Hospital Wage Index Occupational Mix Survey)

Section III. of the preamble of this proposed rule details the proposed changes to the hospital wage index. Specifically, section III.C addresses the proposed occupational mix adjustment to the proposed FY 2008 index. While the preamble does not contain any new information collection requirements, it is important to note that there is an OMB approved collection associated with the hospital wage index.

As stated in section III.C. of the preamble of this proposed rule, section 304(c) of Pub. L. 106-554 amended section 1886(d)(3)(E) of the Act to require CMS to collect data at least once every 3 years on the occupational mix of employees for each short-term, acute care hospital participating in the Medicare program, in order to construct an occupational mix adjustment to the wage index. We collect the data via the occupational mix survey.

The burden associated with this information collection request is the time and effort required to collect and submit the data in the Hospital Wage Index Occupational Mix Survey to CMS. While this burden is subject to the PRA, it is already approved under OMB control number 0938-0907, with an expiration date of May 31, 2009.

[[Page 24830]]

Revisions to the Wage Index Based on Hospital Redesignations (Medicare Geographic Classification Review Board)

As noted in section III.I of the preamble of this proposed rule, section 1886(d)(10) of the Act established the MGCRB, an entity that has the authority to accept IPPS hospital applications requesting geographic reclassification for wage index or standardized payment amounts and to issue decisions on these requests. It is important for CMS to ensure the accuracy of the MGCRB decisions and remain apprised of potential payment impacts. Our regulations at Sec. 412.256 require a hospital to submit a copy of its MGCRB application to CMS.

The burden associated with this requirement is the time and effort associated with a hospital compiling and submitting a copy of its MGCRB application to CMS. While this requirement is subject to the PRA, the burden is approved under OMB control number 0938-0573, with an expiration date of November 30, 2008.

Reporting of Hospital Quality Data for Annual Hospital Payment Update

As noted in section IV.A.1 of the preamble of this proposed rule, section 5001(a) of the DRA sets out new requirements for the RHQDAPU program. The RHQDAPU program was established to implement section 501(b) of Pub. L. 108-173, thereby expanding our Hospital Quality Initiative. The RHQDAPU program originally consisted of a ``starter set'' of 10 quality measures. Hospitals participating in the hospital quality initiative submit their quality data on the 10 measures to receive an increase in their Medicare Annual Payment Update. The Office of Management and Budget approved the collection of data associated with the original starter set of quality measures under OMB control number 0938-0918, with an expiration date of January 31, 2010.

However, we recently submitted a new information collection request containing additional quality measures to OMB for approval. The new measures collect data for the Surgical Care Improvement Project (SCIP) and mortality measures. We announced and sought public comment on the information collection request in both 60-day and 30-day Federal Register notices that published on October 13, 2006 (71 FR 60532), and December 22, 2006 (71 FR 77026), respectively. The revised information collection request is currently under review at OMB.

Section IV.A.1 of the preamble of this proposed rule also discusses the use of the HCAHPS survey to capture quality data. The survey is designed to produce comparable data on the patient's perspective on care that allows objective and meaningful comparisons between hospitals on domains that are important to consumers. The HCAHPS survey is currently approved under OMB control number 0938-0981, with an expiration date of December 31, 2007.

Section IV.A.2.h of the preamble of this proposed rule addresses the reconsideration and appeal procedures for a hospital that we believe did not meet the RHQDAPU program requirements. If a hospital disagrees with our determination, it may submit a written request to us requesting that we reconsider our decision. The hospital's letter must explain the reasons it believes it did meet the RHQDAPU program requirements. While this is a reporting requirement, the burden associated with it is not subject to the PRA under 5 CFR 1320.4(a)(2). The burden associated with information collection requirements imposed subsequent to an administrative action is not subject to the PRA.

If you comment on these information collection and recordkeeping requirements, please mail copies directly to the following:

Centers for Medicare & Medicaid Services, Office of Strategic Operations and Regulatory Affairs, Regulations Development Group, Attn: William N. Parham, III, CMS-1533-P, Room C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850; and Office of Information and Regulatory Affairs, Office of Management and Budget, Room 10235, New Executive Office Building, Washington, DC 20503, Attn: Carolyn Lovett, CMS Desk Officer, CMS-1533-P, carolyn_lovett@omb.eop.gov. Fax (202) 395-6974.

C. Response to Comments

Because of the large number of comments we normally receive on Federal Register documents, we are not able to acknowledge or respond to them individually. We will consider all comments we receive by the date and time specified in the DATES section of this preamble, and, when we proceed with a subsequent document, we will respond to the comments in the preamble to that document.

List of Subjects

42 CFR Part 411

Kidney diseases, Medicare, Physician referral, Reporting and recordkeeping requirements.

42 CFR Part 412

Administrative practice and procedure, Health facilities, Medicare, Puerto Rico, Reporting and recordkeeping requirements.

42 CFR Part 413

Health facilities, Kidney diseases, Medicare, Puerto Rico, Reporting and recordkeeping requirements.

42 CFR Part 489

Health facilities, Medicare, Reporting and recordkeeping requirements.

For the reasons stated in the preamble of this proposed rule, the Centers for Medicare & Medicaid Services is proposing to amend 42 CFR Chapter IV as follows:

PART 411--EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT

1. The authority citation for Part 411 continues to read as follows:

Authority: Secs. 1102, 1860D-4(e)(6), 1871, and 1877(b)(4) and (5) of the Social Security Act (42 U.S.C. 1302, 1395w-10(e)(6), 1395hh, and 1395nn(b)(4) and (5).

2. Section 411.4 is amended by revising the introductory text of paragraph (b) to read as follows:

Sec. 411.4 Services for which neither the beneficiary nor any other person is legally obligated to pay.

* * * * *

(b) Special conditions for services furnished to individuals in custody of penal authorities. Individuals who are in custody include, but are not limited to, individuals who are under arrest, incarcerated, imprisoned, escaped from confinement, under supervised release, required to reside in mental health facilities, required to reside in halfway houses, required to live under home detention, or confined completely or partially in any way under a penal statute or rule. Payment may be made for services furnished to individuals or groups of individuals who are in the custody of police or other penal authorities or in the custody of a government agency under a penal statute only if the following conditions are met. * * * * *

[[Page 24831]]

PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES

3. The authority citation for Part 412 is revised to read as follows:

Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh), and sec. 124 of Pub. L. 106-113 (113 Stat. 1501A-332).

4. Section 412.2 is amended by adding a new paragraph (g) to read as follows:

Sec. 412.2 Basis for payment.

* * * * *

(g) Payment adjustment for certain replaced devices. CMS makes a payment adjustment for certain replaced devices, as provided under Sec. 412.89.

5. Section 412.4 is amended by--

a. Revising paragraphs (d)(3)(ii)(B) and (d)(3)(ii)(C).

b. Adding a new paragraph (d)(3)(ii)(D).

c. Revising paragraph (f)(3).

d. Revising the introductory text of paragraph (f)(5).

e. Revising paragraph (f)(5)(i).

f. Revising paragraph (f)(5)(iv).

g. Adding a new paragraph (f)(6).

The revisions and additions read as follows:

Sec. 412.4 Discharges and transfers.

* * * * *

(d) * * *

(3) * * * * * * * *

(ii) * * *

(B) The proportion of short-stay discharges to postacute care to total discharges in the DRG exceeds the 55th percentile for all DRGs;

(C) The DRG is paired with a DRG based on the presence or absence of a comorbidity or a complication or major cardiovascular condition that meets the criteria specified under paragraphs (d)(3)(ii)(A) and (d)(3)(ii)(B) of this section; and

(D) In the case of MS-DRGs that share the same base MS-DRG, if one MS-DRG meets the criteria specified under paragraph (d)(3)(ii)(B) of this section, every MS-DRG that shares the same base MS-DRG is a qualifying DRG. * * * * *

(f) * * *

(3) Transfer assigned to DRG for newborns that die or are transferred to another hospital. If a transfer is classified into CMS DRG 385 (Neonates, Died or Transferred) prior to October 1, 2007, or into MS-DRG 789 (Neonates, Died or Transferred to Another Acute Care Facility) on or after October 1, 2007, the transferring hospital is paid in accordance with Sec. 412.2(b). * * * * *

(5) Special rule for DRGs meeting specific criteria. For discharges occurring on or after October 1, 2005, and prior to October 1, 2007, a hospital that transfers an inpatient under the circumstances described in paragraph (c) of this section is paid using the provisions of paragraphs (f)(2)(i) and (f)(2)(ii) of this section if the transfer case is assigned to one of the DRGs meeting the following criteria:

(i) The DRG meets the criteria specified in paragraph (d)(3)(i) or (d)(3)(ii) of this section. * * * * *

(iv) If a DRG is paired with a DRG based on the presence or absence of a comorbidity or complication or a major cardiovascular complication that meets the criteria specified in paragraphs (f)(5)(i) through (f)(5)(iii) of this section, that DRG will also be paid under the provisions of paragraphs (f)(2)(i) and (f)(2)(ii) of this section.

(6) Special rule for DRGs meeting specific criteria. For discharges occurring on or after October 1, 2007, a hospital that transfers an inpatient under the circumstances described in paragraph (c) of this section is paid using the provisions of paragraphs (f)(2)(i) and (f)(2)(ii) of this section if the transfer case is assigned to one of the DRGs meeting the following criteria:

(i) The DRG meets the criteria specified in paragraph (d)(3)(i) or (d)(3)(ii) of this section;

(ii) The average charges of the 1-day discharge cases in the DRG must be at least 50 percent of the average charges for all cases in the DRG; and

(iii) The geometric mean length of stay for the DRG is greater than 4 days.

(iv) If a DRG is part of an MS-DRG group that meets the criteria specified in paragraphs (f)(6)(i) through (f)(6)(iii) of this section, that DRG will also be paid under the provisions of paragraphs (f)(2)(i) and (f)(2)(ii) of this section.

6. Section 412.64 is amended by--

a. Revising paragraph (b)(1)(ii)(B).

b. In paragraph (b)(3), designating the existing text as (b)(3)(i) and adding a new paragraph (b)(3)(ii).

c. Adding a new paragraph (e)(3).

d. Revising paragraph (i)(2).

The revisions read as follows:

Sec. 412.64 Federal rates for inpatient operating costs for Federal fiscal year 2005 and subsequent fiscal years.

* * * * *

(b) * * *

(1) * * *

(ii) * * *

(B) For discharges occurring on or after October 1, 1983, and before October 1, 2007, the following New England counties, which are deemed to be parts of urban areas under section 601(g) of the Social Security Amendments of 1983 (Public Law 98-21, 42 U.S.C. 1395ww (note); Litchfield County, Connecticut; York County, Maine; Sagadahoc County, Maine; Merrimack County, New Hampshire; and Newport County, Rhode Island. * * * * *

(3)(i) * * *

(ii) For discharges occurring on or after October 1, 2007, hospitals in the following New England counties, if not already located in an urban area, are deemed to be located in urban areas under section 601(g) of the Social Security Amendments of 1983 (Public Law 98-21, 42 U.S.C. 1395ww (note)): Litchfield County, Connecticut; York County, Maine; Sagadahoc County, Maine; Merrimack County, New Hampshire; and Newport County, Rhode Island. * * * * *

(e) * * *

(3) To the extent CMS determines that changes to the DRG classification and recalibrations of the DRG relative weights for a previous year (or estimates that such adjustments for a future fiscal year) did (or are likely to) result in a change in aggregate payments under this subsection during the fiscal year that are a result of changes in coding or classification of discharges that do not reflect real changes in case mix, CMS may adjust the standardized amount for subsequent fiscal years so as to eliminate the effect of such coding and classification changes.

(i) * * *

(2) Amount of adjustment. A hospital located in a county that meets the criteria under paragraphs (i)(1)(i) through (i)(1)(iii) of this section will receive an increase in its wage index that is equal to a weighted average of the difference between the postreclassified wage index of the MSA (or MSAs) with the higher wage index (or wage indices) and the postreclassified wage index of the MSA or rural statewide area in which the qualifying county is located, weighted by the overall percentage of the hospital employees residing in the qualifying county who are employed in any MSA with a higher wage index. * * * * *

7. The heading of Subpart F is revised to read as follows:

[[Page 24832]]

Subpart F--Payments for Outlier Cases, Special Treatment Payment for New Technology, and Payment Adjustment for Certain Replaced Devices

8. Section 412.88 is amended by revising the introductory text of paragraph (a)(2) to read as follows:

Sec. 412.88 Additional payment for new medical service or technology.

(a) * * *

(2) If the costs of the discharge (determined by applying the operating cost-to-charge ratios as described in Sec. 412.84(h)) exceed the full DRG payment, an additional amount equal to the lesser of-- * * * * *

9. A new undesignated center heading and a new Sec. 412.89 are added under Subpart F following Sec. 412.88 to read as follows:

Payment Adjustment for Certain Replaced Devices

Sec. 412.89 Payment adjustment for certain replaced devices.

(a) General rule. For discharges occurring on or after October 1, 2007, the amount of payment for a discharge described in paragraph (b) of this section is reduced when--

(1) A device is replaced without cost to the hospital;

(2) The provider received full credit for the cost of a device; or

(3) The provider receives a credit equal to 20 percent or more of the cost of the device.

(b) Discharges subject to payment adjustment. (1) Payment is reduced in accordance with paragraph (a) of this section only if the implantation of the device determines the DRG assignment.

(2) CMS lists the DRGs that qualify under paragraph (b)(1) of this section in the annual final rule for the hospital inpatient prospective payment system.

(c) Amount of reduction. (1) For a device provided to the hospital without cost, the cost of the device is subtracted from the DRG payment.

(2) For a device for which the hospital received a full or partial credit, the amount credited is subtracted from the DRG payment.

10. Section 412.103 is amended by revising paragraph (g) to read as follows:

Sec. 412.103 Special treatment: Hospitals located in urban areas and that apply for reclassifications as rural.

* * * * *

(g) Cancellation of classification--(1) Hospitals paid on basis of reasonable costs. For a hospital paid on the basis of reasonable costs--

(i) A hospital may cancel its rural reclassification by submitting a written request to the CMS Regional Office not less than 120 days prior to the end of its current cost reporting period.

(ii) The hospital's cancellation of the classification is effective beginning with the next full cost reporting period.

(2) Hospitals paid under the hospital inpatient prospective payment system. For a hospital paid under the hospital inpatient prospective payment system--

(i) A hospital may cancel its rural reclassification by submitting a written request to the CMS Regional Office not less than 120 days prior to the end of a Federal fiscal year and after being paid as rural for at least one 12-month cost reporting period.

(ii) The hospital's cancellation of the classification is not effective until it has been paid as rural for at least one 12-month cost reporting period, and not until the beginning of the Federal fiscal year following such 12-month cost reporting period.

11. Section 412.105 is amended by adding a sentence at the end of paragraph (f)(1)(iii)(A) to read as follows:

Sec. 412.105 Special treatment: Hospitals that incur indirect costs for graduate medical education programs.

* * * * *

(f) * * *

(1) * * *

(iii) * * *

(A) * * * Effective for cost reporting periods beginning on or after October 1, 2007, vacation leave and sick leave (that do not prolong the total time a resident is participating in the approved program beyond the normal duration of the program) are not included in the determination of full-time equivalency. * * * * *

12. Section 412.308 is amended by--

a. Revising paragraph (c)(1)(ii).

b. Adding new paragraphs (c)(1)(iii) and (c)(1)(iv).

The revision and addition read as follows:

Sec. 412.308 Determining and updating the Federal rate.

* * * * *

(1) * * *

(ii) Effective FY 1996. Except as specified in paragraph (c)(1)(iii) of this section, effective FY 1996, the standard Federal rate is updated based on an analytical framework. The framework includes a capital input price index, which measures the annual change in the prices associated with capital-related costs during the year. CMS adjusts the capital input price index rate of change to take into account forecast errors, changes to the case-mix index, the effect of changes to DRG classification and relative weights, and allowable changes in the intensity of hospital services.

(iii) Effective FY 2008. Effective FY 2008, the update to the standard Federal rate for urban hospitals equals 0 and the update for rural hospitals is determined based on an analytical framework as described in paragraph (c)(1)(ii) of this section.

(iv) Definition of urban and rural hospital. For purposes of paragraph (c)(1)(iii) of this section, an urban hospital is a hospital located in an area that meets the definition under Sec. 412.64(b)(1)(ii)(A) or Sec. 412.64(b)(1)(ii)(B) or that is deemed to be located in an urban area under Sec. 412.64(b)(3). A rural hospital includes a hospital reclassified under Sec. 412.103. * * * * *

13. Section 412.316 is amended by--

a. Revising the introductory text of paragraph (b).

b. Revising paragraph (b)(2).

c. Revising paragraph (b)(3).

The revisions read as follows:

Sec. 412.316 Geographic adjustment factor.

* * * * *

(b) Large urban location. For discharges occurring on or before September 30, 2007, CMS provides an additional payment to a hospital located in a large urban area equal to 3.0 percent of what would otherwise be payable to the hospital based on the Federal rate. * * * * *

(2) For discharges occurring on or after October 1, 2004, and before October 1, 2007, the definition of large urban areas under Sec. 412.63(c)(6) continues to be in effect for purposes of the payment adjustment under this section, based on the geographic classification under Sec. 412.64, except as provided for in paragraph (b)(3) of this section.

(3) For purposes of this section, the geographic classifications specified under Sec. 412.64 apply, except that, effective for discharges occurring on or after October 1, 2006, and before October 1, 2007, for an urban hospital that is reclassified as rural as set forth in Sec. 412.103, the geographic classification is rural. * * * * *

14. Section 412.517 is amended by--

a. Redesignating the introductory text and paragraphs (a), (b), (c), and (d) as paragraphs (a) introductory text, (a)(1), (a)(2), (a)(3), and (a)(4), respectively.

b. Reserving paragraph (b).

c. Adding a new paragraph (c).

[[Page 24833]]

The additions read as follows:

Sec. 412.517 Revision of LTC-DRG group classifications and weighting factors.

* * * * *

(b) [Reserved]

(c) To the extent CMS determines that changes to the DRG classifications and recalibrations of the DRG relative weights for a previous year (or estimates that such adjustments for a future fiscal year) did (or are likely to) result in a change in aggregate payments under this subpart during the fiscal year that are a result of changes in coding or classification of discharges that do not reflect real changes in case mix, CMS may adjust the DRG relative weights for subsequent fiscal years so as to eliminate the effect of such coding and classification changes.

PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES

15. The authority citation for Part 413 is revised to read as follows:

Authority: Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (i), and (n), 1861(v), 1871, 1881, 1883, and 1886 of the Social Security Act (42 U.S.C. 1302, 1395d(d), 1395f(b), 1395g, 1395l(a), (i), and (n), 1395x(v), 1395hh, 1395rr, 1395tt, and 1395ww); and sec. 124 of Pub. L. 106-133 (113 Stat. 1501A-332).

16. Section 413.75(b) is amended by--

a. Adding in alphabetical order a definition of ``orientation activities''.

b. Revising the definition of ``patient care activities''.

The addition and revision read as follows:

Sec. 413.75 Direct GME payments: General requirements.

* * * * *

(b) * * *

Orientation activities means activities that are principally designed to prepare an individual for employment as a resident in a particular setting, or for participation in a particular specialty program and patient care activities associated with that particular specialty program.

Patient care activities means the care and treatment of particular patients, including services for which a physician or other practitioner may bill, and orientation activities as defined in this section. * * * * *

17. Section 413.78 is amended by adding a sentence at the end of paragraph (b) to read as follows:

Sec. 413.78 Direct GME payments: Determination of the total number of FTE residents.

* * * * *

(b) * * * Effective for cost reporting periods beginning on or after October 1, 2007, vacation leave and sick leave (that do not prolong the total time a resident is participating in the approved program beyond the normal duration of the program) are not included in the determination of full-time equivalency. * * * * *

PART 489--PROVIDER AGREEMENTS AND SUPPLIER APPROVAL

18. The authority citation for part 489 is amended to read as follows:

Authority: Secs. 1102, 1819, 1820(e), 1861, 1864(m), 1866, 1869, and 1871 of the Social Security Act (41 U.S.C. 1302, 1395i-3, 1395x, 1395aa(m), 1395cc, 1395ff, and 1395hh)

19. Section 489.3 is amended by adding a definition of ``physician- owned hospital'' in alphabetical order to read as follows:

Sec. 489.3 Definitions.

* * * * *

Physician-owned hospital means any participating hospital (as defined in Sec. 489.24) in which a physician or physicians have an ownership or investment interest. The ownership or investment interest may be through equity, debt, or other means, and includes an interest in an entity that holds an ownership or investment interest in the hospital.

20. Section 489.12 is amended by--

a. Revising paragraph (a)(2).

b. Redesignating paragraph (a)(3) as paragraph (a)(4).

c. Adding a new paragraph (a)(3).

The revision and addition read as follows:

Sec. 489.12 Decision to deny an agreement.

(a) * * *

(2) The prospective provider has failed to disclose ownership and control interests in accordance with Sec. 420.206 of this chapter;

(3) The prospective provider is a physician-owned hospital as defined in Sec. 489.3 and does not have procedures in place for making physician ownership disclosures to patients in accordance with Sec. 489.20(u) of this chapter; or * * * * *

21. Section 489.20 is amended by adding new paragraphs (u) and (v) to read as follows:

Sec. 489.20 Basic commitments.

* * * * *

(u) In the case of a physician-owned hospital as defined in Sec. 489.3--

(1) To furnish all patients notice, in accordance with Sec. 482.13(b)(2), at the beginning of their hospital stay or outpatient visit that the hospital is a physician-owned hospital. The notice should disclose, in a manner reasonably designed to be understood by all patients, the fact that the hospital meets the Federal definition of a physician-owned hospital specified in Sec. 489.3 and that the list of the hospital's physician owners or investors is available upon request. For the purposes of this paragraph, the hospital stay or outpatient visit begins with the provision of a package of information regarding scheduled preadmission testing and registration for a planned hospital admission for inpatient care or outpatient service.

(2) To require all physician owners who also are members of the hospital's medical staff to agree, as a condition of continued medical staff membership, to disclose in writing their ownership interest in the hospital to all patients they refer to the hospital. Disclosure shall be required at the time the referral is made.

(v) In the case of a hospital as defined in Sec. 489.24(b), to furnish all patients written notice, in accordance with Sec. 482.13(b)(2), at the beginning of their hospital stay or outpatient visit if a doctor of medicine or a doctor of osteopathy is not present in the hospital 24 hours per day, seven days per week. The notice must indicate how the hospital will meet the medical needs of any inpatient who develops an emergency medical condition, as defined in Sec. 489.24(b), at a time when there is no physician present in the hospital. For purposes of this paragraph, the hospital stay or outpatient visit begins with the provision of a package of information regarding scheduled preadmission testing and registration for a planned hospital admission for inpatient care or the provision of a package of information regarding an outpatient service.

22. Section 489.24 is amended by revising paragraph (a)(2) to read as follows:

Sec. 489.24 Special responsibilities of Medicare hospitals in emergency cases.

(a) * * *

(2) Nonapplicability of provisions of this section. Sanctions under this section for an inappropriate transfer during a national emergency or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department located in an emergency area, as specified in section 1135(g)(1) of

[[Page 24834]]

the Act. A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided for by section 1135(e)(1)(B) of the Act. * * * * *

23. Section 489.53 is amended by--

a. Redesignating paragraph (c) and (d) as paragraphs (d) as (e), respectively.

b. Adding a new paragraph (c).

c. In newly redesignated paragraph (d) introductory text, removing the cross-reference ``paragraph (c)(2) of this section'' and adding the reference ``paragraph (d)(2) of this section'' in its place.

The revisions and additions read as follows:

Sec. 489.53 Termination by CMS.

* * * * *

(c) Termination of agreements with physician-owned hospitals. In the case of a physician-owned hospital, as defined at Sec. 489.3, CMS may terminate the provider agreement if the hospital failed to comply with the requirements of Sec. 489.20(u). * * * * *

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

Dated: April 13, 2007. Leslie Norwalk, Acting Administrator, Centers for Medicare & Medicaid Services.

Dated: April 13, 2007. Michael O. Leavitt, Secretary.

Editorial Note: The following Addendum and appendices will not appear in the Code of Federal Regulations.

Addendum--Proposed Schedule of Standardized Amounts, Update Factors, and Rate-of-Increase Percentages Effective With Cost Reporting Periods Beginning On or After October 1, 2007

I. Summary and Background

In this Addendum, we are setting forth the proposed methods and data we are using to determine the proposed prospective payment rates for Medicare hospital inpatient operating costs and Medicare hospital inpatient capital-related costs. We are also setting forth the proposed rate-of-increase percentages for updating the target amounts for certain hospitals and hospital units excluded from the IPPS. In general, except for SCHs, MDHs, and hospitals located in Puerto Rico, each hospital's payment per discharge under the IPPS is based on 100 percent of the Federal national rate, also known as the national adjusted standardized amount. This amount reflects the national average hospital cost per case from a base year, updated for inflation.

SCHs 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 costs per discharge; the updated hospital-specific rate based on FY 1987 costs per discharge; or the updated hospital-specific rate based on FY 1996 costs per discharge.

Under section 1886(d)(5)(G) of the Act, MDHs historically have been paid based on the Federal national rate or, if higher, the Federal national rate plus 50 percent of the difference between the Federal national rate and the updated hospital-specific rate based on FY 1982 or FY 1987 costs per discharge, whichever is higher. (MDHs did not have the option to use their FY 1996 hospital-specific rate.) Section 5003(a)(1) of Pub. L. 109-171 extended and modified the MDH special payment provision which was previously set to expire on October 1, 2006, to discharges occurring on or after October 1, 2006, but before October 1, 2011. Under section 5003(b) of Pub. L. 109-171, if the change results in an increase to its target amount, an MDH must rebase its hospital-specific rates to its FY 2002 cost report. In addition, under section 5003(c) of Pub. L. 109-171, MDHs are now paid based on the Federal national rate or, if higher, the Federal national rate plus 75 percent of the difference between the Federal national rate and the updated hospital-specific rate. Further, based upon section 5003(d) of Pub. L. 109-171, MDHs are no longer subject to the 12-percent cap on their DSH payment adjustment factor.

For hospitals in Puerto Rico, the payment per discharge is based on the sum of 25 percent of a Puerto Rico rate that reflects base year average costs per case of Puerto Rico hospitals and 75 percent of the Federal national rate. (See section II.D.3. of this Addendum for a complete description.)

As discussed below in section II. of this Addendum, we are proposing to make changes in the determination of the prospective payment rates for Medicare inpatient operating costs for FY 2008. In section III. of this Addendum, we discuss our proposed changes for determining the prospective payment rates for Medicare inpatient capital-related costs for FY 2008. Section IV. of this Addendum sets forth our proposed changes for determining the rate-of-increase limits for certain hospitals excluded from the IPPS for FY 2008. The tables to which we refer in the preamble of this proposed rule are presented in section VI. of this Addendum of this proposed rule.

II. Proposed Changes to Prospective Payment Rates for Hospital Inpatient Operating Costs

The basic methodology for determining prospective payment rates for hospital inpatient operating costs for FY 2005 and subsequent fiscal years is set forth at Sec. 412.64. The basic methodology for determining the prospective payment rates for hospital inpatient operating costs for hospitals located in Puerto Rico for FY 2005 and subsequent fiscal years is set forth at Sec. Sec. 412.211 and 412.212. Below we discuss the factors used for determining the prospective payment rates.

In summary, the proposed standardized amounts set forth in Tables 1A, 1B, 1C, and 1D of section VI. of this Addendum reflect--

Equalization of the standardized amounts for urban and other areas at the level computed for large urban hospitals during FY 2004 and onward, as provided for under section 1886(d)(3)(A)(iv) of the Act, updated by the applicable percentage increase required under sections 1886(b)(3)(B)(i)(XX) and 1886(b)(3)(B)(viii) of the Act.

The labor-related share that is applied to the standardized amounts and Puerto Rico-specific standardized amounts to give the hospital the highest payment, as provided for under sections 1886(d)(3)(E), and 1886(d)(9)(C)(iv) of the Act.

Proposed updates of 3.3 percent for all areas (that is, the estimated full market basket percentage increase of 3.3 percent), as required by section 1886(b)(3)(B)(i)(XX) of the Act, as amended by section 5001(a)(1) of Pub. L. 109-171, and reflecting the requirements of section 1886(b)(3)(B)(viii) of the Act, as added by section 5001(a)(3) of Pub. L. 109-171, to reduce the applicable percentage increase by 2.0 percentage points for a hospital that fails to submit data, in a form and manner specified by the Secretary, relating to the quality of inpatient care furnished by the hospital.

An adjustment to the standardized amount to ensure budget neutrality for DRG recalibration and reclassification, as provided for under section 1886(d)(4)(C)(iii) of the Act.

An adjustment to ensure the wage index update and changes are budget neutral, as provided for under section 1886(d)(3)(E) of the Act.

An adjustment to ensure the effects of geographic reclassification are budget neutral, as provided for in section 1886(d)(8)(D) of the Act, by removing the FY 2007 budget neutrality factor and applying a revised factor.

An adjustment to remove the FY 2007 outlier offset and apply an offset for FY 2008.

An adjustment to ensure the effects of the rural community hospital demonstration required under section 410A of Pub. L. 108-173 are budget neutral, as required under section 410A(c)(2) of Pub. L. 108-173.

An adjustment to eliminate the effect of coding or classification changes that do not reflect real changes in case-mix using the Secretary's authority under section 1886(d)(3)(A)(vi) of the Act (as discussed in section II.D.6. of the preamble to this proposed rule).

We note that two budget neutrality provisions will no longer be applied to the standardized amounts beginning with FY 2008. First, in the FY 2005 IPPS final rule (69 FR 49032 through 49034), we allowed urban hospitals that became rural under the new labor market area definitions to maintain their assignment to the MSA where they were previously located for the 3-year period of FY 2005, FY 2006, and FY 2007. In these years, we provided for a budget neutrality

[[Page 24835]]

adjustment to the standardized amount to ensure that this policy did not increase Medicare expenditures for hospital inpatient services. For FY 2008, this budget neutrality adjustment to the IPPS standardized amounts will no longer be necessary because the provision has expired. Second, in this proposed rule, we are proposing a prospective change to how budget neutrality is applied to implement the rural floor for FY 2008 and subsequent years. As discussed in section III.G.4. of the preamble of this proposed rule, we are proposing to apply the budget neutrality adjustment to hospital wage indices rather than the standardized amount.

A. Calculation of the Proposed Adjusted Standardized Amount

1. Standardization of Base-Year Costs or Target Amounts

In general, the national standardized amount is based on per discharge averages of adjusted hospital costs from a base period (section 1886(d)(2)(A) of the Act) or, for Puerto Rico, adjusted target amounts from a base period (section 1886(d)(9)(B)(i) of the Act), updated and otherwise adjusted in accordance with the provisions of section 1886(d) of the Act. The September 1, 1983 interim final rule (48 FR 39763) contained a detailed explanation of how base-year cost data (from cost reporting periods ending during FY 1981) were established in the initial development of standardized amounts for the IPPS. The September 1, 1987 final rule (52 FR 33043 and 33066) contains a detailed explanation of how the target amounts were determined, and how they are used in computing the Puerto Rico rates.

Sections 1886(d)(2)(B) and (d)(2)(C) of the Act require us to update base-year per discharge costs for FY 1984 and then standardize the cost data in order to remove the effects of certain sources of cost variations among hospitals. These effects include case-mix, differences in area wage levels, cost-of-living adjustments for Alaska and Hawaii, indirect medical education costs, and costs to hospitals serving a disproportionate share of low- income patients.

In accordance with section 1886(d)(3)(E) of the Act, the Secretary estimates, from time-to-time, the proportion of hospitals' costs that are attributable to wages and wage-related costs. In general, the standardized amount is divided into labor-related and nonlabor-related amounts; only the proportion considered the labor- related amount is adjusted by the wage index. Section 1886(d)(3)(E) of the Act requires that 62 percent of the standardized amount be adjusted by the wage index, unless doing so would result in lower payments to a hospital than would otherwise be made. (Section 1886(d)(9)(C)(iv)(II) of the Act extends this provision to the labor-related share for hospitals located in Puerto Rico.)

For FY 2008, we are not proposing to change the national and Puerto Rico-specific labor-related and nonlabor-related shares from the percentages established for FY 2007. Therefore, the labor- related share would continue to be 69.7 percent for the national standardized amounts and 58.7 percent for the Puerto Rico specific standardized amount. Consistent with section 1886(d)(3)(E) of the Act, we will apply the wage index to a labor-related share of 62 percent for all non-Puerto Rico hospitals whose wage indexes are less than or equal to 1.0000. For all non-Puerto Rico hospitals whose wage indices are greater than 1.0000, we will apply the wage index to a labor share of 69.7 percent of the national standardized amount. For a Puerto Rico hospital, we will apply a labor share of 58.7 percent if its Puerto Rico-specific wage index is less than or equal to 1.0000. For Puerto Rico hospitals whose Puerto Rico- specific wage index values are greater than 1.0000, we will apply a labor share of 62 percent.

The standardized amounts for operating costs appear in Table 1A, 1B, and 1C of the Addendum to this proposed rule.

2. Computing the Average Standardized Amount

Section 1886(d)(3)(A)(iv) of the Act requires that, beginning with FY 2004 and thereafter, an equal standardized amount is to be computed for all hospitals at the level computed for large urban hospitals during FY 2003, updated by the applicable percentage update. Section 1886(d)(9)(A) of the Act equalizes the Puerto Rico- specific urban and rural area rates. Accordingly, we are calculating FY 2008 national and Puerto Rico standardized amounts, irrespective of whether a hospital is located in an urban or rural location.

3. Updating the Average Standardized Amount

In accordance with section 1886(d)(3)(A)(iv)(II) of the Act, we are updating the equalized standardized amount for FY 2008 by the full estimated market basket percentage increase for hospitals in all areas, as specified in section 1886(b)(3)(B)(i)(XX) of the Act, as amended by section 5001(a)(1) of Pub. L. 109-171. 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 hospital market basket increase for FY 2008 is 3.3 percent. Thus, for FY 2008, the proposed update to the average standardized amount is 3.3 percent for hospitals in all areas. The estimated market basket increase of 3.3 percent is based on the 2007 first quarter forecast of the hospital market basket increase by the Office of the Actuary (as discussed in Appendix B of this proposed rule).

Section 1886(b)(3)(B) of the Act specifies the mechanism used to update the standardized amount for payment for inpatient hospital operating costs. Section 1886(b)(3)(B)(viii) of the Act, as added by section 5001(a)(3) of Pub. L. 109-171, provides for a reduction of 2.0 percentage points to the update percentage increase (also known as the market basket update) for FY 2007 and each subsequent fiscal year for any ``subsection (d) hospital'' that does not submit quality data as discussed in section IV.A. of the preamble of this proposed rule. The standardized amounts in Tables 1A through 1C of section VI. of the Addendum to this proposed rule reflect these differential amounts.

Although the update factors for FY 2008 are set by law, we are required by section 1886(e)(4) of the Act to recommend, taking into account MedPAC's recommendations, appropriate update factors for FY 2008 for both IPPS hospitals and hospitals and hospital units excluded from the IPPS. Our recommendation on the update factors (which is required by sections 1886(e)(4)(A) and (e)(5)(A) of the Act) is set forth in Appendix B of this proposed rule.

4. Other Adjustments to the Average Standardized Amount

As in the past, we are adjusting the FY 2008 standardized amount to remove the effects of the FY 2007 geographic reclassifications and outlier payments before applying the FY 2008 updates. We then apply budget neutrality offsets for outliers and geographic reclassifications to the standardized amount based on FY 2008 payment policies.

We do not remove the prior year's budget neutrality adjustments for reclassification and recalibration of the DRG weights and for updated wage data because, in accordance with sections 1886(d)(4)(C)(iii) and 1886(d)(3)(E) of the Act, estimated aggregate payments after the changes in the DRG relative weights and wage index should equal estimated aggregate payments prior to the changes. If we removed the prior year adjustment, we would not satisfy these conditions.

Budget neutrality is determined by comparing aggregate IPPS payments before and after making the changes that are required to be budget neutral (for example, changes to DRG classifications, recalibration of the DRG relative weights, updates to the wage index, and different geographic reclassifications). We include outlier payments in the simulations because they may be affected by changes in these parameters.

We are also proposing to adjust the standardized amount this year by an estimated amount to ensure that aggregate IPPS payments do not exceed the amount of payments that would have been made in the absence of the rural community hospital demonstration required under section 410A of Pub. L. 108-173. This demonstration is required to be budget neutral under section 410A(c)(2) of Pub. L. 108-173. For FY 2008 and FY 2009, we are also proposing an adjustment to eliminate the effect of coding or classification changes that do not reflect real changes in case-mix using the Secretary's authority under section 1886(d)(3)(A)(vi) of the Act.

a. Proposed 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 of this proposed rule, 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

[[Page 24836]]

recalibration. However, 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 payments to hospitals are affected by factors other than average case weight. Therefore, as we have done in past years, we are proposing to make a budget neutrality adjustment to ensure that the requirement of section 1886(d)(4)(C)(iii) of the Act is met.

Section 1886(d)(3)(E) of the Act requires us to update the hospital wage index on an annual basis beginning October 1, 1993. This provision also requires us to make any updates or adjustments to the wage index in a manner that ensures that aggregate payments to hospitals are not affected by the change in the wage index. Consistent with current policy, for FY 2008, we are adjusting 100 percent of the wage index factor for occupational mix. We describe the occupational mix adjustment in section III.C. of the preamble to this proposed rule.

To comply with the requirement that DRG reclassification and recalibration of the relative weights and the updated wage index be budget neutral, we are using FY 2006 discharge data to simulate payments and compare aggregate payments using the FY 2007 relative weights and wage indexes to aggregate payments using the proposed FY 2008 relative weights and wage indexes. The same methodology was used for the FY 2007 budget neutrality adjustment. Based on this comparison, we computed a budget neutrality adjustment factor equal to 0.999317 to be applied to the national standardized amount. We also are adjusting the Puerto Rico-specific standardized amount for the effect of DRG reclassification and recalibration. We computed a budget neutrality adjustment factor of 0.998557 to be applied to the Puerto Rico-specific standardized amount. These budget neutrality adjustment factors are applied to the standardized amounts for FY 2007 without removing prior year budget neutrality adjustments. In addition, as discussed in section IV. of this addendum, we are applying the same DRG reclassification and recalibration budget neutrality factor of 0.998557 to the hospital-specific rates that are to be effective for cost reporting periods beginning on or after October 1, 2007.

b. Reclassified Hospitals--Budget Neutrality Adjustment

Section 1886(d)(8)(B) of the Act provides that, effective with discharges occurring on or after October 1, 1988, certain rural hospitals are deemed urban. In addition, section 1886(d)(10) of the Act provides for the reclassification of hospitals based on determinations by the MGCRB. Under section 1886(d)(10) of the Act, a hospital may be reclassified for purposes of the wage index.

Under section 1886(d)(8)(D) of the Act, the Secretary is required to adjust the standardized amount to ensure that aggregate payments under the IPPS 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. We note that the wage index adjustments provided under section 1886(d)(13) of the Act are not budget neutral. Section 1886(d)(13)(H) of the Act provides that any increase in a wage index under section 1886(d)(13) shall not be taken into account ``in applying any budget neutrality adjustment with respect to such index'' under section 1886(d)(8)(D) of the Act. To calculate the budget neutrality factor, we used FY 2006 discharge data to simulate payments, and compared total IPPS payments prior to any reclassifications under sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the Act to total IPPS payments after such reclassifications. Based on these simulations, we calculated an adjustment factor of 0.991938 to ensure that the effects of this reclassification are budget neutral, consistent with the statute.

The proposed adjustment factor is applied to the standardized amount after removing the effects of the FY 2007 budget neutrality adjustment factor. We note that the FY 2008 adjustment reflects FY 2008 wage index reclassifications approved by the MGCRB or the Administrator. (Section 1886(d)(10)(D)(v) of the Act makes wage index reclassifications effective for 3 years. Therefore, the FY 2008 geographic reclassification could either be the continuation of a 3-year reclassification that began in FY 2006 or FY 2007 or a new one beginning in FY 2008.)

c. Case-Mix Budget Neutrality Adjustment

The proposed MS-DRGs will increase the total number of DRGs from 538 to 745. Such a significant expansion in the number of DRGs could lead hospitals to improve coding and documentation in order to have a case assigned to a DRG with a higher payment. As explained above, we make an adjustment to ensure that the DRG relative weights remain budget neutral assuming constant utilization. However, without an adjustment to the IPPS rates to account for expected case mix growth due to improved coding rather than to underlying changes in patient status, the change to severity DRGs will not be budget neutral. Section 1886(d)(3)(A)(vi) of the Act provides the Secretary with explicit authority to adjust the standardized amounts to account for case mix growth due to improved documentation and coding. Further, the Secretary may subsequently revisit this adjustment if actual data is different than the projection.

Based on the Actuary's analysis, using the Secretary's authority under section 1886(d)(3)(A)(vi) of the Act to adjust the standardized amount to eliminate the effect of changes in coding or classification of discharges that do not reflect real changes in case-mix, we are proposing to reduce the IPPS standardized amounts by 2.4 percent each year for FY 2008 and FY 2009. Section 1886(d)(3)(A)(vi) further gives the Secretary authority to revisit adjustments to the standardized amounts for changes in coding or classification of discharges that were based on estimates in a future year. Consistent with the statute, we will compare the actual increase in case-mix due to documentation and coding to our projection once we have actual data for FY 2008 and FY 2009 for the FY 2010 and FY 2011 IPPS rules. As that time, if necessary, we may make a further adjustment to the standardized amounts to account for the difference between our projection and actual data.

d. Outliers

Section 1886(d)(5)(A) of the Act provides for payments in addition to the basic prospective payments for ``outlier'' cases involving extraordinarily high costs. To qualify for outlier payments, a case must have costs greater than the sum of the prospective payment rate for the DRG, any IME and DSH payments, any new technology add-on payments, and the ``outlier threshold'' or ``fixed loss'' amount (a dollar amount by which the costs of a case must exceed payments in order to qualify for an outlier payment). We refer to the sum of the prospective payment rate for the DRG, any IME and DSH payments, any new technology add-on payments, and the outlier threshold as the outlier ``fixed-loss cost threshold.'' To determine whether the costs of a case exceed the fixed-loss cost threshold, a hospital's CCR is applied to the total covered charges for the case to convert the charges to estimated costs. Payments for eligible cases are then made based on a marginal cost factor, which is a percentage of the estimated costs above the fixed-loss cost threshold. The marginal cost factor for FY 2008 is 80 percent, the same marginal cost factor we have used since FY 1995 (59 FR 45367).

In accordance with section 1886(d)(5)(A)(iv) of the Act, outlier payments for any year are projected to be not less than 5 percent nor more than 6 percent of total operating DRG payments plus outlier payments. Section 1886(d)(3)(B) of the Act requires the Secretary to reduce the average standardized amount by a 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 reduce the average standardized amount applicable to hospitals in Puerto Rico to account for the estimated proportion of total DRG payments made to outlier cases. More information on outlier payments may be found on the CMS Web site at http://www.cms.hhs.gov/AcuteInpatientPPS/04_outlier.asp#TopOfPage .

(1) Proposed FY 2008 Outlier Fixed-Loss Cost Threshold

For FY 2008, we are proposing to use the same methodology used for FY 2007 (71 FR 48148 through 484151) to calculate the outlier threshold. Similar to the methodology used in the FY 2007 final rule, for FY 2008, we are applying an adjustment factor to the CCRs to account for cost and charge inflation (as explained below). As we have done in the past, to calculate the proposed FY 2008 outlier threshold, we simulated payments by applying FY 2008 rates and policies using cases from the FY 2006 MedPAR files. Therefore, in order to determine the proposed FY 2008 outlier threshold, we inflate the charges on the MedPAR claims by 2 years, from FY 2006 to FY 2008.

We are proposing to continue using a refined methodology that takes into account the lower inflation in hospital charges that is occurring as a result of the outlier final rule (68 FR 34494), which changed our methodology for determining outlier

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payments by implementing the use of more current CCRs. Our refined methodology uses more recent data that reflect the rate-of-change in hospital charges under the new outlier policy.

Using the most recent data available, we calculated the 1-year average annualized rate-of-change in charges-per-case from the last quarter of FY 2005 in combination with the first quarter of FY 2006 (July 1, 2005 through December 31, 2005) to the last quarter of FY 2006 in combination with the first quarter of FY 2007 (July 1, 2006 through December 31, 2006). This rate of change was 7.26 percent (1.0726) or 15.04 percent (1.1504) over 2 years.

As we have done in the past, we are proposing to establish the proposed FY 2008 outlier threshold using hospital CCRs from the December 2006 update to the Provider-Specific File--the most recent available at the time of this proposed rule. This file includes CCRs that reflect implementation of the changes to the policy for determining the applicable CCRs that became effective August 8, 2003 (68 FR 34494).

As discussed in the FY 2007 final rule (71 FR 48150), we worked with the Actuary to derive the methodology described below to develop the CCR adjustment factor. For FY 2008, we are proposing to use the same methodology by using the operating cost per discharge increase in combination with the final updated market basket increase determined by Global Insight, Inc., as well as the charge inflation factor described above to estimate the adjustment to the CCRs. By using the market basket rate-of-increase and the increase in the average cost per discharge from hospital cost reports, we are using two different measures of cost inflation. For FY 2008, we determined the adjustment by taking the percentage increase in the operating costs per discharge from FY 2004 to FY 2005 (1.0529) from the cost report and dividing it by the final market basket increase from FY 2005 (1.043) We repeated this calculation for 2 prior years to determine the 3-year average of the rate of adjusted change in costs between the market basket rate-of-increase and the increase in cost per case from the cost report (FY 2002 to FY 2003 percentage increase of operating costs per discharge of 1.0721 divided by FY 2003 final market basket increase of 1.041, FY 2003 to FY 2004 percentage increase of operating costs per discharge of 1.0624 divided by FY 2004 final market basket increase of 1.04). For FY 2008, we averaged the differentials calculated for FY 2003, FY 2004, and FY 2005 which resulted in a mean ratio of 1.0203. We multiplied the 3-year average of 1.0203 by the 2006 market basket percentage increase of 1.0420, which resulted in an operating cost inflation factor of 6.32 percent or 1.0632. We then divided the operating cost inflation factor by the 1-year average change in charges (1.0726) and applied an adjustment factor of 0.9912 to the operating CCRs from the Provider-Specific File.

As stated in the FY 2007 final rule, we continue to believe it is appropriate to apply only a one year adjustment factor to the CCRs. On average, it takes approximately 9 months for fiscal intermediaries (or, if applicable, the MAC) to tentatively settle a cost report from the fiscal year end of a hospital's cost reporting period. The average ``age'' of hospitals'' CCRs from the time the fiscal intermediary or the MAC inserts the CCR in the PSF until the beginning of FY 2007 is approximately 1 year. Therefore, as stated above, we believe a one year adjustment to the CCRs is appropriate.

We used the same methodology for the capital CCRs and applied an adjustment factor of 0.964 (cost inflation factor of 1.0340 divided by a charge inflation factor of 1.0726) to the capital CCRs. We are using the same charge inflation factor for the capital CCRs that was used for the operating CCRs. The charge inflation factor is based on the overall billed charges. Therefore, we believe it is appropriate to apply the charge factor to both the operating and capital CCRs.

Using this methodology, we are proposing an outlier fixed-loss cost threshold for FY 2008 equal to the prospective payment rate for the DRG, plus any IME and DSH payments, and any add-on payments for new technology, plus $23,015. With this threshold, we are projecting that outlier payments will equal 5.1 percent of total IPPS payments.

As we did in establishing the FY 2007 outlier threshold (71 FR 48149), in our projection of FY 2008 outlier payments, we are not making any adjustments for the possibility that hospitals' CCRs and outlier payments may be reconciled upon cost report settlement. We continue to believe that, due to the policy implemented in the outlier final rule (68 FR 34494, June 9, 2003), CCRs will no longer fluctuate significantly and, therefore, few hospitals will actually have these ratios reconciled upon cost report settlement. In addition, it is difficult to predict the specific hospitals that will have CCRs and outlier payments reconciled in any given year. We also noted that reconciliation occurs because hospitals' actual CCRs for the cost reporting period are different than the interim CCRs used to calculate outlier payments when a bill is processed. Our simulations assume that CCRs accurately measure hospital costs based on information available to us at the time we set the outlier threshold. For these reasons, we are not making any assumptions about the effects of reconciliation on the outlier threshold calculation.

We also note that there are several factors that contributed to a lower fixed loss outlier threshold for FY 2008 compared to FY 2007. First, the case-weighted national average operating CCR declined by approximately an additional 1.3 percentage points from the March 2006 (used to calculate the FY 2007 outlier threshold) to the December 2006 update of the Provider-Specific File. Second, we further reduced the CCRs by applying an adjustment to reflect the differential increase between costs and charges. As noted above, using lower CCRs from the December 2006 Provider-Specific File, in combination with the FY 2006 MedPAR claims and inflated charges, contributes to a lower outlier threshold for FY 2008 in this proposed rule compared to an outlier threshold of $24,485 in FY 2007. Finally, as discussed in section II.D. of the preamble of this proposed rule, we are proposing to adopt the use of MS-DRGs under the IPPS for FY 2008. The proposed MS-DRG system would increase the number of DRGs from 538 to 745 and better recognize severity of illness than the CMS DRGs. Better recognition of severity of illness with the MS-DRGs means that nonoutlier payments will compensate hospitals for the higher costs of some cases that previously received outlier payments. As cases are paid more accurately, in order to meet the 5.1 percent target, we would need to decrease the fixed-loss outlier threshold so that more cases qualify for outlier payments. Therefore, we believe that all of the above factors cumulatively contributed to a lower proposed fixed-loss outlier threshold in FY 2008 compared to FY 2007.

(2) Other Proposed Changes Concerning Outliers

As stated in the FY 1994 IPPS final rule (58 FR 46348, September 1, 1993), we establish outlier thresholds that are applicable to both hospital inpatient operating costs and hospital 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 lower percentage of outlier payments for capital-related costs than for operating costs. We are project that the proposed thresholds for FY 2008 would result in outlier payments equal to 5.1 percent of operating DRG payments and 4.87 percent of capital payments based on the Federal rate.

In accordance with section 1886(d)(3)(B) of the Act, we are reducing the FY 2008 standardized amount by the same percentage to account for the projected proportion of payments paid to outliers.

The outlier adjustment factors that would be applied to the standardized amount for the proposed FY 2008 outlier threshold are as follows:

Operating standardized Capital amounts federal rate

National................................

0.948989

0.948377 Puerto Rico.............................

0.965244

0.954922

Consistent with current policy, we are applying the outlier adjustment factors to FY 2008 rates after removing the effects of the FY 2007 outlier adjustment factors on the standardized amount.

To determine whether a case qualifies for outlier payments, we apply hospital-specific CCRs to the total covered charges for the case. Estimated operating and capital costs for the case are calculated separately by applying separate operating and capital CCRs. These costs are then combined and compared with the outlier fixed-loss cost threshold.

The outlier final rule (68 FR 34494) eliminated the application of the statewide average CCRs for hospitals with CCRs that fall below 3 standard deviations from the national mean CCR. However, for those hospitals for which the fiscal intermediary or MAC computes operating CCRs greater than 1.221 or capital CCRs greater than 0.150, or hospitals for whom the fiscal intermediary or MAC is unable to calculate a CCR (as described at Sec. 412.84(i)(3) of our regulations),

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we are still using statewide average CCRs to determine whether a hospital qualifies for outlier payments.\18\ Table 8A in section VI. of this Addendum contains the statewide average operating CCRs for urban hospitals and for rural hospitals for which the fiscal intermediary or MAC is unable to compute a hospital-specific CCR within the above range. Effective for discharges occurring on or after October 1, 2007, these statewide average ratios would replace the ratios published in the IPPS final rule for FY 2007 (71 FR 48303). Table 8B in section VI. of this Addendum contains the comparable statewide average capital CCRs. Again, the CCRs in Tables 8A and 8B would be used during FY 2008 when hospital-specific CCRs based on the latest settled cost report are either not available or are outside the range noted above. For an explanation of Table 8C, please see section VI. of this Addendum.

\18\ These figures represent 3.0 standard deviations from the mean of the log distribution of CCRs for all hospitals.

We finally note that we published a manual update (Change Request 3966) to outliers on October 12, 2005 which updated Chapter 3, Section 20.1.2 of the Medicare Claims Processing Manual. The manual update covered an array of topics, including CCRs, reconciliation, and the time value of money. We encourage hospitals that are assigned the statewide average operating and/or capital CCRs to work with their fiscal intermediaries or MAC on a possible alternative operating and/or capital CCR as explained in Change Request 3966. Use of an alternative CCR developed by the hospital in conjunction with the fiscal intermediary or MAC can avoid possible overpayments or underpayments at cost report settlement thus ensuring better accuracy when making outlier payments and negating the need for outlier reconciliation. We also note a hospital may request an alternative operating or capital CCR ratio at any time as long as the guidelines of Change Request 3966 are followed. To download and view the manual instructions on outlier and cost-to- charge ratios, please visit the Web site: http://www.cms.hhs.gov/manuals/downloads/clm104c03.pdf .

(3) FY 2006 and FY 2007 Outlier Payments

In the FY 2007 IPPS final rule (70 FR 47496), we stated that, based on available data, we estimated that actual FY 2006 outlier payments would be approximately 4.62 percent of actual total DRG payments. This estimate was computed based on simulations using the FY 2005 MedPAR file (discharge data for FY 2005 bills). That is, the estimate of actual outlier payments did not reflect actual FY 2006 bills, but instead reflected the application of FY 2006 rates and policies to available FY 2005 bills.

Our current estimate, using available FY 2006 bills, is that actual outlier payments for FY 2006 were approximately 4.50 percent of actual total DRG payments. Thus, the data indicate that, for FY 2006, the percentage of actual outlier payments relative to actual total payments is lower than we projected before FY 2006. Consistent with the policy and statutory interpretation we have maintained since the inception of the IPPS, we do not plan to make retroactive adjustments to outlier payments to ensure that total outlier payments for FY 2006 are equal to 5.1 percent of total DRG payments.

We currently estimate that actual outlier payments for FY 2007 will be approximately 4.9 percent of actual total DRG payments, 0.2 percentage points lower than the 5.1 percent we projected in setting the outlier policies for FY 2007. This estimate is based on simulations using the FY 2006 MedPAR file (discharge data for FY 2006 bills). We used these data to calculate an estimate of the actual outlier percentage for FY 2007 by applying FY 2007 rates and policies, including an outlier threshold of $24,485 to available FY 2006 bills. We believe the 0.2 percentage point difference between the projected estimate of outlier payments for FY 2007 and our current estimate of actual outlier payments in this proposed rule provides preliminary evidence that incorporating an adjustment factor to the CCRs for FY 2007 in response to public comments has improved our estimating methodology.

e. Proposed Rural Community Hospital Demonstration Program Adjustment (Section 410A of Pub. L. 108-173)

Section 410A of Pub. L. 108-173 requires the Secretary to establish a demonstration that will modify reimbursement for inpatient services for up to 15 small rural hospitals. Section 410A(c)(2) of Pub. L. 108-173 requires that ``in conducting the demonstration program under this section, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration program under this section was not implemented.'' As discussed in section IV.G. of the preamble to this proposed rule, we have satisfied this requirement by adjusting national IPPS rates by a factor that is sufficient to account for the added costs of this demonstration. We estimate that the average additional annual payment that will be made to each participating hospital under the demonstration will be approximately $1,075,765. We based this estimate on the recent historical experience of the difference between inpatient cost and payment for hospitals that are participating in the demonstration. For 9 participating hospitals, the total annual impact of the demonstration program is estimated to be $9,681,893. The required adjustment to the Federal rate used in calculating Medicare inpatient prospective payments as a result of the demonstration is 0.999899.

In order to achieve budget neutrality, we are adjusting the national IPPS rates by an amount sufficient to account for the added costs of this demonstration. In other words, we are applying budget neutrality across the payment system as a whole rather than merely across the participants of this demonstration, consistent with past practice. We believe that the language of the statutory budget neutrality requirement permits the agency to implement the budget neutrality provision in this manner. The statutory language requires that ``aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration * * * was not implemented,'' but does not identify the range across which aggregate payments must be held equal.

5. Proposed FY 2008 Standardized Amount

The proposed adjusted standardized amount is divided into labor- related and nonlabor-related portions. Tables 1A and 1B in section VI. of this Addendum contain the national standardized amount that we are proposing to apply to all hospitals, except hospitals in Puerto Rico. The proposed Puerto Rico-specific amounts are shown in Table 1C. The proposed amounts shown in Tables 1A and 1B differ only in that the labor-related share applied to the standardized amounts in Table 1A is 69.7 percent, and Table 1B is 62 percent. In accordance with sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act, we are applying a labor-related share of 62 percent, unless the application of that percentage would result in lower payments to a hospital than would otherwise be made. In effect, the statutory provision means that we will apply a labor-related share of 62 percent for all hospitals (other than those in Puerto Rico) whose wage indexes are less than or equal to 1.0000.

In addition, Tables 1A and 1B include proposed standardized amounts reflecting the proposed full 3.3 percent update for FY 2008, and proposed standardized amounts reflecting the 2.0 percentage point reduction to the update (a 1.3 percent update) applicable for hospitals that fail to submit quality data consistent with section 1886(b)(3)(B)(viii) of the Act.

Under section 1886(d)(9)(A)(ii) of the Act, the Federal portion of the Puerto Rico payment rate is based on the discharge-weighted average of the national large urban standardized amount (this proposed amount is set forth in Table 1A). The proposed labor- related and nonlabor-related portions of the national average standardized amounts for Puerto Rico hospitals for FY 2008 are set forth in Table 1C of section VI. of this Addendum. This table also includes the proposed Puerto Rico standardized amounts. The labor- related share applied to the proposed Puerto Rico specific standardized amount is 58.7 percent, or 62 percent, depending on which provides higher payments to the hospital. (Section 1886(d)(9)(C)(iv) of the Act, as amended by section 403(b) of Pub. L. 108-173, provides that the labor-related share for hospitals in Puerto Rico will be 62 percent, unless the application of that percentage would result in lower payments to the hospital.)

The following table illustrates the proposed changes from the FY 2007 national average standardized amount. The second column shows the proposed changes from the FY 2007 standardized amounts for hospitals that satisfy the quality data submission requirement for receiving the full update (3.3 percent). The third column shows the proposed changes for hospitals receiving the reduced update (1.3 percent). The first row of the table shows the proposed updated (through FY 2007) average standardized amount after restoring the FY 2007 offsets for outlier payments, demonstration budget neutrality, the wage index transition budget neutrality, and the

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geographic reclassification budget neutrality. The DRG reclassification and recalibration and wage index budget neutrality factor is cumulative. Therefore, the FY 2007 factor is not removed from this table. We have added two additional rows: One for the documentation and coding adjustment and the other for the rural floor adjustment. (For a complete discussion on the documentation and coding adjustment and the rural floor adjustment, see sections II.D.1.c and III.G.4 of the Addendum to this proposed rule). We have also added separate rows to this table to reflect the different labor related shares that apply to hospitals.

Comparison of FY 2007 Standardized Amounts to Proposed FY 2008 Single Standardized Amount With Full Update and Reduced Update

Full update (3.3 percent)

Reduced update (1.3 percent)

FY 2007 Base Rate, after

Labor: $3,609.23....................... Labor: $3,609.23 removing reclassification Nonlabor: $1,569.01.................... Nonlabor: $1,569.01 budget neutrality, demonstration budget neutrality, wage index transition budget neutrality factors and outlier offset (based on the labor and market share percentage for FY 2008). FY 2008 Update Factor.......... 1.033.................................. 1.013 FY 2008 DRG Recalibrations and 0.999317............................... 0.999317 Wage Index Budget Neutrality Factor. FY 2008 Reclassification Budget 0.991938............................... 0.991938 Neutrality Factor. Adjusted for Blend of FY 2007 Labor: $3,695.75....................... Labor: $3,624.20 DRG Recalibration and Wage Nonlabor: $1,606.62.................... Nonlabor: $1,575.51 Index Budget Neutrality Factors. FY 2008 Outlier Factor......... 0.948989............................... 0.948989 Rural Demonstration Budget 0.999899............................... 0.999899 Neutrality Factor. Proposed FY 2008 Documentation 0.976.................................. 0.976 and Coding Adjustment. Rural Floor Adjustment......... 1.002214............................... 1.002214 Proposed Rate for FY 2008

Labor: $3,051.33....................... Labor: $2,992.26 (after multiplying FY 2007 Nonlabor: $1,870.17.................... Nonlabor: $1,833.96 base rate by above factors) where the wage index is less than or equal to 1.0000. Proposed Rate for FY 2008

Labor: $3,430.29....................... Labor: $3,363.88 (after multiplying FY 2007 Nonlabor: $1,491.21.................... Nonlabor: $1,462.34 base rate by above factors) where the wage index is greater than 1.0000.

Under section 1886(d)(9)(A)(ii) of the Act, the Federal portion of the Puerto Rico payment rate is based on the discharge-weighted average of the national large urban standardized amount (as set forth in Table 1A). The labor-related and nonlabor-related portions of the national average standardized amounts for Puerto Rico hospitals are set forth in Table 1C of section VI. of this Addendum. This table also includes the Puerto Rico standardized amounts. The labor-related share applied to the Puerto Rico standardized amount is 58.7 percent, or 62 percent, depending on which results in higher payments to the hospital. (Section 1886(d)(9)(C)(iv) of the Act, as amended by section 403(b) of Pub. L. 108-173, provides that the labor-related share for hospitals in Puerto Rico will be 62 percent, unless the application of that percentage would result in lower payments to the hospital.)

B. Proposed Adjustments for Area Wage Levels and Cost-of-Living

Tables 1A through 1C, as set forth in section VI. of this Addendum, contain the proposed labor-related and nonlabor-related shares that we are using to calculate the proposed prospective payment rates for hospitals located in the 50 States, the District of Columbia, and Puerto Rico for FY 2008. This section addresses two types of adjustments to the standardized amounts that are made in determining the proposed prospective payment rates as described in this Addendum.

1. Proposed Adjustment for Area Wage Levels

Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act require that we make an adjustment to the labor-related portion of the national and Puerto Rico prospective payment rates, respectively, to account for area differences in hospital wage levels. This adjustment is made by multiplying the labor-related portion of the adjusted standardized amounts by the appropriate wage index for the area in which the hospital is located. In section III. of the preamble to this proposed rule, we discuss the data and methodology for the proposed FY 2008 wage index.

2. Proposed 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 2008, we are proposing to adjust the payments for hospitals in Alaska and Hawaii by multiplying the nonlabor-related portion of the standardized amount by the applicable adjustment factor contained in the table below.

Table of Cost-of-Living Adjustment Factors: Alaska and Hawaii Hospitals

Cost of living Area

adjustment factor

Alaska:

City of Anchorage and 80-kilometer (50-mile)

1.24 radius by road.................................

City of Fairbanks and 80-kilometer (50-mile)

1.24 radius by road.................................

City of Juneau and 80-kilometer (50-mile) radius

1.24 by road........................................

Alaska-All areas................................

1.25 Hawaii:

City and County of Honolulu.....................

1.25

County of Hawaii................................

1.17

County of Kauai.................................

1.25

County of Maui and County of Kalawao............

1.25

(The above factors are based on data obtained from the U.S. Office of Personnel Management.)

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C. Proposed DRG Relative Weights

As discussed in section II. of the preamble of this proposed rule, we are proposing to adopt a revised classification system for all hospital discharges, assigning them into proposed MS-DRGs, and have developed proposed relative weights for each MS-DRG that reflect the resource utilization of cases in each proposed MS-DRG relative to Medicare cases in other proposed MS-DRGs. Table 5 of section VI. of this Addendum contains the proposed relative weights that we would use for discharges occurring in FY 2008. These factors have been recalibrated as explained in section II. of the preamble of this proposed rule.

D. Calculation of the Proposed Prospective Payment Rates

General Formula for Calculation of the Proposed Prospective Payment Rates for FY 2008

In general, the operating prospective payment rate for all hospitals paid under the IPPS located outside of Puerto Rico, except SCHs and MDHs, for FY 2008 equals the Federal rate.

The prospective payment rate for SCHs for FY 2008 equals the higher of the applicable Federal rate or the hospital-specific rate as described below. The prospective payment rate for MDHs for FY 2008 equals the higher of the Federal rate, or the Federal rate plus 75 percent of the difference between the Federal rate and the hospital-specific rate as described below. The prospective payment rate for Puerto Rico for FY 2008 equals 25 percent of the Puerto Rico rate plus 75 percent of the applicable national rate.

1. Federal Rate

The Federal rate is determined as follows:

Step 1--Select the applicable average standardized amount depending on whether the hospital has submitted qualifying quality data (full update for qualifying hospitals, update minus 2.0 percentage points for nonqualifying hospitals).

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 or the area to which the hospital is reclassified.

Step 3--For hospitals in Alaska and Hawaii, multiply the non- labor-related portion of the standardized amount by the applicable cost-of-living adjustment factor.

Step 4--Add the amount from Step 2 and the non-labor-related portion of the standardized amount (adjusted, if applicable, under Step 3).

Step 5--Multiply the final amount from Step 4 by the relative weight corresponding to the applicable MS-DRG (see Table 5 of section VI. of this Addendum).

The Federal rate as determined in Step 5 may then be further adjusted if the hospital qualifies for either the IME or DSH adjustment. In addition, for hospitals that qualify for a low-volume payment adjustment under section 1886(d)(12) of the Act, the payment in Step 5 would be increased by 25 percent.

2. Hospital-Specific Rate (Applicable Only to SCHs and MDHs)

a. Calculation of Hospital-Specific Rate

Section 1886(b)(3)(C) of the Act provides that SCHs 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 costs per discharge; the updated hospital- specific rate based on FY 1987 costs per discharge; or the updated hospital-specific rate based on FY 1996 costs per discharge.

As discussed previously, MDHs are required to rebase their hospital-specific rates to their FY 2002 cost reports if doing so results in higher payments. In addition, effective for discharges occurring on or after October 1, 2006, MDHs are to be paid based on the Federal national rate or, if higher, the Federal national rate plus 75 percent (changed from 50 percent) of the difference between the Federal national rate and the greater of the updated hospital- specific rates based on either FY 1982, FY 1987 or FY 2002 costs per discharge. Further, MDHs will no longer be subject to the 12-percent cap on their DSH payment adjustment factor.

Hospital-specific rates have been determined for each of these hospitals based on the FY 1982 costs per discharge, the FY 1987 costs per discharge, or, for SCHs, the FY 1996 costs per discharge and for MDHs, the FY 2002 cost per discharge. For a more detailed discussion of the calculation of the hospital-specific rates, we refer the reader to the FY 1984 IPPS interim final rule (48 FR 39772); the April 20, 1990 final rule with comment (55 FR 15150); the FY 1991 IPPS final rule (55 FR 35994); and the FY 2001 IPPS final rule (65 FR 47082). In addition, for both SCHs and MDHs, the hospital-specific rate is adjusted by the budget neutrality adjustment factor as discussed in section IV.C. of the preamble to this proposed rule. The resulting rate will be used in determining the payment rate an SCH or MDH will receive for its discharges beginning on or after October 1, 2007.

b. Updating the FY 1982, FY 1987, FY 1996, and FY 2002 Hospital- Specific Rates for FY 2008

We are proposing to increase the hospital-specific rates by 3.3 percent (the proposed estimated hospital market basket percentage increase) for SCHs and MDHs for FY 2008. Section 1886(b)(3)(C)(iv) of the Act provides that the update factor applicable to the hospital-specific rates for SCHs is equal to the update factor provided under section 1886(b)(3)(B)(iv) of the Act, which, for SCHs in FY 2007, is the market basket rate-of-increase. Section 1886(b)(3)(D) of the Act provides that the update factor applicable to the hospital-specific rates for MDHs also equals the update factor provided under section 1886(b)(3)(B)(iv) of the Act, which, for FY 2007, is the market basket rate-of-increase.

3. General Formula for Calculation of Proposed Prospective Payment Rates for Hospitals Located in Puerto Rico Beginning On or After October 1, 2007, and Before October 1, 2008

Section 1886(d)(9)(E)(iv) of the Act provides that, effective for discharges occurring on or after October 1, 2004, hospitals located in Puerto Rico are paid based on a blend of 75 percent of the national prospective payment rate and 25 percent of the Puerto Rico-specific rate.

a. Puerto Rico Rate

The Puerto Rico prospective payment rate is determined as follows:

Step 1--Select the applicable average standardized amount considering the applicable wage index (see Table 1C).

Step 2--Multiply the labor-related portion of the standardized amount by the applicable Puerto Rico-specific wage index.

Step 3--Add the amount from Step 2 and the nonlabor-related portion of the standardized amount.

Step 4--Multiply the amount from Step 3 by the applicable MS-DRG relative weight (see Table 5 of section IV. of the Addendum).

Step 5--Multiply the result in Step 4 by 25 percent.

b. National Rate

The national prospective payment rate is determined as follows:

Step 1--Select the applicable average standardized amount.

Step 3--Add the amount from Step 2 and the nonlabor-related portion of the national average standardized amount.

Step 4--Multiply the amount from Step 3 by the applicable MS-DRG relative weight (see Table 5 of section VI. of the Addendum).

Step 5--Multiply the result in Step 4 by 75 percent.

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. This rate may then be further adjusted if the hospital qualifies for either the IME or DSH adjustment.

III. Proposed Changes to Payment Rates for Acute Care Hospital Inpatient Capital-Related Costs for FY 2008

(If you choose to comment on issues in this section, please include the caption ``Capital Payment Rate'' at the beginning of your comment.)

The PPS for acute care hospital inpatient capital-related costs was implemented for cost reporting periods beginning on or after October 1, 1991. Effective with that cost reporting period, hospitals were paid during a 10-year transition period (which extended through FY 2001) to change the payment methodology for Medicare acute care hospital inpatient capital-related costs from a reasonable cost-based methodology to a prospective methodology (based fully on the Federal rate).

The basic methodology for determining Federal capital prospective rates is set forth in regulations at Sec. Sec. 412.308 through 412.352. Below we discuss the factors that we are proposing to use to determine the capital Federal rate for FY 2008, which will be effective for discharges occurring on or after October 1, 2007.

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The 10-year transition period ended with hospital cost reporting periods beginning on or after October 1, 2001 (FY 2002). Therefore, for cost reporting periods beginning in FY 2002, all hospitals (except ``new'' hospitals under Sec. 412.304(c)(2)) are paid based on 100 percent of the capital Federal rate. For FY 1992, we computed the standard Federal payment rate for capital-related costs under the IPPS 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 capital standard Federal rate, as provided at Sec. 412.308(c)(1), to account for capital input price increases and other factors. The regulations at Sec. 412.308(c)(2) provide that the capital Federal rate is adjusted annually by a factor equal to the estimated proportion of outlier payments under the capital Federal rate to total capital payments under the capital Federal rate. In addition, Sec. 412.308(c)(3) requires that the capital Federal rate be reduced by an adjustment factor equal to the estimated proportion of payments for (regular and special) exceptions under Sec. 412.348. Section 412.308(c)(4)(ii) requires that the capital standard Federal rate be adjusted so that the effects of the annual DRG reclassification and the recalibration of DRG weights and changes in the geographic adjustment factor are budget neutral.

For FYs 1992 through 1995, Sec. 412.352 required that the capital Federal rate also be adjusted by a budget neutrality factor so that aggregate payments for inpatient hospital capital costs were projected to equal 90 percent of the payments that would have been made for capital-related costs on a reasonable cost basis during the fiscal year. That provision expired in FY 1996. Section 412.308(b)(2) describes the 7.4 percent reduction to the capital rate that was made in FY 1994, and Sec. 412.308(b)(3) describes the 0.28 percent reduction to the capital rate made in FY 1996 as a result of the revised policy of paying for transfers. In FY 1998, we implemented section 4402 of Pub. L. 105-33, which required that, for discharges occurring on or after October 1, 1997, the budget neutrality adjustment factor in effect on September 30, 1995, be applied to the unadjusted capital standard Federal rate and the unadjusted hospital-specific rate. That factor was 0.8432, which was equivalent to a 15.68 percent reduction to the unadjusted capital payment rates. An additional 2.1 percent reduction to the rates was effective from October 1, 1997 through September 30, 2002, making the total reduction 17.78 percent. As we discussed in the FY 2003 IPPS final rule (67 FR 50102) and implemented in Sec. 412.308(b)(6), the 2.1 percent reduction was restored effective October 1, 2002.

To determine the appropriate budget neutrality adjustment factor and the regular exceptions payment adjustment during the 10-year transition period, we developed a dynamic model of Medicare inpatient capital-related costs; that is, a model that projected changes in Medicare inpatient capital-related costs over time. With the expiration of the budget neutrality provision, the capital cost model was only used to estimate the regular exceptions payment adjustment and other factors during the transition period. As we explained in the FY 2002 IPPS final rule (66 FR 39911), beginning in FY 2002, an adjustment for regular exception payments is no longer necessary because regular exception payments were only made for cost reporting periods beginning on or after October 1, 1991, and before October 1, 2001 (see Sec. 412.348(b)). Because payments are no longer being made under the regular exception policy effective with cost reporting periods beginning in FY 2002, we no longer use the capital cost model. The capital cost model and its application during the transition period are described in Appendix B of the FY 2002 IPPS final rule (66 FR 40099).

Section 412.374 provides for the use of a blended payment system for payments to Puerto Rico hospitals under the IPPS for acute care hospital inpatient capital-related costs. Accordingly, under the capital PPS, we compute a separate payment rate specific to Puerto Rico hospitals using the same methodology used to compute the national Federal rate for capital-related costs. In accordance with section 1886(d)(9)(A) of the Act, under the IPPS for acute care hospital operating costs, hospitals located in Puerto Rico are paid for operating costs under a special payment formula. Prior to FY 1998, hospitals in Puerto Rico were paid a blended operating rate that consisted of 75 percent of the applicable standardized amount specific to Puerto Rico hospitals and 25 percent of the applicable national average standardized amount. Similarly, prior to FY 1998, hospitals in Puerto Rico were paid a blended capital rate that consisted of 75 percent of the applicable capital Puerto Rico- specific rate and 25 percent of the applicable capital Federal rate. However, effective October 1, 1997, in accordance with section 4406 of Pub. L. 105-33, operating payments to hospitals in Puerto Rico were revised to be based on a blend of 50 percent of the applicable standardized amount specific to Puerto Rico hospitals and 50 percent of the applicable national average standardized amount. In conjunction with this change to the operating blend percentage, effective with discharges occurring on or after October 1, 1997, we also revised the methodology for computing capital payments to hospitals in Puerto Rico to be based on a blend of 50 percent of the Puerto Rico capital rate and 50 percent of the capital Federal rate.

As we discussed in the FY 2005 IPPS final rule (69 FR 49185), section 504 of Pub. L. 108-173 increased the national portion of the operating IPPS payments for Puerto Rico hospitals from 50 percent to 62.5 percent and decreased the Puerto Rico portion of the operating IPPS payments from 50 percent to 37.5 percent for discharges occurring on or after April 1, 2004 through September 30, 2004 (see the March 26, 2004 One-Time Notification (Change Request 3158)). In addition, section 504 of Pub. L. 108-173 provided that the national portion of operating IPPS payments for Puerto Rico hospitals is equal to 75 percent and the Puerto Rico portion of operating IPPS payments is equal to 25 percent for discharges occurring on or after October 1, 2004. Consistent with that change in operating IPPS payments to hospitals in Puerto Rico, for FY 2005 (as we discussed in the FY 2005 IPPS final rule), we revised the methodology for computing capital payments to hospitals located in Puerto Rico to be based on a blend of 25 percent of the Puerto Rico capital rate and 75 percent of the capital Federal rate for discharges occurring on or after October 1, 2004.

A. Determination of Proposed Federal Hospital Inpatient Capital- Related Prospective Payment Rate Update

In the FY 2007 IPPS final rule (71 FR 48161), we established a tentative capital Federal rate of $427.38 for FY 2007. In the Federal Register notice establishing the occupational mix adjusted payment rates for FY 2007 (71 FR 59891), we established the final FY 2007 Federal rate of $427.03 for FY 2007. In the discussion that follows, we explain the factors that we are proposing to use to determine the proposed FY 2008 capital Federal rate. However, as discussed in section V. of the preamble of this proposed rule, we are proposing two separate capital Federal rates for FY 2008: a capital Federal rate for rural hospitals and a capital Federal rate for urban hospitals. In particular, we explain why the proposed FY 2008 capital Federal rate for rural hospitals would decrease approximately 2.3 percent, compared to the FY 2007 capital Federal rate, and why the proposed FY 2008 capital Federal rate for urban hospitals would decrease approximately 3.1 percent, compared to the FY 2007 capital Federal rate. Consequently, despite an estimated increase in Medicare fee-for-service discharges in FY 2008 as compared to FY 2007, we estimate aggregate capital payments would decrease by 0.13 percent during this same period. Total payments to hospitals under the IPPS are relatively unaffected by changes in the capital prospective payments. Since capital payments constitute about 10 percent of hospital payments, a 1-percent change in the capital Federal rate yields only about 0.1 percent change in actual payments to hospitals. As noted above, aggregate payments under the capital IPPS are estimated to decrease in FY 2008 compared to FY 2007.

1. Projected Capital Standard Federal Rate Update

a. Description of the Update Framework

Under Sec. 412.308(c)(1), the capital standard Federal rate is updated on the basis of an analytical framework that takes into account changes in a capital input price index (CIPI) and several other 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 2008 under that framework is 0.8 percent based on the best data available at this time. The proposed update factor under that framework is based on a projected 1.2 percent increase in the CIPI, a 0.0 percent adjustment for intensity, a 0.0 percent adjustment for case-mix, a -0.4 percent adjustment for the FY 2006 DRG

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reclassification and recalibration, and a forecast error correction of 0.0 percent. As discussed below in section III.C. of this Addendum, we believe that the CIPI is the most appropriate input price index for capital costs to measure capital price changes in a given year. We also explain the basis for the FY 2008 CIPI projection in that same section of this Addendum. (However, as discussed in greater detail in section V. of the preamble of this proposed rule, we are proposing a zero percent update factor for urban hospitals instead of the 0.8 percent proposed update factor that we are proposing for rural hospitals. In addition, as also note below, the proposed capital rates would be further adjusted to account for upcoding under the proposed MS-DRGs discussed in section II.D. of the preamble of this proposed rule.) Below we describe the policy adjustments that have been applied in the update framework for FY 2008.

The case-mix index is the measure of the average DRG weight for cases paid under the IPPS. Because the DRG weight determines the prospective payment for each case, any percentage increase in the case-mix index corresponds to an equal percentage increase in hospital payments.

The case-mix index can change for any of several reasons:

The average resource use of Medicare patients changes (``real'' case-mix change);

Changes in hospital coding of patient records result in higher weight DRG assignments (``coding effects''); and

The annual DRG reclassification and recalibration changes may not be budget neutral (``reclassification effect'').

We define real case-mix change as actual changes in the mix (and resource requirements) of Medicare patients as opposed to changes in coding behavior that result in assignment of cases to higher weighted DRGs but do not reflect higher resource requirements. The capital update framework includes the same case-mix index adjustment used in the former operating IPPS update framework (as discussed in the May 18, 2004 IPPS proposed rule for FY 2005 (69 FR 28816)). (We are no longer using an update framework in making a recommendation for updating the operating IPPS standardized amounts as discussed in section II. of Appendix B in the FY 2006 IPPS final rule (70 FR 47707).)

Absent the proposed change to the MS-DRGs, for FY 2008, we are projecting a 1.0 percent total increase in the case-mix index. We estimate that the real case-mix increase will also equal 1.0 percent in FY 2008. The net adjustment for change in case-mix is the difference between the projected real increase in case-mix and the projected total increase in case-mix. Therefore, the net adjustment for case-mix change in FY 2008 is 0.0 percentage points.

The capital update framework also contains an adjustment for the effects of DRG reclassification and recalibration. This adjustment is intended to remove the effect on total payments of prior year changes to the DRG classifications and relative weights, in order to retain budget neutrality for all case-mix index-related changes other than those due to patient severity. Due to the lag time in the availability of data, there is a 2-year lag in data used to determine the adjustment for the effects of DRG reclassification and recalibration. For example, we are adjusting for the effects of the FY 2006 DRG reclassification and recalibration as part of our proposed update for FY 2008. We estimate that FY 2006 DRG reclassification and recalibration resulted in a 0.4 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. Therefore, we are proposing to make a -0.4 percent adjustment for DRG reclassification in the proposed update for FY 2008 to maintain budget neutrality.

The capital update framework also 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 and the forecast used in calculating the update factors. In setting a prospective payment rate under the framework, we make an adjustment for forecast error only if our estimate of the change in the capital input price index 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. A forecast error of 0.10 percentage point was calculated for the FY 2006 update. That is, current historical data indicate that the forecasted FY 2006 CIPI (0.80 percent) used in calculating the FY 2006 update factor slightly understated the actual realized price increases (0.90 percent) by 0.10 percentage point. This slight underprediction was mostly due to the incorporation of newly available source data for fixed asset prices into the market basket. However, because this estimation of the change in the CIPI is less than 0.25 percentage points, it is not reflected in the update recommended under this framework. Therefore, we are proposing to make a 0.0 percent adjustment for forecast error in the update for FY 2008.

Under the capital IPPS update framework, we also make an adjustment for changes in intensity. We calculate this adjustment using the same methodology and data that were used in the past under the framework for operating IPPS. 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, for changes in within-DRG severity, and for expected modification of practice patterns to remove noncost-effective services.

We calculate case-mix constant intensity as the change in total charges per admission, adjusted for price level changes (the CPI for hospital and related services) and changes in real case-mix. The use of total charges in the calculation of the intensity factor makes it a total intensity factor; that is, charges for capital services are already built into the calculation of the factor. Therefore, we have incorporated the intensity adjustment from the operating update framework into the capital update framework. Without reliable estimates of the proportions of the overall annual intensity increases that are due, respectively, to ineffective practice patterns and to the combination of quality-enhancing new technologies and within-DRG complexity, we assume, as in the 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.

We have developed a Medicare-specific intensity measure based on a 5-year average. Past studies of case-mix change by the RAND Corporation (``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)) suggest that real case- mix change was not dependent on total change, but was usually a fairly steady 1.0 to 1.5 percent per year. However, 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.

We calculate case-mix constant intensity as the change in total charges per admission, adjusted for price level changes (the CPI for hospital and related services), and changes in real case-mix. As we noted above, in accordance with Sec. 412.308(c)(1)(ii), we began updating the capital standard Federal rate in FY 1996 using an update framework that takes into account, among other things, allowable changes in the intensity of hospital services. For FYs 1996 through 2001, we found that case-mix constant intensity was declining and we established a 0.0 percent adjustment for intensity in each of those years. For FYs 2002 and 2003, we found that case- mix constant intensity was increasing and we established a 0.3 percent adjustment and 1.0 percent adjustment for intensity, respectively. For FYs 2004 and 2005, we found that the charge data appeared to be skewed (as discussed in greater detail below) and we established a 0.0 percent adjustment in each of those years. Furthermore, we stated that we would continue to apply a 0.0 percent adjustment for intensity until any increase in charges can be tied to intensity rather than attempts to maximize outlier payments.

As noted above, our intensity measure is based on a 5-year average, and therefore, the intensity adjustment for FY 2008 is based on data from the 5-year period FY 2002 through FY 2006. We found a dramatic increase in hospital charges for each of those 5 years without a corresponding increase in the hospital case-mix index. These findings are similar to the considerable increase in hospitals' charges, which we found when we were determining the intensity factor in the FY 2004, FY 2005 and FY 2006 update recommendations as discussed in the FY 2004 IPPS final rule (68 FR 45482), the FY 2005 IPPS final rule (69 FR 49285) the FY 2006 IPPS final rule (70 FR 47500), and the

[[Page 24843]]

FY 2007 IPPS final rule (72 FR 47500), respectively. If hospitals were treating new or different types of cases, which would result in an appropriate increase in charges per discharge, then we would expect hospitals' case-mix to increase proportionally.

As we discussed in the FY 2006 IPPS final rule (70 FR 47500) and the FY 2007 IPPS final rule (71 FR 48157), because our intensity calculation relies heavily upon charge data and we believe that these charge data may be inappropriately skewed, we established a 0.0 percent adjustment for intensity for FY 2006 and FY 2007, respectively.

On June 9, 2003, we published revisions to our outlier policy for determining the additional payment for extraordinarily high-cost cases (68 FR 34494 through 34515). These revised policies were effective on August 8, 2003, and October 1, 2003. While it does appear that a response to these policy changes is beginning to occur, that is, the change in charges for FYs 2004 and 2005 are somewhat less than the previous 4 years, and the change in charges for FY 2006 is slightly less than FY 2005, they still show a significant annual increase in charges without a corresponding increase in hospital case-mix. The increase in charges in FY 2004, for example, is approximately 12 percent, which, while less than the increase in the previous 3 years, is still much higher than increases in years prior to FY 2001. In addition, this approximate 12-percent increase in charges for FY 2004 significantly exceeds the case-mix increase for the same period. Based on the approximate 12- percent increase in charges for FY 2004, we believe residual effects of hospitals' charge practices prior to the implementation of the outlier policy revisions established in the June 9, 2003 final rule continue to appear in the data because hospitals may not have had enough time to adopt changes in their behavior in response to the new outlier policy. Thus, we believe that the FY 2004, FY 2005, and FY 2006 charge data may still be skewed. Because the intensity adjustment is based on a 5-year average, and although the new outlier policy was generally effective in FY 2004, we believe the effects of hospitals attempting to maximize outlier payments, while lessening, continue to skew the charge data.

Therefore, we are proposing to make a 0.0 percent adjustment for intensity for FY 2008. In the past (FYs 1996 through 2001) when we found intensity to be declining, we believed a zero (rather than negative) intensity adjustment was appropriate. Similarly, we believe that it is appropriate to apply a zero intensity adjustment for FY 2008 until any increase in charges can be tied to intensity rather than to attempts to maximize outlier payments.

Above, we described the basis of the components used to develop the proposed 0.8 percent capital update factor under the capital update framework for FY 2008 as shown in the table below. However, as discussed in section V. of the preamble of this proposed rule, we are proposing that the proposed 0.8 percent capital update be applied to rural hospitals only. We are proposing a 0.0 percent update for urban hospitals for reasons also discussed in section V. of the preamble of this proposed rule.

CMS Proposed FY 2008 Update Factor to the Capital Federal Rate for Rural Hospitals

Capital Input Price Index....................................... 1.2 Intensity:

0.0 Case-Mix Adjustment Factors:

Real Across DRG Change...................................... 1.0

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

Subtotal...................................................... 0.0

Effect of FY 2005 Reclassification and Recalibration............ -0.4 Forecast Error Correction....................................... 0.0

Total Update for Rural Hospitals.............................. 0.8

b. Comparison of CMS and MedPAC Update Recommendation

In the past, MedPAC has included update recommendations for capital PPS in a Report to Congress. In its March 2007 Report to Congress, MedPAC did not make an update recommendation for capital IPPS payments for FY 2008. However, in that same report, MedPAC made an update recommendation for hospital inpatient and outpatient services (page 67). MedPAC reviews inpatient and outpatient services together because they are so closely interrelated. For FY 2008, MedPAC recommended an increase in the payment rate for the operating IPPS by the projected increase in the hospital market basket index concurrent with implementation of a quality incentive payment policy. (MedPAC's Report to the Congress: Medicare Payment Policy, March 2007, Section 2A.)

2. Proposed 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. 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 capital-related outlier payments to total inpatient capital-related PPS payments. The outlier thresholds are set so that operating outlier payments are projected to be 5.1 percent of total operating DRG payments.

In the Federal Register notice establishing the final occupational mix adjusted payment rates for FY 2007 (71 FR 59890), we estimated that outlier payments for capital would equal 4.32 percent of inpatient capital-related payments based on the capital Federal rate in FY 2007. Based on the proposed thresholds as set forth in section II.A.4.c. of this Addendum, we estimate that proposed outlier payments for capital-related costs would equal 5.16 percent for inpatient capital-related payments based on the proposed Federal rate in FY 2008. Therefore, we are proposing to apply an outlier adjustment factor of 0.9484 to the capital Federal rate. Thus, we estimate that the percentage of capital outlier payments to total capital standard payments for FY 2008 will be slightly higher than the percentages for FY 2007.

The outlier reduction factors are not built permanently into the capital rates; that is, they are not applied cumulatively in determining the capital Federal rate. The proposed FY 2008 outlier adjustment of 0.9484 is a -0.88 percent change from the FY 2007 outlier adjustment of 0.9568. Therefore, the net change in the proposed outlier adjustment to the proposed capital Federal rate for FY 2008 is 0.9912 (0.9484/0.9568). Thus, the proposed outlier adjustment decreases the proposed FY 2008 capital Federal rate by 0.88 percent compared with the FY 2007 outlier adjustment.

3. Proposed Budget Neutrality Adjustment Factor for Changes in DRG Classifications and Weights and the GAF

Section 412.308(c)(4)(ii) requires that the capital Federal rate be adjusted so that aggregate payments for the fiscal year based on the capital Federal rate after any changes resulting from the annual DRG reclassification and recalibration and changes in the GAF are projected to equal aggregate payments that would have been made on the basis of the capital Federal rate without such changes. Because we implemented a separate GAF for Puerto Rico, we apply separate budget neutrality adjustments for the national GAF and the Puerto Rico GAF. We apply the same budget neutrality factor for DRG reclassifications and recalibration nationally and for Puerto Rico. Separate adjustments were unnecessary for FY 1998 and earlier because the GAF for Puerto Rico was implemented in FY 1998.

In the past, we used the actuarial capital cost model (described in Appendix B of the FY 2002 IPPS final rule (66 FR 40099)) to estimate the aggregate payments that would have been made on the basis of the capital Federal rate with and without changes in the DRG classifications and weights and in the GAF to compute the adjustment required to maintain budget neutrality for changes in DRG weights and in the GAF. During the transition period, the capital cost model was also used to estimate the regular exception payment adjustment factor. As we explain in section III.A.4. of this Addendum, beginning in FY 2002, an adjustment for regular exception payments is no longer necessary. Therefore, we are no longer using the capital cost model. Instead, we are using historical data based on hospitals' actual cost experiences to determine the exceptions payment adjustment factor for special exceptions payments.

To determine the proposed factors for FY 2008, we compared (separately for the national capital rate and the Puerto Rico capital rate) estimated aggregate capital Federal rate payments based on the FY 2007 DRG relative weights and the FY 2007 GAF to estimated aggregate capital Federal rate payments based on the proposed FY 2008 relative weights and the proposed FY 2008 GAF. As we established in the final FY 2007 occupational mix adjusted payment rates notice (71 FR 59890), the budget neutrality factors were 0.9906 for the national capital

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rate and 0.9968 for the Puerto Rico capital rate. In making the comparison, we set the exceptions reduction factor to 1.00. To achieve budget neutrality for the changes in the national GAF, based on calculations using updated data, we propose to apply an incremental budget neutrality adjustment of 1.0026 for FY 2008 to the previous cumulative FY 2007 adjustments of 0.9906, yielding a proposed adjustment of 0.9932, through FY 2008 (calculations done on unrounded numbers). For the Puerto Rico GAF, we are proposing to apply a proposed incremental budget neutrality adjustment of 1.0009 for FY 2008 to the previous cumulative FY 2007 adjustment of 0.9968, yielding a proposed cumulative adjustment of 0.9978 through FY 2008 (calculations done on unrounded numbers).

We then compared estimated aggregate capital Federal rate payments based on the FY 2007 DRG relative weights and the FY 2007 GAF to estimated aggregate capital Federal rate payments based on the proposed FY 2008 DRG relative weights and the proposed FY 2008 GAF. The proposed incremental adjustment for DRG classifications and changes in relative weights is 0.9992 both nationally and for Puerto Rico. The proposed cumulative adjustments for DRG classifications and changes in relative weights and for changes in the GAF through FY 2008 are 0.9924 nationally and 0.9970 for Puerto Rico. The following table summarizes the adjustment factors for each fiscal year:

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Budget Neutrality Adjustment for DRG Reclassifications and Recalibration and the Geographic Adjustment Factors

National

Puerto Rico

Incremental adjustment

Incremental adjustment Fiscal year

Geographic

DRG

Cumulative Geographic

DRG

Cumulative adjustment reclassifications Combined

adjustment reclassifications Combined factor and recalibration

factor and recalibration

1992...................................................... .............. ................. ..............

1.00000 .............. ................. .............. .............. 1993...................................................... .............. .................

0.99800

0.99800 .............. ................. .............. .............. 1994...................................................... .............. .................

1.00531

1.00330 .............. ................. .............. .............. 1995...................................................... .............. .................

0.99980

1.00310 .............. ................. .............. .............. 1996...................................................... .............. .................

0.99940

1.00250 .............. ................. .............. .............. 1997...................................................... .............. .................

0.99873

1.00123 .............. ................. .............. .............. 1998...................................................... .............. .................

0.99892

1.00015 .............. ................. ..............

1.00000 1999......................................................

0.99944

1.00335

1.00279

1.00294

0.99898

1.00335

1.00233

1.00233 2000......................................................

0.99857

0.99991

0.99848

1.00142

0.99910

0.99991

0.99901

1.00134 2001 \1\..................................................

0.99782

1.00009

0.99791

0.99933

1.00365

1.00009

1.00374

1.00508 2001 \2\.................................................. \3\ 0.99771 \3\ 1.00009 \3\ 0.99780

0.99922 \3\ 1.00365 \3\ 1.00009 \3\ 1.00374

1.00508 2002...................................................... \4\ 0.99666 \4\ 0.99668 \4\ 0.99335

0.99268 \4\ 0.98991 \4\ 0.99668 \4\ 0.99662

0.99164 2003 \5\..................................................

0.99915

0.99662

0.99577

0.98848

1.00809

0.99662

1.00468

0.99628 2003 \6\.................................................. \7\ 0.99896 \7\ 0.99662 \7\ 0.99558

0.98830

1.00809

0.99662

1.00468

0.99628 2004 \8\.................................................. \9\ 1.00175 \9\ 1.00081 \9\ 1.00256

0.99083

1.00028

1.00081

1.00109

0.99736 2004 \10\................................................. \9\ 1.00164 \9\ 1.00081 \9\ 1.00245

0.99072

1.00028

1.00081

1.00109

0.99736 2005 \11\................................................. \12\ 0.99967

1.00094 \12\ 1.00061

0.99137

0.99115

1.00094

0.99208

0.98946 2005 \13\................................................. \12\ 0.99946

1.00094 \12\ 1.00040

0.99117

0.99115

1.00094

0.99208

0.98946 2006...................................................... \14\ 1.00185

0.99892 \14\ 1.00076

0.99198

1.00762

0.99892

1.00653

0.99592 2007......................................................

1.00000

0.99858

0.99057

1.00234

0.99858

1.00092

0.99683 2008...................................................... \15\ 1.00261

0.99921 \15\ 1.00182 \15\ 0.99237 \15\ 1.00093

0.99921 \15\ 1.00014 \15\ 0.99697

\1\ Factors effective for the first half of FY 2001 (October 2000 through March 2001). \2\ Factors effective for the second half of FY 2001 (April 2001 through September 2001). \3\ Incremental factors are applied to FY 2000 cumulative factors. \4\ Incremental factors are applied to the cumulative factors for the first half of FY 2001. \5\ Factors effective for the first half of FY 2003 (October 2002 through March 2003). \6\ Factors effective for the second half of FY 2003 (April 2003 through September 2003). \7\ Incremental factors are applied to FY 2002 cumulative factors. \8\ Factors effective for the first half of FY 2004 (October 2003 through March 2004). \9\ Incremental factors are applied to the cumulative factors for the second half of FY 2003. \10\ Factors effective for the second half of FY 2004 (April 2004 through September 2004). \11\ Factors effective for the first quarter of FY 2005 (September 2004 through December 2004). \12\ Incremental factors are applied to average of the cumulative factors for the first half (October 1, 2003 through March 31, 2004) and second half (April 1, 2004 through September 30, 2004) of FY 2004. \13\ Factors effective for the last three quarters of FY 2005 (January 2005 through September 2005). \14\ Incremental factors are applied to average of the cumulative factors for 2005. \15\ Proposed factors for FY 2008, as discussed above in section III. of this Addendum.

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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 PPS for operating costs. One difference is that, under the operating PPS, 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 PPS, there is a single DRG/GAF budget neutrality adjustment factor (the national capital rate and the Puerto Rico capital rate are determined separately) for changes in the GAF (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, indirect medical education payments, or the large urban add-on payments.

In the Federal Register notice establishing the final FY 2007 occupational mix adjusted payment rates (71 FR 59890), we calculated a GAF/DRG budget neutrality factor of 0.9986 for FY 2007. For FY 2008, we are proposing to establish a proposed GAF/DRG budget neutrality factor of 1.0018. The GAF/DRG budget neutrality factors are built permanently into the capital rates; that is, they are applied cumulatively in determining the capital Federal rate. This follows from the requirement that estimated aggregate payments each year be no more or less than they would have been in the absence of the annual DRG reclassification and recalibration and changes in the GAF. The incremental change in the proposed adjustment from FY 2007 to FY 2008 is 1.0018. The cumulative change in the proposed capital Federal rate due to this proposed adjustment is 0.9924 (the product of the incremental factors for FYs 1994 through 2007 and the proposed incremental factor of 1.0018 for FY 2008). (We note that averages of the incremental factors that were in effect during FYs 2004 and 2005, respectively, were used in the calculation of the proposed cumulative adjustment of 0.9924 for FY 2008.)

This proposed factor accounts for DRG reclassifications and recalibration and for changes in the GAF. It also incorporates the effects on the proposed GAF of FY 2008 geographic reclassification decisions made by the MGCRB compared to FY 2007 decisions. However, it does not account for changes in payments due to changes in the DSH and IME adjustment factors or in the large urban add-on.

4. Exceptions Payment Adjustment Factor

Section 412.308(c)(3) requires that the capital standard Federal rate be reduced by an adjustment factor equal to the estimated proportion of additional payments for both regular exceptions and special exceptions under Sec. 412.348 relative to total capital PPS payments. In estimating the proportion of regular exception payments to total capital PPS payments during the transition period, we used the actuarial capital cost model originally developed for determining budget neutrality (described in Appendix B of the FY 2002 IPPS final rule (66 FR 40099)) to determine the exceptions payment adjustment factor, which was applied to both the Federal and hospital-specific capital rates.

An adjustment for regular exception payments is no longer necessary in determining the FY 2008 capital Federal rate because, in accordance with Sec. 412.348(b), regular exception payments were only made for cost reporting periods beginning on or after October 1, 1991 and before October 1, 2001. Accordingly, as we explained in the FY 2002 IPPS final rule (66 FR 39949), in FY 2002 and subsequent fiscal years, no payments will be made under the regular exceptions provision. However, in accordance with Sec. 412.308(c), we still need to compute a budget neutrality adjustment for special exception payments under Sec. 412.348(g). We describe our methodology for determining the exceptions adjustment used in calculating the FY 2007 capital Federal rate below.

Under the special exceptions provision specified at Sec. 412.348(g)(1), eligible hospitals include SCHs, urban hospitals with at least 100 beds that have a disproportionate share percentage of at least 20.2 percent or qualify for DSH payments under Sec. 412.106(c)(2), and hospitals with a combined Medicare and Medicaid inpatient utilization of at least 70 percent. An eligible hospital may receive special exceptions payments if it meets: (1) a project need requirement as described at Sec. 412.348(g)(2), which, in the case of certain urban hospitals, includes an excess capacity test as described at Sec. 412.348(g)(4); (2) an age of assets test as described at Sec. 412.348(g)(3); and (3) a project size requirement as described at Sec. 412.348(g)(5).

Based on information compiled from our fiscal intermediaries, six hospitals have qualified for special exceptions payments under Sec. 412.348(g). Because we have cost reports ending in FY 2006 for all of these hospitals, we calculated the adjustment based on actual cost experience. Using data from cost reports ending in FY 2006 from the December 2006 update of the HCRIS data, we divided the capital special exceptions payment amounts for the six hospitals that qualified for special exceptions by the total capital PPS payment amounts (including special exception payments) for all hospitals. Based on the data from cost reports ending in FY 2006, this ratio is rounded to 0.0003. Because we have not received all cost reports ending in FY 2006, we also divided the FY 2005 special exceptions payments by the total capital PPS payment amounts for all hospitals with cost reports ending in FY 2005. This ratio also rounds to 0.0003. Because special exceptions are budget neutral, we are offsetting the proposed capital Federal rate by 0.03 percent for special exceptions payments for FY 2008. Therefore, the exceptions adjustment factor is equal to 0.9997 (1 - 0.0003) to account for special exceptions payments in FY 2008.

In the FY 2007 IPPS final rule (71 FR 48161) we estimated that total (special) exceptions payments for FY 2007 would equal 0.03 percent of aggregate payments based on the capital Federal rate. Therefore, we applied an exceptions adjustment factor of 0.9997 (1 - 0.0003) in determining the FY 2007 capital Federal rate. As we stated above, we estimate that exceptions payments in FY 2008 will equal 0.03 percent of aggregate payments based on the proposed FY 2008 capital Federal rate. Therefore, we are proposing to apply an exceptions payment adjustment factor of 0.9997 to the capital Federal rate for FY 2008. The proposed exceptions adjustment factor for FY 2008 is the same as the factor used in determining the FY 2007 capital Federal rate in the FY 2007 IPPS final rule (71 FR 48161) and is the same factor used for the occupational mix adjusted payment rates since the adjustments made to the wage index had no effect on capital exceptions payments (71 FR 59890). The exceptions reduction factors are not built permanently into the capital rates; that is, the factors are not applied cumulatively in determining the capital Federal rate. Therefore, the net change in the proposed exceptions adjustment factor used in determining the proposed FY 2008 capital Federal rate is 1.0000(0.9997/0.9997).

5. Proposed Capital Standard Federal Rate for FY 2008

In the Federal Register notice that established the occupational mix adjusted payment rates for FY 2007 (71 FR 59891), we established a capital Federal rate of $427.03 for FY 2007. As discussed above and in section V. of the preamble of this proposed rule, we are proposing two separate capital Federal rates for FY 2008: a rural capital Federal rate based on an update of 0.8 percent and an urban capital Federal rate based on a 0.0 percent update. However, under the statutory authority at section 1886(d)(3)(A)(vi) of the Act, we are proposing an additional 2.4 percent reduction to the proposed standardized amounts for both capital and operating Federal payment rates. The proposed 2.4 percent reduction is based on our actuary's analysis to eliminate the effect of changes in coding or classification of discharges that do not reflect real changes in case-mix in light of the proposed MS-DRGs. Although the proposed 2.4 percent reduction is outside the established process for developing the proposed capital Federal payment rate, it nevertheless is a factor in the final prospective payment rate to hospitals for capital-related costs. For that reason, the capital Federal payment rates proposed in this proposed rule were determined by applying the proposed 2.4 percent reduction. As a result of the proposed 0.8 percent update for rural hospitals, the proposed 0.0 percent update for urban hospitals, the proposed 2.4 percent reduction to account for upcoding (for all hospitals), and the other factors as discussed above, we are proposing to establish a capital Federal rate for rural hospitals of $417.26 for FY 2008, and we are proposing to establish a capital Federal rate for urban hospitals of $413.87 for FY 2008. The proposed capital Federal rates for FY 2008 were calculated as follows:

The proposed FY 2008 update factor for rural hospitals is 1.0080, that is, the update is 0.8 percent; and the proposed FY 2008 update factor for urban hospitals is 1.0000, that is, the update is 0.0 percent.

The proposed FY 2008 budget neutrality adjustment factor that is applied to the capital standard Federal payment rate for

[[Page 24847]]

changes in the DRG relative weights and in the GAF (for all hospitals) is 1.0018.

The proposed FY 2008 outlier adjustment factor is 0.9484.

The proposed FY 2008 (special) exceptions payment adjustment factor is 0.9997.

The proposed FY 2008 reduction for upcoding under the proposed MS-DRGs is -2.40 percent.

Because the proposed capital 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 are not making additional adjustments in the capital standard Federal rate for these factors, other than the proposed budget neutrality factor for changes in the DRG relative weights and the GAF.

We are providing the following charts that show how each of the proposed factors and adjustments for FY 2008 affected the computation of the proposed FY 2008 capital Federal rate for urban hospitals and the proposed FY 2008 capital Federal rate for rural hospitals in comparison to the FY 2007 capital Federal rate. The proposed FY 2008 update factor for urban hospitals of zero percent would have a 0.0 percent net effect on the proposed FY 2008 capital Federal compared to the FY 2007 capital Federal rate. The proposed FY 2008 update factor for rural hospitals has the effect of increasing the proposed capital Federal rate by 0.80 percent compared to the FY 2007 capital Federal rate. The proposed GAF/DRG budget neutrality factor has the effect of increasing the proposed capital Federal rate by 0.18 percent for both urban and rural hospitals. The proposed FY 2008 outlier adjustment factor has the effect of decreasing the proposed capital Federal rate by 0.89 percent compared to the FY 2007 capital Federal rate for both urban and rural hospitals. The proposed FY 2008 exceptions payment adjustment factor remains unchanged from the FY 2007 exceptions payment adjustment factor, and therefore, has a 0.0 percent net effect on the proposed FY 2008 capital Federal rate for both urban and rural hospitals. In addition to the factors historically used to determine the capital Federal rate, for FY 2008, we are proposing an adjustment factor to account for upcoding expected to result if the proposed MS-DRGs are adopted, as discussed above in section III. of this Addendum, in determining the capital Federal rate for FY 2008. The combined effect of all the changes is to decrease the proposed capital Federal rate by 3.09 percent compared to the FY 2007 capital Federal rate for urban hospitals and to decrease the proposed capital Federal rate by 2.29 percent compared to the FY 2007 capital Federal rate for rural hospitals.

Comparison of Factors and Adjustments: FY 2007 Capital Federal Rate and Proposed FY 2008 Capital Federal Rate for Urban Hospitals

Proposed FY

Percent FY 2007

2008\4\

Change

change\5\

Update Factor\1\................................

1.0110

1.0000

0.0000

0.00 GAF/DRG Adjustment Factor\1\....................

0.9986

1.0018

0.18 Outlier Adjustment Factor \2\...................

0.9568

0.9484

0.9912

-0.88 Exceptions Adjustment Factor \2\................

0.9997

1.0000

0.00 MS-DRG Upcoding Adjustment Factor \3\........... ..............

0.9760

-2.40 Capital Federal Rate............................

$427.03

$413.87

0.9692

-3.10

\1\ The proposed update factor for rural hospitals and the proposed GAF/DRG budget neutrality factors are built permanently into the capital rates. Thus, for example, the incremental change from FY 2007 to FY 2008 resulting from the application of the proposed 1.0018 GAF/DRG budget neutrality factor for FY 2008 is 1.0018. \2\ The proposed outlier reduction factor and the proposed exceptions adjustment factor are not built permanently into the capital rates; that is, these factors are not applied cumulatively in determining the capital rates. Thus, for example, the net change resulting from the application of the proposed FY 2008 outlier adjustment factor would be 0.9484/0.9568, or 0.9912. \3\ Proposed adjustment to FY 2008 IPPS rates to account for upcoding expected to result if the proposed MS-DRGs are adopted, as discussed above in section III. of this Addendum. \4\ Proposed factors for FY 2008, as discussed above in section III. of this Addendum. \5\ Percent change of individual proposed factors may not sum due to rounding.

Comparison of Factors and Adjustments: FY 2007 Capital Federal Rate and Proposed FY 2008 Capital Federal Rate for Rural Hospitals

Proposed FY

Percent FY 2007

2008\4\

Change

change\5\

Update Factor \1\...............................

1.0110

1.0080

0.80 GAF/DRG Adjustment Factor \1\...................

0.9986

1.0018

0.18 Outlier Adjustment Factor \2\...................

0.9568

0.9484

0.9912

-0.88 Exceptions Adjustment Factor \2\................

0.9997

1.0000

0.00 MS-DRG Upcoding Adjustment Factor \3\........... ..............

0.9760

-2.40 Capital Federal Rate............................

$427.03

$417.26

0.9771

-2.29

6. Proposed Special Capital Rate for Puerto Rico Hospitals

Section 412.374 provides for the use of a blended payment system for payments to Puerto Rico hospitals under the PPS for acute care hospital inpatient capital-related costs. Accordingly, under the capital PPS, we compute a separate payment rate specific to Puerto Rico hospitals using the same methodology used to compute the national Federal rate for capital-related costs. Under the broad authority of section 1886(g) of the Act, as discussed in section V. of the preamble of this proposed rule, beginning with discharges occurring on or after October

[[Page 24848]]

1, 2004, capital payments to hospitals in Puerto Rico are based on a blend of 25 percent of the Puerto Rico capital rate and 75 percent of the capital Federal rate. The Puerto Rico capital rate is derived from the costs of Puerto Rico hospitals only, while the capital Federal rate is derived from the costs of all acute care hospitals participating in the IPPS (including Puerto Rico).

To adjust hospitals' capital payments for geographic variations in capital costs, we apply a GAF to both portions of the blended capital rate. The GAF is calculated using the operating IPPS wage index and varies, depending on the labor market area or rural area in which the hospital is located. We use the Puerto Rico wage index to determine the GAF for the Puerto Rico part of the capital-blended rate and the national wage index to determine the GAF for the national part of the blended capital rate.

Because we implemented a separate GAF for Puerto Rico in FY 1998, we also apply separate budget neutrality adjustments for the national GAF and for the Puerto Rico GAF. However, we apply the same budget neutrality factor for DRG reclassifications and recalibration nationally and for Puerto Rico. As we stated above in section III.A.4. of this Addendum, for Puerto Rico, the proposed GAF budget neutrality factor is 1.0009, while the DRG adjustment is 0.9992, for a combined proposed cumulative adjustment of 1.0001.

In computing the payment for a particular Puerto Rico hospital, the Puerto Rico portion of the capital rate (25 percent) is multiplied by the Puerto Rico-specific GAF for the labor market area in which the hospital is located, and the national portion of the capital rate (75 percent) is multiplied by the national GAF for the labor market area in which the hospital is located (which is computed from national data for all hospitals in the United States and Puerto Rico). In FY 1998, we implemented a 17.78 percent reduction to the Puerto Rico capital rate as a result of Pub. L. 105-33. In FY 2003, a small part of that reduction was restored.

For FY 2007, before application of the GAF, the special capital rate for Puerto Rico hospitals was $203.06 for discharges occurring on or after October 1, 2006 through September 30, 2007. With the changes we are making to the factors used to determine the capital rate, in addition to the proposed zero percent update for urban hospitals, the proposed FY 2008 special capital rate for rural hospitals in Puerto Rico is $197.21 For urban hospitals in Puerto Rico, the proposed FY 2008 special capital rate is $195.60.

B. Calculation of the Proposed Inpatient Capital-Related Prospective Payments for FY 2008

Because the 10-year capital PPS transition period ended in FY 2001, all hospitals (except ``new'' hospitals under Sec. 412.324(b) and under Sec. 412.304(c)(2)) are paid based on 100 percent of the capital Federal rate in FY 2007. The applicable capital Federal rate was determined by making adjustments as follows:

For outliers, by dividing the capital standard Federal rate by the outlier reduction factor for that fiscal year; and

For the payment adjustments applicable to the hospital, by multiplying the hospital's GAF, disproportionate share adjustment factor, and IME adjustment factor, when appropriate.

For purposes of calculating payments for each discharge during FY 2008, the capital standard Federal rate would be adjusted as follows: (Standard Federal Rate) x (DRG weight) x (GAF) x (COLA for hospitals located in Alaska and Hawaii) x (1 + Disproportionate Share Adjustment Factor + IME Adjustment Factor, if applicable). The result is the adjusted capital Federal rate. (As discussed above and in section V. of the preamble of this proposed rule, we are proposing to eliminate the large urban add-on adjustment in existing regulations at Sec. 412.316, beginning in FY 2008.)

Hospitals also may 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. The proposed outlier thresholds for FY 2008 are in section II.A.4.c. of this Addendum. For FY 2008, a case qualifies as a cost outlier if the cost for the case plus the IME and DSH payments is greater than the prospective payment rate for the DRG plus the proposed fixed-loss amount of $23,015.

An eligible hospital may also qualify for a special exceptions payment under Sec. 412.348(g) for up through the 10th year beyond the end of the capital transition period if it meets: (1) a project need requirement described at Sec. 412.348(g)(2), which in the case of certain urban hospitals includes an excess capacity test as described at Sec. 412.348(g)(4); and (2) a project size requirement as described at Sec. 412.348(g)(5). Eligible hospitals include SCHs, urban hospitals with at least 100 beds that have a DSH patient percentage of at least 20.2 percent or qualify for DSH payments under Sec. 412.106(c)(2), and hospitals that have a combined Medicare and Medicaid inpatient utilization of at least 70 percent. Under Sec. 412.348(g)(8), the amount of a special exceptions payment is determined by comparing the cumulative payments made to the hospital under the capital PPS to the cumulative minimum payment level. This amount is offset by: (1) any amount by which a hospital's cumulative capital payments exceed its cumulative minimum payment levels applicable under the regular exceptions process for cost reporting periods beginning during which the hospital has been subject to the capital PPS; and (2) any amount by which a hospital's current year operating and capital payments (excluding 75 percent of operating DSH payments) exceed its operating and capital costs. Under Sec. 412.348(g)(6), the minimum payment level is 70 percent for all eligible hospitals.

During the transition period, new hospitals (as defined under Sec. 412.300) were exempt from the capital IPPS for their first 2 years of operation and were paid 85 percent of their reasonable costs during that period. Effective with the third year of operation through the remainder of the transition period, under Sec. 412.324(b), we paid the hospitals under the appropriate transition methodology (if the hold-harmless methodology were 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).

Under Sec. 412.304(c)(2), for cost reporting periods beginning on or after October 1, 2002, we pay a new hospital 85 percent of its reasonable costs during the first 2 years of operation unless it elects to receive payment based on 100 percent of the capital Federal rate. Effective with the third year of operation, we pay the hospital based on 100 percent of the capital Federal rate (that is, the same methodology used to pay all other hospitals subject to the capital PPS).

C. Capital Input Price Index

1. Background

Like the operating input price index, the capital input price index (CIPI) is a fixed-weight price index that measures the price changes associated with capital costs during a given year. The CIPI differs from the operating input price index in one important aspect--the CIPI reflects the vintage nature of capital, which is the acquisition and use of capital over time. Capital expenses in any given year are determined by the stock of capital in that year (that is, capital that remains on hand from all current and prior capital acquisitions). An index measuring capital price changes needs to reflect this vintage nature of capital. Therefore, the CIPI was developed to capture the vintage nature of capital by using a weighted-average of past capital purchase prices up to and including the current year.

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. The CIPI was last rebased to FY 2002 in the FY 2006 IPPS final rule (70 FR 47387).

2. Forecast of the CIPI for FY 2008

Based on the latest forecast by Global Insight, Inc. (first quarter of 2007), we are forecasting the CIPI to increase 1.20 percent in FY 2008. This reflects a projected 1.9 percent increase in vintage-weighted depreciation prices (building and fixed equipment, and movable equipment) and a 3.0 percent increase in other capital expense prices in FY 2008, partially offset by a 2.5 percent decline in vintage-weighted interest expenses in FY 2008. The weighted average of these three factors produces the 1.2 percent increase for the CIPI as a whole in FY 2008.

IV. Proposed Changes to Payment Rates for Excluded Hospitals and Hospital Units: Rate-of-Increase Percentages

(If you choose to comment on issues in this section, please include the caption ``Excluded Hospitals Rate of Increase'' at the beginning of your comments.)

[[Page 24849]]

limit (the target amount as defined in Sec. 413.40(a)) was set for each hospital or hospital unit based on the hospital's own cost experience in its base year. The target amount was multiplied by the Medicare discharges and applied as an aggregate upper limit (the ceiling as defined in Sec. 413.40(a)) on total inpatient operating costs for a hospital's cost reporting period. Prior to October 1, 1997, these payment provisions applied consistently to all categories of excluded providers (rehabilitation hospitals and units (now referred to as IRFs), psychiatric hospitals and units (now referred to as IPFs), LTCHs, children's hospitals, and cancer hospitals).

Payment for children's hospitals and cancer hospitals that are excluded from the IPPS continues to be subject to the rate-of- increase ceiling based on the hospital's own historical cost experience. (We note that, in accordance with Sec. 403.752(a), RNHCIs are also subject to the rate-of-increase limits established under Sec. 413.40. IRFs, IPFs, and LTCHs were paid previously under the reasonable cost methodology. However, the statute was amended to provide for the implementation of prospective payment systems for IRFs, IPFs, and LTCHs. In general, the prospective payment systems for IRFs, IPFs, and LTCHs provide(d) transition periods of varying lengths during which time a portion of the prospective payment is (was) based on cost-based reimbursement rules under Part 413 (certain providers do not receive a transition period or may elect to bypass the transition as applicable under Subparts N, O, and P.) We note that the various transition periods provided for under the IRF PPS, IPF PPS, and LTCH PPS have ended or will soon end.

For cost reporting periods beginning on or after October 1, 2002, all IRFs are paid 100 percent of the adjusted Federal rate under the IRF PPS. Therefore, for cost reporting periods beginning on or after October 1, 2002, no portion of an IRF PPS payment is subject to Part 413. Similarly, for cost reporting periods beginning on or after October 1, 2006, all LTCHs are paid 100 percent of the adjusted Federal rate under the LTCH PPS. Therefore, for cost reporting periods beginning on or after October 1, 2006, no portion of the LTCH PPS payment is subject to Part 413. However, except as provided in Sec. 412.426(c), IPFs remain under a blend methodology for cost reporting periods beginning on or after January 1, 2005, and before January 1, 2008.

For IPFs paid under the blend methodology, the portion of the IPF PPS payment that is based on reasonable cost principles is subject to the rules of Part 413. In order to calculate the portion of the PPS payment that is based on reasonable cost principles, it is necessary to determine whether the IPF would be considered ``existing'' for purposes of section 1886(b)(3)(H) of the Act or ``new'' for purposes of section 1886(b)(7) of the Act. We note that readers should not confuse an IPF that is considered ``new'' for purposes of section 1886(b)(7) of the Act and Sec. 413.40(f)(2)(ii) with an IPF that is considered ``new'' under Sec. 412.426(c). Any IPF that, under present or previous ownership or both, has its first cost reporting period as an IPF beginning on or after January 1, 2005, is considered ``new'' for purposes of Sec. 412.426(c). An IPF that is considered ``new'' under Sec. 412.426(c) is paid based on 100 percent of the Federal per diem payment amount. Consequently, only those IPFs considered ``new'' under section 1886(b)(7) of the Act, but not ``new'' under Sec. 412.426(c) will be paid under a PPS blended payment methodology. An IPF considered ``new'' for purposes of Sec. 413.40(f)(2)(ii) would have its ``reasonable-cost based'' portion of its prospective payment subject to Sec. 413.40(f)(2)(ii) and Sec. 413.40(c)(4)(v), as applicable. An IPF considered ``new'' for purposes of section 1886(b)(7) of the Act has the target amount for its third cost reporting period determined in accordance with sections 1886(b)(7)(A)(ii) and 1886(b)(3)(A)(ii) of the Act. For the fourth and subsequent cost reporting periods, the target amount is calculated in accordance with section 1886(b)(3)(A)(ii) of the Act. An IPF that would be considered ``existing'' for purposes of section 1886(b)(3)(H) of the Act has the target amount for the ``reasonable- cost based'' portion of its prospective payment determined in accordance with section 1886(b)(3)(A)(ii) of the Act and Sec. 413.40(c)(4)(ii).

We are proposing that the applicable percentage increase to update the target amount for the reasonable cost-based portion of the PPS payment of an IPF that is considered existing under section 1886(b)(3)(H) of the Act or new under section 1886(b)(7) of the Act, but not new under Sec. 412.426(c), is 3.4 percent using the first quarter of the 2007 forecast made by Global Insight, Inc.

V. Tables

This section contains the tables referred to throughout the preamble to this proposed rule and in this Addendum. Tables 1A, 1B, 1C, 1D, 2, 3A, 3B, 4A, 4B, 4C, 4D, 4F, 4G, 4H, 4J, 5, 6A, 6B, 6C, 6D, 6E, 6F, 6J, 6K, 7A, 7B, 8A, 8B, 8C, 9A, 9C, 10, and 11 are presented below. As explained in sections II.D. 2. and II.G.8. of the preamble of this final rule, Table 6G--Additions to the CC Exclusions List, Table 6H, Deletions from the CC Exclusions List, and Table 6I--Complete List of Complication and Comorbidity (CC) Exclusions are available only through the Internet on the CMS Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS/. The tables

presented below are as follows:

Table 1A--National Adjusted Operating Standardized Amounts, Labor/ Nonlabor (69.7 Percent Labor Share/30.3 Percent Nonlabor Share If Wage Index Is Greater Than 1) Table 1B--National Adjusted Operating Standardized Amounts, Labor/ Nonlabor (62 Percent Labor Share/38 Percent Nonlabor Share If Wage Index Is Less Than or Equal To 1) Table 1C--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor Table 1D--Capital Standard Federal Payment Rate Table 2--Hospital Case-Mix Indexes for Discharges Occurring in Federal Fiscal Year 2006; Hospital Wage Indexes for Federal Fiscal Year 2008; Hospital Average Hourly Wages for Federal Fiscal Years 2006 (2002 Wage Data), 2007 (2003 Wage Data), and 2008 (2004 Wage Data); and 3-Year Average of Hospital Average Hourly Wages Table 3A--FY 2008 and 3-Year Average Hourly Wage for Urban Areas by CBSA Table 3B--FY 2008 and 3-Year Average Hourly Wage for Rural Areas by CBSA Table 4A--Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas by CBSA--FY 2008 Table 4B--Wage Index and Capital Geographic Adjustment Factor (GAF) for Rural Areas by CBSA--FY 2008 Table 4C--Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified by CBSA--FY 2008 Table 4F--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) by CBSA--FY 2008 Table 4J--Out-Migration Adjustment--FY 2008 Table 5--List of Proposed Medicare Severity Diagnosis-Related Groups (MS-DRGs), Relative Weighting Factors, and Geometric and Arithmetic Mean Length of Stay 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 6J--Major Complication and Comorbidity (MCC) List Table 6K--Complications and Comorbidity (CC) List Table 7A--Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2006 MedPAR Update--December 2006 GROUPER V24.0 CMS DRGs Table 7B--Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2006 MedPAR Update--December 2006 GROUPER V25.0 MS-DRGs Table 8A--Proposed Statewide Average Operating Cost-to-Charge Ratios--March 2007 Table 8B--Proposed Statewide Average Capital Cost-to-Charge Ratios-- March 2007 Table 8C--Proposed Statewide Average Total Cost-to-Charge Ratios for LTCHs--March 2007 Table 9A--Revised Hospital Reclassifications and Redesignations--FY 2008 Table 9C--Hospitals Redesignated as Rural under Section 1886(d)(8)(E) of the Act--FY 2008 Table 10--Geometric Mean Plus the Lesser of .75 of the National Adjusted Operating Standardized Payment Amount (Increased to Reflect the Difference Between Costs and Charges) or .75 of One Standard Deviation of Mean Charges by Proposed Medicare Severity Diagnosis- Related Group (MS-DRG)--April 2007 Table 11--Proposed FY 2008 MS-LTC-DRGs, Relative Weights, Geometric Average Length of Stay, and 5/6ths of the Geometric Average Length of Stay

[[Page 24850]]

Table 1A.--National Adjusted Operating Standardized Amounts; Labor/Nonlabor (69.7 Percent Labor Share/30.3 Percent Nonlabor Share if Wage Index Greater Than 1)

Full update (3.3 percent)

Reduced update (1.3 percent)

Labor-related

Nonlabor-related Labor-related Nonlabor-related

$3,430.29........................................

$1,491.21

$3,363.88

$1,462.34

Table 1B.--National Adjusted Operating Standardized Amounts, Labor/Nonlabor (62 Percent Labor Share/38 Percent Nonlabor Share if Wage Index Less Than or Equal to 1)

Full update (3.3 percent)

Reduced update (1.3 percent)

Labor-related

Nonlabor-related Labor-related Nonlabor-related

$3,051.33........................................

$1,870.17

$2,992.26

$1,833.96

Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico Labor, Labor/Nonlabor

Rates if wage index greater Rates if wage index less than than 1

or equal to 1

Labor

Nonlabor

Labor

Nonlabor

National........................................ $3,430.29 $1,491.21 $3,051.33 $1,870.17

Puerto Rico.....................................

1,442.56

884.15

1,365.78

960.93

Table 1D.--Capital Standard Federal Payment Rate

Urban Rural rate rate

National.......................................... $413.87 $417.26 Puerto Rico....................................... 195.60 197.21

[[Page 24851]]

\1\ Based on salaries adjusted occupational mix, according to the calculation in section II.D.6. of the preamble to this final rule.

\2\ The transfer-adjusted case-mix index is based on the billed DRG on the FY 2006 MedPAR.

* Denotes wage data not available for the provider for that year.

** Based on the sum of the salaries and hours computed for Federal FYs 2006, 2007, and 2008.

*** Denotes MedPAR data not available for the provider for FY 2006.

[[Page 24851]]

TABLE 2.--Hospital Case-Mix Indexes for Discharges Occurring in Federal Fiscal Year 2006; Hospital Wage Indexes for Federal Fiscal Year 2008; Hospital Average Hourly Wages for Federal Fiscal Years 2006 (2002 Wage Data), 2007 (2003 Wage Data, and 2008 (2004 Wage Data); and 3-Year Average of Hospital Average Hourly Wages

Average Average Case-mix FY 2008 Average Average hourly wage hourly Provider No.

index \2\ wage index hourly wage hourly wage FY 2008 wage** (3 FY 2006 FY 2007 \1\

years)

010001............................ 1.5195 0.7598 21.6546 22.1989 23.2171 22.3607 010005............................ 1.1370 0.8760 22.4906 23.6022 23.0192 23.0412 010006............................ 1.5127 0.7971 23.4823 23.4975 25.1891 23.9924 010007............................ 1.0231 0.7598 18.2429 19.9329 21.2159 19.8249 010008............................ 1.0409 0.7843 20.4591 17.9533 22.0766 19.9260 010009............................ 0.9710 0.8760 23.2228 23.5626 25.8995 24.2263 010010............................ 1.1050 0.8737 21.4974 27.0385 22.8588 23.5938 010011............................ 1.6744 0.8873 27.4850 27.6658 27.4650 27.5387 010012............................ 1.2346 0.9391 22.7020 24.4059 25.5764 24.1955 010015............................ 1.0427 0.7641 21.5111 22.3383 27.0786 23.3434 010016............................ 1.5763 0.8873 25.1502 24.6488 26.8613 25.5445 010018............................ 1.7123 0.8873 22.2990 23.7048 24.6173 23.5172 010019............................ 1.2720 0.7971 22.0906 22.8766 23.3445 22.7780 010021............................ 1.1864 0.7598 18.6785 19.7367 21.0596 19.7966 010022............................ 0.9503 0.9845 24.5671 25.8404 27.4306 25.9296 010023............................ 1.8483 0.8366 27.6174 25.4272 27.5972 26.8926 010024............................ 1.6036 0.8366 20.7265 22.0819 25.0694 22.5299 010025............................ 1.3014 0.8594 21.2674 22.7635 23.6162 22.5532 010027............................ 0.7631 0.7598 15.3705 16.4682 17.0501 16.2714 010029............................ 1.5702 0.8594 22.6976 23.9007 25.0667 23.9196 010032............................ 0.9327 0.7918 19.1555 19.3311 20.5944 19.8444 010033............................ 2.0856 0.8873 26.3784 27.4181 28.9456 27.5755 010034............................ 1.0461 0.8366 16.9686 17.7457 19.1508 17.9500 010035............................ 1.3138 0.8737 22.2870 24.2425 24.2739 23.6060 010036............................ 1.1607 0.7598 22.9747 21.5796 24.2867 22.9472 010038............................ 1.2692 0.8081 21.4509 23.7039 27.0732 24.1203 010039............................ 1.6579 0.9175 25.8820 26.9919 29.2918 27.3990 010040............................ 1.6552 0.8129 22.8851 24.3207 24.7653 23.9965 010043............................ 1.0833 0.8873 22.5944 21.9774 23.9116 22.8203 010044............................ 1.0847 0.8737 21.4036 22.5009 24.4278 22.7205 010045............................ 1.2226 0.8737 19.8803 20.4927 23.1687 21.0753 010046............................ 1.5338 0.8129 21.6965 23.4219 25.7750 23.5002 010047............................ 0.8958 0.7777 21.0605 26.4851 19.7500 21.9482 010049............................ 1.1433 0.7598 20.2413 21.7888 22.4234 21.5067 010050............................ 1.0407 0.8873 22.1584 22.9620 24.4046 23.1653 010051............................ 0.8299 0.8534 15.2207 18.7701 18.0235 17.3856 010052............................ 0.8742 0.7722 16.4958 25.9233 36.3510 26.9113 010053............................

***

* 19.0108

* 19.0108 010054............................ 1.0737 0.8760 22.5554 23.3624 24.4797 23.4775 010055............................ 1.6104 0.7598 22.3800 22.5396 22.4131 22.4446 010056............................ 1.6382 0.8873 23.7144 23.7398 25.3239 24.2816 010058............................ 1.0119 0.8873 18.5538 19.5092 17.0128 18.2407 010059............................ 1.0247 0.8760 21.3237 23.0012 24.8195 23.0576 010061............................ 0.9828 0.8164 21.9370 24.1185 25.2415 23.7777 010062............................ 1.0229 0.7598 18.3435 21.4805 21.6281 20.4629 010064............................ 1.6966 0.8873 26.1110 24.8155 27.6143 26.1440 010065............................ 1.5287 0.8737 21.3785 23.0477 24.3340 22.9445 010066............................ 0.8370 0.7598 17.6152 19.8692 25.1251 20.8278 010068............................

***

* 19.0789 22.7156 24.4131 22.0065 010069............................ 1.0243 0.7598 21.3609 23.1243 23.6305 22.6678 010072............................

***

* 21.8169 24.4989 25.9729 24.0804 010073............................ 0.9794 0.7598 16.4168 18.3963 19.0009 17.9403 010078............................ 1.6186 0.8081 21.6857 23.5279 24.3805 23.2222 010079............................ 1.2223 0.9175 21.8199 22.7337 22.1795 22.2414 010083............................ 1.1876 0.7950 22.3040 22.4279 24.0017 22.9546 010084............................ 1.3254 0.8873 24.7127 26.3238 26.5072 25.8381 010085............................ 1.3296 0.8760 24.4710 24.2609 24.1142 24.2806 010086............................ 1.1007 0.7598 18.6081 22.2096 21.5581 20.7408 010087............................ 1.9814 0.7950 22.5225 22.4318 24.8042 23.2180 010089............................ 1.2937 0.8873 22.8448 25.0811 26.2624 24.6787 010090............................ 1.7447 0.8544 23.6948 26.0494 26.3950 25.3394 010091............................ 0.9554 0.7641 18.6912 23.1310 22.5237 21.3015

[[Page 24852]]

010092............................ 1.5528 0.8534 24.4592 26.6796 26.9923 26.0268 010095............................ 0.8469 0.8534 13.9326 16.5250 16.9952 15.8664 010097............................ 0.7113 0.8366 16.7549 19.4511 19.2462 18.4993 010098............................ 0.9805

* 14.3076

* 14.3076 010099............................ 0.9668 0.7598 18.7910 20.8383 20.6723 20.0887 010100............................ 1.6853 0.8127 21.2915 23.8919 25.1439 23.5423 010101............................ 1.1065 0.8737 21.6593 24.2575 25.0963 23.6319 010102............................ 0.9355 0.7598 21.0902 25.6158 26.9801 24.5958 010103............................ 1.8826 0.8873 26.1163 27.8272 28.9628 27.5988 010104............................ 1.8819 0.8873 24.7394 27.6471 28.3109 26.8460 010108............................ 1.0930 0.8366 28.4624 24.6740 27.0236 26.7335 010109............................ 0.9845 0.7967 21.6194 17.6733 21.0403 20.0217 010110............................ 0.7589 0.7901 17.5957 26.0038 19.8672 20.8809 010112............................ 0.9638 0.7598 16.8902 17.1833 20.4001 18.1174 010113............................ 1.6643 0.7950 21.4121 22.3282 24.7059 22.7828 010114............................ 1.3627 0.8873 22.3752 25.6152 25.7061 24.6261 010115............................ 0.6881

* 21.7477

* 21.7477 010118............................ 1.2168 0.8166 19.7673 21.4630 22.7172 21.2736 010120............................ 0.9648 0.7598 20.9450 20.9019 22.1859 21.3550 010121............................

***

* 24.0867

* 24.0867 010125............................ 1.0630 0.8069 18.4113 21.5123 22.8897 20.8635 010126............................ 1.1765 0.8366 23.1381 23.9327 24.4934 23.8544 010128............................ 0.8769 0.7641 21.4200 23.6647 24.9854 23.3827 010129............................ 1.0370 0.7723 21.3555 22.1574 21.8496 21.7886 010130............................ 1.0247 0.8873 23.2488 23.7528 24.5639 23.8766 010131............................ 1.3971 0.9175 25.7837 26.4297 27.2704 26.5326 010137............................ 1.2222 0.8873 24.7366 27.5782 28.5798 26.9175 010138............................ 0.6028 0.7711 13.8476 16.7602 14.5508 15.1016 010139............................ 1.5889 0.8873 25.3014 26.8726 28.1771 26.8342 010143............................ 1.2118 0.8737 22.0215 26.2762 24.0663 24.0857 010144............................ 1.6386 0.7950 20.8209 22.5133 22.3897 21.9331 010145............................ 1.4710 0.8534 24.9531 24.5092 25.8279 25.1079 010146............................ 1.0814 0.8081 20.8917 22.6586 22.6870 22.1060 010148............................ 0.8685 0.7598 20.5589 23.9246 23.5683 22.6789 010149............................ 1.2881 0.8366 26.5854 24.4805 26.7486 25.9662 010150............................ 1.0284 0.8366 21.6377 23.6080 24.4087 23.2036 010152............................ 1.2950 0.7950 22.6202 22.4075 23.7803 22.9411 010157............................ 1.1360 0.7971 24.3559 23.3828 25.4582 24.3716 010158............................ 1.1924 0.7927 24.3531 23.5533 25.5902 24.4669 010162............................

***

* 33.8777

* 33.8777 010163............................

***

* 34.0293 34.0293 010164............................ 1.1750 0.8043

* 010165............................

***

* 28.8030 28.8030 010166............................

***

* 29.7218 29.7218 010167............................ 1.4977 0.8873

* 010168............................ 1.1410 0.9023

* 020001............................ 1.7970 1.1840 32.8120 35.4232 36.5276 34.9502 020004............................ 1.1210 1.1817 32.0966 31.8004 33.5991 32.4852 020006............................ 1.3200 1.1840 36.0540 34.3752 37.0215 35.7759 020008............................ 1.2398 1.1840 35.9236 36.1250 39.3416 37.1498 020012............................ 1.3779 1.1817 31.8995 32.5975 33.9363 32.8387 020014............................ 1.1267 1.1817 32.0894 29.4472 30.9718 30.8220 020017............................ 1.9205 1.1840 33.5852 35.4119 35.8810 34.9151 020018............................ 0.9351 1.9287

* 020019............................ 0.8687 1.9287

* 020024............................ 1.1749 1.1817 33.0644 29.5195 38.6904 33.4491 020026............................ 1.4939 1.9287

* 020027............................ 0.9384 1.9287

* 030001............................ 1.5465 1.0115 29.9840 32.4791 33.4166 31.9038 030002............................ 2.0925 1.0115 29.0519 30.2200 31.0794 30.0867 030006............................ 1.6966 0.9484 25.8872 27.0599 27.8624 26.9763

[[Page 24853]]

030007............................ 1.4533 0.9386 29.6174 31.1928 33.7190 31.5810 030009............................

***

* 22.3993 26.5408

* 23.8204 030010............................ 1.4068 0.9484 24.8275 28.5684 31.1684 28.1880 030011............................ 1.4906 0.9484 25.1361 28.1423 29.3385 27.6326 030012............................ 1.3882 0.9913 26.3859 27.3895 28.8355 27.5891 030013............................ 1.4760 0.9468 25.7050 27.0111 29.3504 27.3749 030014............................ 1.5924 1.0115 25.6259 29.6582 29.8251 28.4291 030016............................ 1.2381 1.0115 26.7003 29.1980 31.9830 29.4207 030017............................ 2.0661 1.0115 26.2452 30.6007 34.7863 30.8882 030018............................ 1.3196 1.0115 28.9476 29.4566 31.8047 30.0509 030019............................ 1.3553 1.0115 27.3156 29.5921 30.1929 29.0813 030022............................ 1.5745 1.0115 26.4404 30.5710 30.3718 29.2058 030023............................ 1.7864 1.1558 33.8333 34.2142 35.8265 34.6818 030024............................ 2.0620 1.0115 31.6658 31.9247 33.1810 32.2887 030027............................ 0.9709

* 20.4032

* 20.4032 030030............................ 1.5755 1.0115 30.2712 32.0994 34.4162 32.2545 030033............................ 1.2964 1.1310 26.6531 28.7508 29.9363 28.4678 030036............................ 1.4582 1.0115 30.3521 30.9834 33.0517 31.6114 030037............................ 2.1468 1.0115 28.6453 31.2877 34.1070 31.4095 030038............................ 1.6738 1.0115 29.5509 29.9314 31.6720 30.2088 030040............................ 0.9098 0.9398 24.8145 27.5322 29.5727 27.3145 030043............................ 1.2683 0.9386 24.7932 26.5834 27.3802 26.2787 030055............................ 1.4609 0.9534 24.5202 27.1473 27.0569 26.3168 030060............................ 1.0905 0.9386 24.3523 24.8373 29.6494 26.3133 030061............................ 1.6820 1.0115 25.5529 28.0696 27.7958 27.1919 030062............................ 1.2021 0.9386 23.8068 26.6880 28.9557 26.5828 030064............................ 1.9609 0.9484 25.4922 28.3853 29.7464 27.9854 030065............................ 1.5921 1.0115 27.1646 29.5883 31.0784 29.3868 030067............................ 1.0573 0.9616 20.4376 20.7591 27.4426 22.9577 030068............................ 1.1143 0.9386 20.8846 23.1394 24.0540 22.7233 030069............................ 1.4255 0.9386 26.3518 30.2224 29.7783 28.7287 030071............................ 0.8871 1.4406

* 030073............................ 0.8952 1.4406

* 030074............................ 0.8727 1.4406

* 030077............................ 0.7676 1.4406

* 030078............................ 0.9879 1.4406

* 030080............................ 1.5499 0.9484 25.2077 27.1360 28.7349 27.0418 030083............................ 1.4209 1.0115 27.5353 27.4983 33.5289 29.3975 030084............................ 0.9014 1.4406

* 030085............................ 1.5899 0.9484 24.5792 26.8364 28.1362 26.6157 030087............................ 1.6946 1.0115 26.6594 29.5962 31.2063 29.3936 030088............................ 1.3692 1.0115 26.6796 27.8604 29.9743 28.2304 030089............................ 1.6385 1.0115 27.1835 28.9068 30.1558 28.8088 030092............................ 1.4976 1.0115 27.3203 31.7512 30.6298 30.0149 030093............................ 1.2964 1.0115 25.8955 26.4430 27.4271 26.6702 030094............................ 1.4055 1.0115 29.5948 31.5422 33.4045 31.6118 030099............................ 0.8736 0.9386 26.3236 27.1402 26.7474 26.7410 030100............................ 2.0536 0.9484 29.0691 31.5628 35.1381 31.9181 030101............................ 1.4386 1.1205 26.1927 27.8302 30.6747 28.3387 030102............................ 2.3668 1.0115 29.0942 31.6285 34.2046 31.6905 030103............................ 1.7576 1.0115 30.1994 31.7322 32.2839 31.3999 030105............................ 2.2412 1.0115 31.3094 31.2970 32.7440 31.8776 030106............................ 1.7570 1.0115 34.7221 32.9840 36.4650 34.9441 030107............................ 1.9168 1.0115

* 35.6197 35.5345 35.5697 030108............................ 2.0343 1.0115

* 31.3337 31.3337 030109............................

***

* 16.5906 32.6823 26.5780 030110............................ 1.6153 1.0115

* 31.4852 29.7956 30.5019 030111............................ 1.0328 0.9484

* 34.7976 34.7976 030112............................ 1.9764 1.0115

* 37.4931 37.4931 030113............................ 0.8965 1.4406

* 030114............................ 1.3891 0.9484

[[Page 24854]]

030115............................ 1.3513 1.0115

* 030117............................ 1.1172 0.9386

* 030118............................ 1.0947 0.9913

* 030119............................ 1.1646 1.0115

* 040001............................ 1.0784 0.8876 23.7718 22.9327 22.9909 23.2119 040002............................ 1.2054 0.7519 20.1384 21.2020 24.9965 22.0316 040004............................ 1.7231 0.8876 25.0286 27.1741 28.1077 26.7777 040007............................ 1.7566 0.8965 25.7142 40.1291 29.1919 31.6848 040010............................ 1.4680 0.8876 23.0274 24.2315 26.5274 24.6221 040011............................ 1.0468 0.7519 20.3970 21.0967 22.2391 21.2815 040014............................ 1.3549 0.8721 25.3451 26.4777 29.0061 26.8567 040015............................ 0.9946 0.7519 19.2831 20.4279 20.1045 19.9373 040016............................ 1.7637 0.8965 22.1228 25.8056 26.5895 24.8381 040017............................ 1.0958 0.8719 21.9875 21.9147 23.8741 22.5732 040018............................ 1.0813 0.8056 23.6044 24.0026 25.6731 24.3846 040019............................ 1.1103 0.8951 23.7328 23.8706 24.9108 24.1693 040020............................ 1.5840 0.8951 21.6603 22.6497 23.9443 22.7533 040021............................ 1.5369 0.8965 25.6917 25.4046 26.1832 25.7531 040022............................ 1.5691 0.8876 25.4052 29.5000 27.9883 27.5941 040026............................ 1.5094 0.9110 25.4072 27.7931 29.5278 27.6084 040027............................ 1.4822 0.8943 21.1412 21.4252 23.8205 22.1269 040029............................ 1.4949 0.8965 24.0704 24.8409 25.1455 24.6984 040036............................ 1.6116 0.8965 26.3226 27.6234 29.7111 27.9661 040039............................ 1.2751 0.8145 19.5998 21.2712 21.4793 20.7967 040041............................ 1.1737 0.8721 22.1531 23.7787 26.4923 24.1425 040042............................ 1.3814 0.9291 19.9627 21.1716 19.8670 20.3330 040045............................ 1.0416

* 17.2281

* 17.2281 040047............................ 1.1246 0.7636 21.9163 22.4249 22.9939 22.4384 040050............................ 1.2272 0.7519 16.3930 17.6906 18.5104 17.5655 040051............................ 0.9636 0.7519 19.1400 21.3342 22.0350 20.8371 040053............................

***

* 20.7823

* 20.7823 040054............................

***

* 18.2685 18.0509 19.5333 18.6002 040055............................ 1.5255 0.8056 23.3156 23.0448 24.9139 23.7090 040062............................ 1.6634 0.8056 23.3082 23.8994 25.2283 24.1348 040067............................ 1.1389 0.7527 16.8800 19.0471 18.9849 18.2674 040069............................ 1.0195 0.8951 24.4662 24.8060 24.9975 24.7596 040071............................ 1.4618 0.8721 24.3824 25.4680 25.2804 25.0562 040072............................ 1.1155 0.7519 19.9009 22.4741 22.1027 21.4210 040074............................ 1.1976 0.8965 25.2423 25.2699 26.2628 25.5873 040075............................

***

* 18.3253

* 18.3253 040076............................ 1.0003 0.8721 20.6272 23.5742 23.0930 22.4189 040077............................ 0.9991

* 18.2082

* 18.2082 040078............................ 1.5953 0.8721 24.5377 23.5915 26.1923 24.6731 040080............................ 1.0440 0.8507 22.3392 24.1921 24.8730 23.8545 040081............................ 0.8586 0.7877 15.1081 16.8437 17.2484 16.4107 040084............................ 1.1954 0.8965 24.7225 27.7626 26.6430 26.4194 040085............................ 0.9761 0.8951 29.8444 22.9916 25.7190 25.8628 040088............................ 1.4629 0.7766 22.6183 22.4860 23.5774 22.9018 040091............................ 1.1778 0.8131 23.1320 24.2398 23.1902 23.5097 040100............................ 1.3421 0.8721 20.0460 21.3051 22.6107 21.3761 040105............................ 1.0556

* 18.2182

* 18.2182 040109............................ 1.1066

* 22.8801

* 22.8801 040114............................ 1.8067 0.8965 24.8992 26.7581 27.7902 26.5373 040118............................ 1.4739 0.8507 24.7363 26.0388 26.8888 25.8805 040119............................ 1.4199 0.8721 21.0103 24.3680 24.2386 23.2176 040126............................

***

* 14.0700 15.6985 17.3697 15.6131 040132............................

***

* 28.1393

* 22.0041 24.3526 040134............................ 2.3675 0.8965 27.3412 31.9325 32.2786 30.5646 040137............................ 1.3088 0.8965 25.2907 25.9979 27.7350 26.2747 040138............................ 1.4228 0.8876 25.7513 27.8584 28.3338 27.5135 040141............................ 0.8436 0.8876 24.0901 26.1041 30.3458 26.8841

[[Page 24855]]

040142............................ 1.4686 0.9110 27.9696 21.4222 23.8619 24.1239 040143............................

***

* 37.1976

* 37.1976 040144............................

***

* 21.4008

* 21.4008 040145............................ 1.7857 0.8507

* 24.4378 24.4378 040146............................

***

* 33.7847 33.7847 040147............................ 1.7126 0.8965

* 050002............................ 1.3851 1.5308 34.1948 35.5184 41.7235 37.3172 050006............................ 1.6409 1.2666 30.5373 33.5751 37.1649 33.5394 050007............................ 1.4954 1.4906 38.7033 43.4440 44.3636 42.1957 050008............................ 1.2737 1.4766 39.1539 49.3167 46.6961 45.1213 050009............................ 1.8128 1.4201 39.6393 43.0584 46.2195 43.0446 050013............................ 1.9755 1.4201 31.9837 35.7591 42.0547 36.4664 050014............................ 1.2470 1.2853 33.0373 36.0305 36.6124 35.2529 050015............................ 1.3326

* 30.7940 32.2188

* 31.5274 050016............................ 1.3291 1.1912 26.2161 24.5768 30.7245 27.1606 050017............................ 1.9798 1.2999 36.6593 39.6653 41.8986 39.4161 050018............................ 1.1984 1.1633 22.3472 23.3204 32.0787 25.3874 050022............................ 1.5660 1.1607 29.8632 31.6467 33.0584 31.4880 050024............................ 1.1369 1.1607 27.5587 29.4062 33.4319 30.1998 050025............................ 1.8832 1.1607 36.1622 33.5466 32.7463 34.1066 050026............................ 1.5092 1.1607 28.3027 31.5250 33.1265 31.0369 050028............................ 1.2326 1.1607 26.6160 27.3826 28.5775 27.5352 050030............................ 1.2224 1.1607 24.9707 27.2945 30.8991 27.6427 050036............................ 1.5126 1.1607 32.7929 33.8000 36.1357 34.2635 050038............................ 1.6564 1.5378 38.7527 44.2265 47.1554 43.4736 050039............................ 1.6086 1.1607 31.6734 35.2630 36.6920 34.5165 050040............................ 1.2745 1.1633 34.3279 35.8322 35.7021 35.3245 050042............................ 1.5024 1.2666 33.9415 37.3760 40.3545 37.2138 050043............................ 1.6351 1.5308 43.1589 45.4887 46.5540 45.1118 050045............................ 1.3005 1.1607 23.8408 25.0150 27.0633 25.4065 050046............................ 1.1311 1.1607 25.6875 26.1926 29.1122 26.9714 050047............................ 1.7663 1.4766 40.9874 55.9367 45.1678 47.4628 050054............................ 1.1907 1.1607 24.1262 21.3650 24.3196 23.2719 050055............................ 1.3282 1.4766 37.5879 42.9516 44.2917 41.4280 050056............................ 1.3806 1.1633 27.9330 30.6126 32.7669 30.4544 050057............................ 1.6643 1.1607 29.4351 30.0236 31.7448 30.4500 050058............................ 1.6025 1.1633 33.8215 33.1409 36.7723 34.5428 050060............................ 1.4468 1.1607 27.3282 29.9762 32.0159 29.7243 050061............................

***

* 32.2172

* 32.2172 050063............................ 1.3855 1.1633 33.3039 34.0906 36.3153 34.5052 050065............................

***

* 34.0280 34.9110 38.2458 35.7018 050067............................ 1.1904 1.1989 31.9597 38.8070 40.1284 37.4041 050069............................ 1.7481 1.1607 31.2172 34.6353 35.3837 33.8181 050070............................ 1.2855 1.4906 45.3382 47.4099 46.4023 46.4528 050071............................ 1.2901 1.5299 44.9464 50.7602 49.6475 48.7318 050072............................ 1.3299 1.5299 44.2651 49.4344 50.0340 48.1854 050073............................ 1.2899 1.5299 45.9765 49.9730 49.0059 48.5022 050075............................ 1.3067 1.5308 47.2356 54.4089 49.8285 50.5647 050076............................ 1.9114 1.5299 46.4991 52.3788 50.2028 49.9368 050077............................ 1.6174 1.1607 32.0245 34.8660 36.5360 34.5322 050078............................ 1.2621 1.1633 31.1425 32.0133 30.4267 31.1476 050079............................ 1.5036 1.5299 47.8597 47.3449 48.9005 47.9787 050082............................ 1.6860 1.1607 37.7783 38.2878 37.6622 37.9070 050084............................ 1.5634 1.1870 33.0179 35.5196 39.3825 35.9583 050088............................

***

* 25.7385

* 25.7385 050089............................ 1.3526 1.1607 33.5324 33.9593 36.6955 34.6956 050090............................ 1.2774 1.4766 32.9584 33.8953 37.7343 34.8362 050091............................ 1.0225 1.1633 30.8560 32.1301 37.1046 33.3130 050093............................ 1.5010 1.1607 33.4118 36.9481 36.8258 35.7320 050096............................ 1.2246 1.1633 24.6679 34.9237 35.3586 31.7202 050099............................ 1.4900 1.1607 31.0437 33.4174 30.2843 31.6087

[[Page 24856]]

050100............................ 1.8340 1.1607 29.6949 31.4404 33.3955 32.0304 050101............................ 1.2896 1.5299 40.3195 42.4589 47.1051 43.3558 050102............................ 1.2784 1.1607 29.1364 32.0617 33.1773 31.7561 050103............................ 1.5384 1.1633 34.2529 34.0935 35.6753 34.7042 050104............................ 1.4343 1.1633 29.7326 32.3043 33.6194 31.9097 050107............................ 1.5161 1.1607 33.1358 32.5846 33.3632 33.0279 050108............................ 1.9249 1.2999 35.5711 38.8672 41.2472 38.6817 050110............................ 1.2782 1.1607 26.1453 26.8408 28.0669 27.0290 050111............................ 1.2607 1.1633 28.1588 28.7875 31.8716 29.6669 050112............................ 1.5328 1.1633 36.8026 37.7281 38.9441 37.8605 050113............................ 1.2281 1.4906 33.8064 39.4882 42.8855 38.6355 050114............................ 1.4308 1.1633 31.1295 34.0309 35.7244 33.6736 050115............................ 1.4652 1.1607 30.9288 28.8051 31.3553 30.3610 050116............................ 1.7182 1.1633 34.5109 36.8825 37.7999 36.4915 050117............................

***

* 32.4413 34.2020 35.0365 33.2948 050118............................ 1.2267 1.1989 35.4044 39.9683 41.6676 39.0057 050121............................ 1.2979 1.1607 27.9537 30.6105 34.6208 31.1203 050122............................ 1.5166 1.1870 34.2416 33.9812 33.4644 33.8813 050124............................ 1.2868 1.1633 28.0288 30.2522 29.9912 29.4686 050125............................ 1.4991 1.5378 41.7020 44.9523 47.5179 44.7128 050126............................ 1.4832 1.1633 29.3360 31.7619 32.6678 31.2865 050127............................ 1.3323 1.2999 26.1222 32.0355 40.6863 31.7609 050128............................ 1.4725 1.1607 31.0662 31.1308 33.4220 31.8925 050129............................ 1.8434 1.1607 32.2680 34.7359 36.8660 34.5472 050131............................ 1.3349 1.4766 40.5321 45.3152 46.4089 44.1170 050132............................ 1.4284 1.1633 35.1544 35.9199 39.7742 36.9321 050133............................ 1.5409 1.2853 31.3530 31.9527 33.1808 32.2800 050135............................ 1.0356 1.1633 24.3927 25.1813 25.3138 25.0595 050136............................ 1.3586 1.4766 37.4560 43.3747 46.6589 42.5331 050137............................ 1.4390 1.1633 38.4827 39.1496 40.2454 39.4249 050138............................ 1.8383 1.1633 46.9557 45.3727 40.6348 43.8131 050139............................ 1.1867 1.1633 37.6217 37.8986 38.7381 38.1891 050140............................ 1.3250 1.1607 39.6269 40.9725 39.4950 39.9745 050144............................

***

* 33.5109 33.6662 38.2322 35.1744 050145............................ 1.4358 1.4408 42.3134 42.2921 47.7276 44.2033 050146............................ 1.7437

* 050148............................ 1.0844

* 27.3005 28.2305

* 27.7734 050149............................ 1.5003 1.1633 33.2270 35.8821 37.5338 35.8255 050150............................ 1.2112 1.2853 31.7560 33.6583 37.9935 34.4495 050152............................ 1.4654 1.4766 43.6487 46.1553 51.6554 47.1764 050153............................ 1.4478 1.5378 43.3190 42.8955 47.6370 44.7561 050155............................

***

* 21.8550 16.9516 16.7744 18.0647 050158............................ 1.3562 1.1633 35.1326 35.7805 39.9584 36.9833 050159............................ 1.4342 1.1607 31.3199 32.5704 34.6887 32.9759 050167............................ 1.3285 1.1870 28.5179 31.4798 34.0379 31.2291 050168............................ 1.6239 1.1607 33.2506 37.9784 40.5914 37.3803 050169............................ 1.4414 1.1633 27.4644 29.4693 31.4104 29.5643 050172............................

***

* 28.5604

* 28.5604 050173............................ 1.3511 1.1607 30.3582 29.0576 31.6677 30.3441 050174............................ 1.5304 1.4766 40.1747 44.4199 46.5960 43.8522 050175............................

***

* 30.5733 33.3061 35.0178 32.9399 050177............................

***

* 25.1442 24.0717

* 24.6196 050179............................ 1.2436 1.1989 27.1155 30.4973 31.6619 30.0118 050180............................ 1.5479 1.5299 40.2504 42.0358 45.8035 42.8295 050188............................ 1.4249 1.5378 39.5110 41.0943 43.7368 41.3969 050189............................ 1.0036 1.4408 29.1279 30.1155 28.7585 29.3260 050191............................ 1.5059 1.1633 34.2091 37.7805 38.1482 36.6461 050192............................ 0.9796 1.1607 27.0424 27.1400 27.8369 27.3395 050193............................ 1.2019 1.1607 29.6421 33.9520 29.3437 30.8548 050194............................ 1.3917 1.5378 40.9096 44.7107 49.0012 44.8981 050195............................ 1.5361 1.5308 48.4358 48.8595 53.5569 50.3390

[[Page 24857]]

050196............................ 1.0257 1.1607 32.1933 34.0956 32.8081 33.0293 050197............................ 2.1096 1.5299 48.9053 50.0728 53.0188 50.6957 050204............................ 1.4245 1.1633 28.6423 32.0121 35.3934 32.0132 050205............................ 1.4343 1.1633 27.8611 29.3334 30.6295 29.3017 050207............................

***

* 29.5214 30.0062 31.3426 30.2627 050211............................ 1.2807 1.5308 41.2166 35.0515 35.0280 36.9044 050214............................

***

* 23.9972 25.4647

* 24.7211 050215............................

***

* 43.7985 48.8112 50.7559 47.7254 050219............................ 1.2468 1.1633 22.4065 26.4143 25.8363 24.8922 050222............................ 1.7017 1.1607 29.1094 32.3882 33.7497 31.8383 050224............................ 1.7128 1.1607 29.3143 32.5010 35.6597 32.5126 050225............................ 1.4566 1.1607 29.9656 34.0836 35.1213 33.2219 050226............................ 1.6579 1.1607 30.5867 32.4411 35.4589 32.8047 050228............................ 1.2788 1.4766 42.4226 43.7939 47.1404 44.4641 050230............................ 1.5673 1.1607 32.9555 34.0600 35.8511 34.3224 050231............................ 1.6215 1.1633 30.9607 32.1813 33.7123 32.3028 050232............................ 1.7615 1.1912 27.4099 26.3004 33.8542 29.2047 050234............................ 1.1631 1.1607 29.6561 32.3726 34.8300 32.2029 050235............................ 1.5179 1.1633 29.2979 30.5405 37.0848 32.3685 050236............................ 1.4101 1.1607 32.1647 33.0686 32.6449 32.6397 050238............................ 1.5170 1.1633 31.1764 33.3346 33.6829 32.8238 050239............................ 1.6079 1.1633 31.0963 33.1148 35.9031 33.4237 050240............................

***

* 35.5735 36.1154 40.8103 37.5129 050242............................ 1.3921 1.5378 44.3130 46.4844 51.0202 47.3613 050243............................ 1.6372 1.1607 31.4883 32.9385 36.1250 33.6127 050245............................ 1.3931 1.1607 28.6527 27.3866 30.1898 28.7713 050248............................ 1.0716 1.4408 35.3864

* 37.5312 36.3536 050251............................

***

* 27.2675 27.8452 31.2316 28.9392 050253............................

***

* 24.0044 23.5381

* 23.7879 050254............................ 1.2481 1.2999 27.0041 31.2386 33.0846 30.5672 050256............................

***

* 29.8194 29.6793 32.7134 30.6554 050257............................ 0.9659 1.1607 21.3216 20.1829 24.0681 21.8475 050261............................ 1.3127 1.1607 27.3234 29.2150 30.8667 29.2674 050262............................ 2.1485 1.1633 44.0256 39.9946 41.4804 41.8523 050264............................ 1.3229 1.5308 41.1211 47.7024 42.5208 43.7371 050270............................

***

* 32.4812 33.6855 36.0101 34.0808 050272............................ 1.3845 1.1607 27.1989 29.4671 29.7379 28.8393 050276............................ 1.1469 1.5299 39.3778 41.1406 43.7919 41.5068 050277............................ 1.0179 1.1633 32.5213 35.4443 35.0053 34.2959 050278............................ 1.5501 1.1633 29.9244 31.8712 34.3775 32.1732 050279............................ 1.1687 1.1607 27.6573 29.7118 31.6720 29.7046 050280............................ 1.6972 1.2827 35.2030 38.8341 41.4106 38.4388 050281............................ 1.3952 1.1633 27.3824 29.4882 31.6589 29.5764 050283............................ 1.4814 1.5308 43.0638 44.3122 43.6531 43.6816 050289............................ 1.6758 1.4906 41.1774 44.2814 50.1743 45.4605 050290............................ 1.7004 1.1633 34.5482 37.3563 40.6183 37.4594 050291............................ 1.9448 1.4766 35.3653 38.4365 40.5938 38.0951 050292............................ 1.0728 1.1607 26.8879 26.9786 27.3320 27.0736 050295............................ 1.4731 1.1607 36.1950 34.7382 38.4514 36.5567 050296............................ 1.1731 1.5378 39.0060 39.9842 42.4133 40.4982 050298............................ 1.1705 1.1607 27.7416 30.2022 33.7827 30.5459 050299............................

***

* 31.5435 35.1249 32.3683 32.9738 050300............................ 1.4374 1.1607 30.7148 30.2874 33.6814 31.6607 050301............................ 1.2925 1.3959 31.9995 35.9491 37.1092 35.1038 050305............................ 1.4791 1.5308 44.8630 44.9681 48.5337 46.1773 050308............................ 1.5108 1.5378 43.0691 43.7413 46.4167 44.3891 050309............................ 1.4575 1.2999 34.4145 38.2659 39.4649 37.4701 050312............................

***

* 33.9022 36.8498

* 35.1423 050313............................ 1.2017 1.1870 31.8003 35.0478 36.4099 34.5831 050315............................ 1.2450 1.1607 28.5933 33.2038 32.7454 31.6158 050320............................ 1.3087 1.5308 40.2352 45.7686 46.2016 44.0250

[[Page 24858]]

050324............................ 1.7816 1.1607 32.9792 34.5503 36.3466 34.6946 050325............................ 1.2711 1.1653 30.6116 31.3730 34.1213 32.1145 050327............................ 1.7344 1.1607 33.0087 33.9507 35.9352 34.3186 050329............................ 1.2920 1.1607 26.2121 23.2927 33.0376 27.5535 050331............................ 1.1678

* 20.2692

* 20.2692 050333............................ 1.0014 1.1607 23.4009 19.6352 18.6523 20.3799 050334............................ 1.6310 1.4408 40.7467 43.9656 47.2949 44.0643 050335............................ 1.3975 1.1653 28.9403 30.9928 34.7177 31.6175 050336............................ 1.2358 1.1870 28.5659 30.4664 31.5467 30.2591 050342............................ 1.2392 1.1607 26.8507 29.2244 30.4210 28.9056 050348............................ 1.7661 1.1607 37.7898 31.5156 32.7100 33.8507 050349............................ 0.9614 1.1607 17.4791 24.4863 25.4172 22.6502 050350............................ 1.3638 1.1633 31.1833 31.0136 31.7899 31.3395 050351............................ 1.5080 1.1633 30.8661 30.6599 33.3053 31.6202 050352............................ 1.3698 1.2999 33.9362 36.7673 37.0787 35.9203 050353............................ 1.4800 1.1633 31.8291 29.4215 30.4196 30.5532 050357............................ 1.4453 1.1607 32.3095 32.6763 36.2079 33.9112 050359............................ 1.1700 1.1607 25.7739 29.8345 31.3346 29.0474 050360............................ 1.4970 1.4766 37.0769 47.4497 52.3803 45.4207 050366............................ 1.1799 1.1632 31.1854 33.6714 37.2628 33.8566 050367............................ 1.4038 1.5299 38.7727 38.6330 40.1880 39.2564 050369............................ 1.4156 1.1633 29.5697 30.6439 32.2454 30.8342 050373............................ 1.5222 1.1633 31.9271 35.1380 34.3691 33.8391 050376............................ 1.5665 1.1633 32.9393 34.3539 35.2799 34.2228 050378............................ 0.9465 1.1633 34.2417 37.9904 40.1809 37.5492 050379............................

***

* 32.9576

* 32.9576 050380............................ 1.6825 1.5378 42.0781 46.0276 49.5391 45.8231 050382............................ 1.3846 1.1633 29.4323 30.4014 32.6664 30.8161 050385............................ 1.3037 1.4766 34.5183 36.8107 36.4189 35.9493 050390............................ 1.1270 1.1607 26.0066 27.3183 27.9319 27.0754 050391............................

***

* 18.1005 17.2141

* 17.6460 050393............................ 1.4106 1.1633 30.0661 34.1743 35.6327 33.2864 050394............................ 1.6045 1.1607 27.5061 27.4861 32.1896 29.1045 050396............................ 1.6169 1.1607 33.5699 32.4918 37.3957 34.4570 050397............................ 0.7585 1.1607 28.1639 28.3671 29.6760 28.7665 050407............................ 1.1110 1.4766 37.9066 42.2748 44.6803 41.6942 050410............................

***

* 21.3814

* 21.3814 050411............................ 1.2156 1.1633 37.8064 38.8294 38.6322 38.4661 050414............................ 1.3232 1.2999 34.6672 38.7585 41.8000 38.4949 050417............................ 1.2775 1.1607 29.5031 32.9341 35.4935 32.6699 050419............................ 0.8450

* 33.3124

* 33.3124 050420............................

***

* 24.9401 35.2869 39.9207 32.7471 050423............................ 1.0736 1.1607 30.6416 28.3768 31.9703 30.4039 050424............................ 1.9922 1.1607 31.0730 34.5680 36.6083 34.1649 050425............................ 1.3129 1.2999 42.4177 49.2245 46.6607 46.3205 050426............................ 1.4945 1.1607 30.6899 33.2031 34.9839 32.9980 050430............................ 0.9735 1.1607 25.0604 23.9045 24.5322 24.4190 050432............................

***

* 30.8030 33.1876 35.2390 33.0678 050433............................ 1.6238 1.1607 23.0807 21.3573 21.1315 21.8793 050434............................ 1.0477 1.1607 26.1622 32.6255 33.7752 31.2596 050435............................ 1.2739 1.1607 28.0305 30.6530 33.0355 30.6062 050438............................ 1.5355 1.1633 27.2662 36.3026 35.3864 33.0894 050441............................ 1.9488 1.5378 42.9765 44.5694 46.5348 44.7312 050444............................ 1.3278 1.2190 30.5504 34.6313 37.6608 34.7182 050447............................ 0.9388 1.1607 25.2573 26.7960 29.0758 27.0881 050448............................ 1.3448 1.1607 27.9759 30.6201 32.7714 30.3926 050454............................ 1.9034 1.4766 43.5311 38.5833 40.2800 40.7576 050455............................ 1.6170 1.1607 22.7235 30.4606 34.6359 29.0896 050456............................ 1.2382 1.1633 22.5630 21.6261 27.7648 24.0206 050457............................ 1.6418 1.4766 45.5828 47.8947 50.0192 47.8408 050464............................ 1.6913 1.1989 37.3692 38.3058 41.6239 39.0263

[[Page 24859]]

050468............................ 1.5319 1.1633 29.5448 31.1111 35.7762 32.2134 050469............................ 1.0269

* 28.9080 30.6502

* 29.7684 050470............................ 1.1011 1.1607 24.6755 27.8678 31.0441 28.1043 050471............................ 1.7564 1.1633 34.5211 35.4768 36.9130 35.6374 050476............................ 1.4491 1.3959 34.6585 38.7856 40.0425 37.8312 050477............................

***

* 34.6995 37.7668 40.1536 37.8017 050478............................ 0.9888 1.1607 33.3999 40.2558 41.1616 38.4325 050481............................ 1.4433 1.1633 33.7445 36.1394 38.8656 36.2142 050485............................ 1.6549 1.1633 31.4233 36.1488 34.6206 34.0200 050488............................ 1.3383 1.5308 42.9904 42.6854 44.0641 43.2687 050491............................

***

* 32.1379 34.3598

* 33.1420 050492............................ 1.2507 1.1607 27.1540 28.0826 30.7637 28.6534 050494............................ 1.3609 1.2853 35.9910 38.1177 40.6396 38.1898 050496............................ 1.7129 1.5299 42.2672 48.2468 51.6358 47.5808 050498............................ 1.3359 1.2999 33.0298 37.1667 40.8114 36.9608 050502............................ 1.7107 1.1633 29.5616 28.7046 31.8871 30.0325 050503............................ 1.5082 1.1607 31.6418 34.0994 36.4360 34.1126 050506............................ 1.6141 1.1912 36.0164 37.7420 39.8585 37.9166 050510............................ 1.1758 1.5299 47.5510 52.5376 49.4515 49.9476 050512............................ 1.3824 1.5308 46.9233 50.9264 48.8054 49.0410 050515............................ 1.3440 1.1607 38.9978 38.9542 40.2968 39.4969 050516............................ 1.4933 1.2999 36.2772 39.8161 42.9590 39.7253 050517............................ 1.2446 1.1607 23.9007 20.0213 17.0548 19.9099 050523............................ 1.2609 1.5299 35.5452 40.6535 42.4719 39.5900 050526............................ 1.3227 1.1607 31.3744 28.1997 33.3951 30.8787 050528............................ 1.1384 1.1607 29.6838 31.4941 36.0123 32.5346 050531............................ 1.0428 1.1633 26.9420 27.1974 28.3319 27.4850 050534............................ 1.4831 1.1607 29.8603 33.1666 36.6525 33.1997 050535............................

***

* 32.3723 34.6143 37.8210 35.0693 050537............................ 1.4155 1.2999 31.3844 34.9931 37.4208 34.7283 050539............................

***

* 29.8242

* 29.8242 050541............................ 1.5613 1.5299 46.1121 52.5908 48.0854 48.9361 050543............................ 0.7511 1.1607 26.1103 29.4443 24.4854 26.5566 050545............................ 0.8423 1.1633 30.5554 31.3080 35.3180 32.3823 050546............................ 0.6608 1.1607 30.2329 33.2245 36.5097 33.2376 050547............................ 0.9307 1.4766 33.2204 34.8401 33.8021 33.9238 050548............................ 0.8110 1.1607 30.3775 39.2234 41.0903 36.6511 050549............................ 1.5395 1.1607 34.9818 35.2792 38.3717 36.2083 050550............................

***

* 30.2301 30.9612 34.9589 31.9521 050551............................ 1.3357 1.1607 31.6165 34.0467 37.2494 34.3696 050552............................ 1.0550 1.1633 27.1744 33.0711 33.9787 31.2577 050557............................ 1.6018 1.1989 31.8048 33.3654 35.3341 33.5504 050561............................ 1.6005 1.1633 38.8652 38.0196 38.2536 38.3442 050567............................ 1.6021 1.1607 32.9829 35.7063 37.6375 35.4787 050568............................ 1.1551 1.1607 24.4061 25.2337 26.0875 25.2903 050569............................ 1.3174

* 33.0259 31.6785

* 32.3431 050570............................ 1.5427 1.1607 34.0171 34.5161 38.5202 35.7251 050571............................

***

* 33.6156 34.7627 39.0735 35.8473 050573............................ 1.6272 1.1607 34.1991 34.7279 35.2835 34.7592 050575............................ 1.2410 1.1633 25.2513 25.1457 23.7972 24.6719 050577............................

***

* 30.8841 32.3744

* 31.6437 050578............................ 1.4930 1.1633 33.8825 35.2390 31.3598 33.5038 050579............................

***

* 39.4976 42.5081

* 40.8657 050580............................ 1.2328 1.1607 31.6256 31.5806 34.1537 32.4723 050581............................ 1.4907 1.1633 32.1801 34.0136 37.7567 34.6700 050583............................ 1.6465 1.1607 33.3697 34.5747 37.4560 35.0083 050584............................ 1.3234 1.1607 24.8180 30.3434 30.7795 28.6016 050585............................

***

* 22.7121 22.2521 29.4264 24.4704 050586............................ 1.2846 1.1607 27.4173 26.4782 31.3482 28.3860 050588............................ 1.3412 1.1633 32.8212 32.7556 37.7367 34.4128 050589............................ 1.1523 1.1607 30.9546 34.5100 37.6873 34.3938

[[Page 24860]]

050590............................ 1.2935 1.2999 32.2142 38.4971 41.6861 37.3399 050591............................

***

* 28.8549 30.6106 34.7108 31.3299 050592............................

***

* 24.4542 27.3606 31.8084 27.4577 050594............................

***

* 34.7946 36.5256 42.0829 37.6368 050597............................ 1.2589 1.1633 27.5691 28.8294 31.5618 29.3957 050599............................ 1.8935 1.2999 38.1975 32.7835 34.7192 35.1753 050601............................ 1.5556 1.1633 34.7409 36.0572 39.7718 36.8583 050603............................ 1.4451 1.1607 30.2464 34.0275 35.0261 33.2299 050604............................ 1.3991 1.5378 49.9428 55.0821 49.4433 51.2946 050608............................ 1.2668 1.1607 23.3630 30.4169 36.3844 29.5731 050609............................ 1.2823 1.1607 41.1797 41.7208 39.7400 40.7274 050613............................

***

* 42.8108 42.9921 42.8888 050615............................

***

* 33.2909 35.9547 39.0455 36.0526 050616............................ 1.5105 1.1607 36.9017 37.7284 36.7844 37.1319 050618............................ 0.9805 1.1607 27.4539 31.3182 33.1445 30.7673 050623............................

***

* 32.0627

* 32.0627 050624............................ 1.2791 1.1633 32.2907 33.9594 35.9335 34.1562 050625............................ 1.7399 1.1633 36.3631 38.6591 40.4646 38.5119 050630............................

***

* 30.9410

* 30.9410 050633............................ 1.2279 1.1912 35.3734 36.8302 38.4914 36.8992 050636............................ 1.2912 1.1607 30.5156 32.5576 32.7924 31.9970 050641............................ 1.2917 1.1633 21.4612 39.6921 32.3562 29.3375 050644............................ 0.9882 1.1633 27.6547 28.8237 30.7956 29.0870 050660............................ 1.7424

* 050662............................ 0.8701 1.5378 32.6362 33.2446 38.2978 34.3623 050663............................ 1.2772 1.1633 25.7747 27.7334 17.7021 22.5197 050667............................ 0.8494 1.4201 26.3937 24.2771 25.9164 25.5328 050668............................ 1.2080 1.4766 31.8065 56.6555 51.6039 44.4443 050674............................ 1.1203 1.2999 42.6866 48.0893 47.0699 46.1683 050677............................ 1.4565 1.1633 38.7984 38.5770 39.2158 38.8993 050678............................ 1.3172 1.1607 30.7219 32.4473 33.7604 32.3831 050680............................ 1.2341 1.5299 38.3946 38.2871 37.9841 38.2002 050682............................ 0.8469 1.1607 21.7792 17.9077 22.2175 20.5426 050684............................ 1.1147 1.1607 26.4234 27.5256 28.8345 27.6181 050686............................ 1.2077 1.1607 40.9486 41.0188 39.7765 40.4756 050688............................ 1.2025 1.5378 41.9325 44.1510 49.4057 45.3228 050689............................ 1.5246 1.5299 42.2018 45.0951 48.8526 45.3622 050690............................ 0.9979 1.4766 47.2769 50.9094 49.0219 49.1860 050693............................ 1.3853 1.1607 35.0621 34.5797 39.7191 36.4072 050694............................ 1.0504 1.1607 28.9544 30.7858 32.1040 30.6710 050695............................

***

* 35.6548 39.6004 49.0312 41.9280 050696............................ 2.2819 1.1633 35.9220 37.3837 39.9251 37.7376 050697............................ 1.1042 1.2827 25.1984 16.6605 22.1435 20.8109 050699............................

***

* 26.8211 28.9083 21.5729 25.9116 050701............................ 1.3266 1.1607 29.6253 31.9529 34.9885 32.5135 050704............................ 1.0008 1.1633 25.3488 29.7740 31.6053 29.0130 050707............................ 1.2478 1.4906 34.0550 35.7311 43.5546 37.4835 050708............................ 1.5869 1.1607 22.5034 30.5860 31.8452 27.9330 050709............................ 1.4175 1.1607 25.6119 26.8549 24.5600 25.5795 050710............................ 1.4517 1.1607 39.9858 45.8022 44.2474 43.5806 050713............................

***

* 20.2803 21.1273 21.4809 20.8075 050714............................ 1.3837 1.5378 33.6676 31.9527 33.6833 33.1222 050717............................ 1.4243 1.1633 38.0796 39.3227 38.8757 38.7310 050718............................

***

* 21.4996 25.5140 31.9633 26.0532 050720............................ 0.9023 1.1607 30.0811 29.4726 30.3598 29.9464 050722............................ 0.9960 1.1607

* 31.4867 33.8005 32.6977 050723............................ 1.3624 1.1633 35.0119 38.5446 38.7138 37.6299 050724............................ 1.9836 1.1607 34.4267 31.6910 38.4705 34.9427 050725............................ 0.8893 1.1633 21.7816 24.3100 30.0558 25.0162 050726............................ 1.4929 1.1989 27.8433 30.6479 29.2940 29.3768 050727............................ 1.1939 1.1633 24.3026 33.9118 32.7726 30.6197

[[Page 24861]]

050728............................

***

* 36.0820 39.3581 41.8244 38.7029 050729............................

***

* 34.2580 36.5432 38.1758 36.3888 050730............................

***

* 51.5425 37.0629 39.2017 42.2681 050732............................ 2.3945 1.1607

* 33.6903 33.6903 050733............................ 1.6526 1.2827

* 40.1993 40.1993 050734............................

***

* 31.2860 31.2860 050735............................ 1.3420 1.1633

* 050736............................ 1.2208 1.1633

* 050737............................ 1.4932 1.1633

* 050738............................ 1.3746 1.1633

* 050739............................ 1.6730 1.1633

* 050740............................ 1.3849 1.1633

* 050741............................ 1.4970 1.1633

* 050742............................ 1.3975 1.1633

* 050744............................ 1.9678 1.1613

* 050745............................ 1.3654 1.1613

* 050746............................ 1.7819 1.1613

* 050747............................ 1.3997 1.1613

* 050748............................ 1.0732 1.1870

* 050749............................ 1.2517 1.1607

* 050750............................ 1.4161 1.1989

* 050751............................ 3.2977 1.1633

* 050752............................ 1.4164 1.1633

* 050753............................ 1.7096 1.1633

* 050754............................ 1.3352 1.4906

* 050755............................ 1.4093 1.1633

* 050756............................ 1.9522 1.1612

* 060001............................ 1.5646 1.0490 26.8470 29.6191 30.9980 29.1621 060003............................ 1.3969 1.0490 24.2224 29.4809 31.3617 28.3333 060004............................ 1.2516 1.0490 29.9649 32.4609 32.0087 31.4835 060006............................ 1.3325 0.9451 24.5704 25.2139 27.2049 25.6626 060008............................ 1.2017 0.9451 23.3859 23.0947 26.5156 24.3263 060009............................ 1.4938 1.0490 28.7645 31.5210 32.4188 30.9671 060010............................ 1.6914 0.9664 28.9850 27.1916 29.5311 28.5346 060011............................ 1.6393 1.0490 27.2833 35.1573 32.0985 31.3626 060012............................ 1.4822 0.9451 26.2469 27.3885 28.7720 27.4499 060013............................ 1.5070 0.9451 24.5994 26.8675 27.9147 26.4239 060014............................ 1.8624 1.0490 31.2588 31.0542 31.9644 31.4172 060015............................ 1.7856 1.0490 30.4533 32.5285 32.2927 31.6808 060016............................ 1.2375 0.9451 25.6527 26.5427 27.2625 26.4975 060018............................ 1.2860 0.9451 25.7628 24.1086 25.3951 25.0897 060020............................ 1.6180 0.9451 22.6748 24.5992 25.9131 24.3728 060022............................ 1.6508 0.9471 26.5238 28.2944 29.3376 28.0338 060023............................ 1.6737 1.0490 27.7644 29.5760 31.1545 29.4765 060024............................ 1.8352 1.0490 29.0130 30.0279 32.1201 30.4150 060027............................ 1.6708 1.0490 28.0909 29.6121 30.9359 29.6320 060028............................ 1.5172 1.0490 30.0448 31.6900 32.1646 31.3043 060030............................ 1.4469 0.9664 26.6251 27.8642 29.9492 28.1539 060031............................ 1.5587 0.9471 26.3650 27.8345 29.3903 27.8461 060032............................ 1.4866 1.0490 30.4247 31.0686 32.7381 31.4187 060034............................ 1.6603 1.0490 29.8445 30.9359 32.1087 30.9310 060036............................ 1.1013 0.9451 20.7131 20.3226 22.8253 21.2501 060041............................ 0.8769 0.9451 23.4978 24.6142 25.9681 24.7293 060043............................ 1.1879 0.9451 18.7897 18.2143 21.9824 19.6548 060044............................ 1.2127 0.9451 25.0360 26.5611 24.8343 25.4577 060049............................ 1.2785 0.9577 29.0598 29.3724 29.9878 29.4858 060054............................ 1.4507 1.0141 22.3490 24.3389 25.0987 23.9190 060064............................ 1.7291 1.0490 31.3105 32.3681 33.2430 32.1358 060065............................ 1.3997 1.0490 31.1987 32.4735 33.8541 32.5474 060071............................ 1.1696 0.9451 25.7248 27.6657 28.1744 27.2773 060075............................ 1.3332 1.0141 32.7563 32.2545 37.6040 34.1974

[[Page 24862]]

060076............................ 1.2672 0.9451 26.8236 26.5631 30.7794 28.0379 060096............................ 1.5553 1.0490 30.0602 32.1310 37.8250 33.2700 060100............................ 1.6877 1.0490 32.1537 32.6104 33.2259 32.6698 060103............................ 1.3574 1.0490 30.3003 31.6314 32.9699 31.6641 060104............................ 1.3822 1.0490 32.0889 32.4232 35.4406 33.2463 060107............................ 1.4409 1.0490 26.1883 26.8388 28.0661 27.0406 060112............................ 1.6546 1.0490

* 34.9272 34.6910 34.8011 060113............................ 1.4263 1.0490

* 32.6081 32.6081 060114............................ 1.3802 1.0490

* 34.8551 34.8551 060115............................ 0.8095 0.9451

* 060116............................ 1.4116 1.0490

* 060117............................ 1.5193 0.9451

* 060118............................ 1.1985 0.9451

* 070001............................ 1.6168 1.2565 34.0302 35.8958 37.0362 35.6784 070002............................ 1.7626 1.2439 31.1530 33.4398 34.7608 33.1047 070003............................ 1.1121 1.2439 32.4197 34.1352 34.1274 33.5632 070004............................ 1.1692 1.2439 29.2544 29.4448 29.9492 29.5629 070005............................ 1.3946 1.2565 32.1668 33.7813 34.9377 33.6339 070006............................ 1.3747 1.2993 36.8469 37.9148 39.3915 38.0389 070007............................ 1.3254 1.2439 31.7125 35.9617 36.6407 34.7798 070008............................ 1.1970 1.2439 26.4806 28.5506 29.6687 28.2382 070009............................ 1.1839 1.2439 30.2706 32.9299 35.2475 32.8064 070010............................ 1.7654 1.2993 32.5798 35.3730 36.6948 34.9639 070011............................ 1.4451 1.2439 29.9105 31.8987 31.2283 31.0248 070012............................ 1.2709 1.2439 44.1424 29.4216 31.9349 33.9311 070015............................ 1.3970 1.2993 33.4595 35.3385 36.6708 35.2092 070016............................ 1.4996 1.2565 31.0904 31.4930 33.2371 31.9049 070017............................ 1.3568 1.2565 31.7223 34.0490 35.6418 33.8503 070018............................ 1.4233 1.2993 37.6081 39.7515 41.9173 39.8452 070019............................ 1.3270 1.2565 31.8148 34.5125 33.7229 33.3664 070020............................ 1.3297 1.2439 31.0935 33.6453 33.6696 32.8254 070021............................ 1.1568 1.2439 33.2357 36.9241 38.5585 36.2050 070022............................ 1.6749 1.2565 35.4120 39.0462 40.2702 38.3013 070024............................ 1.3613 1.2439 32.0430 35.2323 34.7400 34.0483 070025............................ 1.8064 1.2439 30.9938 32.4085 34.5858 32.6659 070027............................ 1.4451 1.2439 31.8018 29.8513 30.4430 30.7111 070028............................ 1.5984 1.2993 31.5035 35.1966 38.0833 34.9177 070029............................ 1.3083 1.2439 27.7213 30.9299 31.0636 29.9122 070031............................ 1.2711 1.2565 28.9189 30.1915 30.4044 29.8550 070033............................ 1.4708 1.2993 37.1929 40.1594 43.7004 40.4535 070034............................ 1.3980 1.2993 36.3899 38.3965 39.3798 38.0564 070035............................ 1.2872 1.2439 27.5585 30.7440 31.1401 29.7921 070036............................ 1.6067 1.2439 36.1610 38.3413 42.3416 39.0119 070038............................ 1.3936 1.2565 25.7516 25.7914 35.8029 27.8679 070039............................ 0.9377 1.2565 31.2269 36.1369 34.7131 33.8173 070040............................ 0.9996 1.2439

* 080001............................ 1.6239 1.0778 30.0242 32.0105 33.5308 31.8695 080002............................

***

* 27.7932 29.6800 30.4575 29.3051 080003............................ 1.5693 1.0778 29.2266 30.7697 34.2596 31.4914 080004............................ 1.5151 1.0752 27.4921 30.1094 32.2239 29.9990 080006............................ 1.3057 1.0023 25.6160 27.4749 28.8828 27.4029 080007............................ 1.3920 1.0358 27.0074 30.1100 31.1628 29.4879 090001............................ 1.7712 1.0679 35.0413 36.6577 38.1321 36.5957 090003............................ 1.2511 1.0679 29.2660 31.0419 32.1944 30.9271 090004............................ 1.9599 1.0679 32.2021 35.6964 37.3772 35.0391 090005............................ 1.3874 1.0679 30.7728 33.0178 33.7415 32.5062 090006............................ 1.4067 1.0679 29.5590 29.4912 31.3551 30.1261 090008............................ 1.3393 1.0679 29.1059 32.0745 33.7464 31.3882 090011............................ 2.0566 1.0990 34.0693 36.7579 37.7551 36.1901 100001............................ 1.5278 0.9129 24.4060 26.4631 27.2801 26.0725 100002............................ 1.4353 1.0245 25.3389 27.2350 28.7046 27.1080

[[Page 24863]]

100004............................ 0.9210

* 16.5974

* 16.5974 100006............................ 1.6439 0.9383 26.3789 29.1505 29.0886 28.2008 100007............................ 1.6370 0.9383 26.5378 28.5702 29.1608 28.1327 100008............................ 1.7232 1.0023 27.4314 29.1705 30.3372 29.0485 100009............................ 1.4531 1.0023 25.9381 27.4424 27.8595 27.0413 100012............................ 1.6158 0.9490 26.3788 28.4600 29.8330 28.2805 100014............................ 1.4087 0.9245 24.5862 25.1524 27.4005 25.7596 100015............................ 1.3031 0.9174 24.6038 26.0916 27.2172 25.9252 100017............................ 1.6269 0.9245 26.1580 27.9654 28.2380 27.5012 100018............................ 1.6499 0.9756 28.1481 30.2423 30.6513 29.7097 100019............................ 1.6615 0.9385 27.6179 28.6630 30.2983 28.8662 100020............................

***

* 23.9414 27.1257

* 25.5458 100022............................ 1.7406 1.0245 29.9345 32.8088 36.7902 33.2230 100023............................ 1.5155 0.9245 23.0074 25.2652 25.4238 24.5727 100024............................ 1.1735 1.0023 30.2395 29.1894 29.5413 29.6467 100025............................ 1.6820 0.8749 22.1580 23.3843 26.7005 24.0623 100026............................ 1.5785 0.8749 21.4703 23.4730 25.3313 23.5015 100027............................

***

* 16.1223 18.9432

* 17.4007 100028............................ 1.3559 0.9385 26.8661 27.7497 27.5647 27.4069 100029............................ 1.2842 1.0023 27.5844 28.8842 30.5354 29.0520 100030............................ 1.2822 0.9383 24.0943 24.6314 25.3501 24.7166 100032............................ 1.8033 0.9174 25.2450 26.8162 26.9247 26.3589 100034............................ 1.8267 1.0023 25.9415 28.1280 27.2895 27.0668 100035............................ 1.5643 0.9758 26.9407 29.4803 29.9645 28.7904 100038............................ 1.8187 1.0245 29.8583 31.3403 31.6634 30.9762 100039............................ 1.5150 1.0245 28.4627 28.2531 29.3708 28.6925 100040............................ 1.7018 0.9129 23.6443 26.2429 27.2813 25.7448 100043............................ 1.3790 0.9174 25.2273 26.4221 27.0030 26.2279 100044............................ 1.4158 0.9990 28.3596 30.3659 33.1112 30.6144 100045............................ 1.3355 0.9245 26.9641 29.7375 26.5408 27.7585 100046............................ 1.3033 0.9174 26.3673 26.9469 26.7694 26.6960 100047............................ 1.8638 0.9758 25.0404 26.7674 29.9682 27.2642 100048............................ 0.9252 0.8749 18.8770 19.3226 20.2658 19.5008 100049............................ 1.1600 0.8839 22.9809 24.0385 24.5536 23.8777 100050............................ 1.1288 1.0023 19.8713 21.5101 25.3238 22.2723 100051............................ 1.3534 0.9383 23.1940 28.0946 28.7737 26.7720 100052............................ 1.4455 0.8839 22.3920 23.6796 23.4019 23.1671 100053............................ 1.2920 1.0023 27.3224 28.5118 31.7384 29.1111 100054............................ 1.3034 0.8749 28.0512 28.7646 30.5206 29.0875 100055............................ 1.4156 0.9174 23.5332 25.6243 27.3802 25.3794 100057............................ 1.4516 0.9383 25.3897 24.8010 26.3122 25.5302 100061............................ 1.5414 1.0023 29.2565 31.4413 30.4499 30.3963 100062............................ 1.6808 0.8749 25.2340 25.1280 25.9585 25.4595 100063............................ 1.3036 0.9174 24.7026 25.5097 26.4124 25.5740 100067............................ 1.4074 0.9174 26.1213 26.8628 27.4739 26.8557 100068............................ 1.6613 0.9245 25.9202 26.1341 27.6575 26.5514 100069............................ 1.4508 0.9174 24.7442 25.7450 27.2096 25.8883 100070............................ 1.7116 0.9758 24.8883 26.8461 29.1991 26.9663 100071............................ 1.2756 0.9174 24.9682 26.3768 25.3651 25.5845 100072............................ 1.3879 0.9245 26.0459 25.7962 27.1887 26.3539 100073............................ 1.7697 1.0245 30.3358 30.5845 28.7281 29.8848 100075............................ 1.4457 0.9174 25.1691 25.7612 27.6513 26.2369 100076............................ 1.1677 1.0023 21.9483 23.4551 24.0435 23.1100 100077............................ 1.3560 0.9758 26.0347 30.6925 30.7522 29.1481 100079............................ 1.4994

* 100080............................ 1.7074 1.0245 27.0126 28.2188 29.5332 28.2762 100081............................ 0.9413 0.8749 15.6661 16.9756 19.5662 17.4288 100084............................ 1.7880 0.9383 26.3393 27.4947 32.7477 28.7729 100086............................ 1.2961 1.0245 28.2641 28.5971 29.9082 28.9237 100087............................ 1.8973 0.9758 27.1531 29.5823 30.5733 29.1231 100088............................ 1.5785 0.9129 25.9182 26.7574 28.0793 26.9516

[[Page 24864]]

100090............................ 1.4902 0.9129 24.2422 26.5703 27.6128 26.1872 100092............................ 1.5151 0.9385 28.4789 27.8341 26.6301 27.6308 100093............................ 1.7136 0.8749 21.3524 21.6438 22.5555 21.8792 100099............................ 1.0877 0.8839 21.3035 25.8454 26.2362 24.4514 100102............................ 1.0972 0.8749 23.8596 26.1015 27.9371 25.9898 100105............................ 1.4481 0.9990 26.8091 29.9745 30.9880 29.1998 100106............................ 1.0557 0.8749 24.0389 24.7650 24.8062 24.5422 100107............................ 1.2356 0.9490 26.1337 27.4760 30.5712 28.1061 100108............................ 0.8045 0.8749 22.0750 21.3540 22.6250 21.9874 100109............................ 1.2501 0.9245 24.9951 25.5669 26.2294 25.6245 100110............................ 1.6562 0.9383 29.1494 29.4788 29.5964 29.4181 100113............................ 2.0208 0.9306 26.3806 28.0440 29.2410 27.9265 100114............................ 1.3823 1.0023 29.2195 29.2862 30.2549 29.5960 100117............................ 1.2128 0.9129 26.4536 27.7198 28.5709 27.6304 100118............................ 1.3599 0.9129 28.0569 27.6438 27.0971 27.5184 100121............................ 1.1040 0.8839 24.8579 26.2990 27.9335 26.4257 100122............................ 1.2270 0.8749 23.4751 24.6285 26.7143 24.9527 100124............................ 1.1549 0.8749 22.7023 24.0333 24.8875 23.9085 100125............................ 1.1784 1.0023 26.7452 29.7750 31.7723 29.5535 100126............................ 1.3316 0.9174 24.4515 29.6247 28.3189 27.4135 100127............................ 1.5660 0.9174 24.4485 26.0923 27.4608 26.0307 100128............................ 2.2062 0.9174 29.4979 29.2566 30.0299 29.6024 100130............................ 1.1799 1.0245 24.2046 26.0268 28.3616 26.1493 100131............................ 1.4156 1.0023 29.2462 27.8164 29.7632 28.9648 100132............................ 1.2458 0.9174 24.3293 26.0526 27.2007 25.9267 100134............................ 0.8562 0.9129 20.9243 20.7367 21.6532 21.1182 100135............................ 1.6098 0.9032 24.0024 26.7030 29.1837 26.5344 100137............................ 1.2884 0.8839 25.1974 24.8519 26.8344 25.6687 100139............................ 0.8318 0.9306 17.5489 18.2197 21.1258 18.9546 100140............................ 1.0846 0.9129 26.4720 26.1352 27.8649 26.8242 100142............................ 1.2099 0.8749 22.9577 24.8853 25.5354 24.4855 100150............................ 1.2678 1.0023 26.1990 26.8492 27.7741 26.9186 100151............................ 1.7467 0.9129 28.1322 30.6447 30.6281 29.7879 100154............................ 1.5748 1.0023 27.6127 28.2506 29.7317 28.5810 100156............................ 1.1336 0.9306 26.7092 27.5706 28.3909 27.6104 100157............................ 1.5752 0.9174 27.3851 29.7455 30.3052 29.2294 100160............................ 1.1392 0.8749 26.9851 30.7454 30.6896 29.5443 100161............................ 1.5169 0.9383 28.8077 28.0545 29.5663 28.8152 100166............................ 1.4668 0.9758 27.9618 28.8685 30.1807 28.9923 100167............................ 1.3035 1.0245 30.3694 30.2166 31.7804 30.8185 100168............................ 1.4079 1.0245 27.1292 27.6739 27.0923 27.2992 100172............................ 1.2812 1.0023 18.2735 20.7857 22.2204 20.2640 100173............................ 1.6813 0.9174 24.8721 26.5436 28.6368 26.6618 100175............................ 0.9372 0.8749 23.5455 23.9665 25.0985 24.2176 100176............................ 1.9303 1.0245 31.2694 30.7087 33.3165 31.7296 100177............................ 1.3039 0.9385 26.6781 28.0089 29.6265 28.1065 100179............................ 1.8024 0.9129 29.5619 29.1111 29.0431 29.2333 100180............................ 1.3657 0.9174 27.1804 29.9238 31.0064 29.4502 100181............................ 1.0909 1.0023 21.8540 24.3708 23.9591 23.5687 100183............................ 1.2321 1.0023 27.4951 29.0270 30.5104 28.9871 100187............................ 1.2376 1.0023 27.3653 27.8144 30.7495 28.5855 100189............................ 1.3212 1.0245 28.4136 28.8320 29.9369 29.0845 100191............................ 1.3259 0.9174 26.6341 28.3710 29.4499 28.2023 100200............................ 1.3580 1.0245 29.8963 28.7694 29.6406 29.4299 100204............................ 1.5566 0.9306 25.7537 27.4763 27.2798 26.8486 100206............................ 1.3050 0.9174 25.2196 27.0295 27.7525 26.6834 100209............................ 1.4522 1.0023 26.6245 26.8473 28.5311 27.3559 100210............................ 1.6430 1.0245 28.9486 29.8515 32.0804 30.2950 100211............................ 1.2007 0.9174 24.7095 24.7533 26.2817 25.2452 100212............................ 1.5281 0.8749 24.7566 26.1846 27.7936 26.2582 100213............................ 1.5668 0.9758 27.1936 27.9283 29.5190 28.1989

[[Page 24865]]

100217............................ 1.2132 0.9990 25.2907 27.3989 27.7642 26.8865 100220............................ 1.7260 0.9490 26.0905 28.3868 29.3570 28.0175 100223............................ 1.5835 0.8749 24.7015 25.0332 26.1109 25.3046 100224............................ 1.2839 1.0245 24.8077 26.6446 28.0429 26.4939 100225............................ 1.2937 1.0245 28.4316 28.5259 30.8876 29.2153 100226............................ 1.2744 0.9129 29.3317 28.8165 29.7725 29.3198 100228............................ 1.3709 1.0245 29.8952 28.1396 30.1621 29.3737 100230............................ 1.3733 1.0245 28.1703 29.8493 31.9424 29.9630 100231............................ 1.7080 0.8749 25.5175 25.7037 26.6772 25.9675 100232............................ 1.2524 0.9306 24.9322 28.5537 28.3856 27.3012 100234............................ 1.2976 1.0245 26.3601 27.4456 28.8835 27.5798 100236............................ 1.4832 0.9758 26.6585 28.9955 28.2984 27.9868 100237............................ 1.9057 1.0245 31.3543 31.7848 33.1739 32.0770 100238............................ 1.6522 0.9174 28.4302 30.1094 31.4171 30.0491 100239............................ 1.2460 0.9758 27.7592 28.6893 29.7638 28.7444 100240............................ 1.0076 1.0023 25.3265 27.3523 29.6971 27.5087 100242............................ 1.4479 0.8749 24.0990 25.6083 26.1976 25.3020 100243............................ 1.5946 0.9174 26.1131 27.4534 28.3866 27.3439 100244............................ 1.4203 0.9490 25.2584 26.6876 28.2865 26.8118 100246............................ 1.5758 0.9990 28.9894 29.3310 30.1050 29.4942 100248............................ 1.5253 0.9174 27.7798 28.8082 30.2111 28.9505 100249............................ 1.2737 0.9174 23.2084 24.9876 26.4639 24.9121 100252............................ 1.1792 0.9482 25.8540 27.8256 27.1607 26.9474 100253............................ 1.3715 1.0245 25.7121 27.4927 28.7770 27.3720 100254............................ 1.5090 0.9032 25.7338 26.1406 27.4880 26.4891 100255............................ 1.2936 0.9174 24.4808 26.5571 27.3842 26.1577 100256............................ 1.8521 0.9174 28.8856 30.3081 30.2061 29.8124 100258............................ 1.5130 1.0245 31.2482 31.2203 33.8699 32.1188 100259............................ 1.2828 0.9174 26.0175 27.4809 29.0586 27.5346 100260............................ 1.3245 0.9990 27.5188 26.7129 27.5087 27.2404 100264............................ 1.3422 0.9174 25.5489 26.8216 28.0330 26.7861 100265............................ 1.2694 0.9174 24.1454 25.7432 26.3305 25.4668 100266............................ 1.4188 0.8749 23.2340 23.0208 24.2518 23.5319 100267............................ 1.3150 0.9758 27.3769 28.7259 28.9660 28.3534 100268............................ 1.1556 1.0245 29.2898 29.0668 30.5747 29.6377 100269............................ 1.3559 1.0245 26.7450 26.6047 27.8403 27.0868 100271............................ 2.3619

* 100275............................ 1.2874 1.0245 26.0361 26.8943 28.6334 27.2552 100276............................ 1.2400 1.0245 30.0576 29.7606 30.5728 30.1330 100277............................ 1.4125 1.0023 16.5427 20.4791 30.6239 22.8795 100279............................ 1.3368 0.9490 26.8606 28.6383 29.2235 28.2854 100281............................ 1.3697 1.0245 28.6660 29.6698 30.9112 29.8011 100284............................ 1.0112 1.0023 23.8170 22.3134 25.2610 23.6819 100285............................ 1.2699 1.0245

* 41.9448 41.9448 100286............................ 1.6117 0.9756 29.4284 28.3645 27.9816 28.5432 100287............................ 1.3865 1.0245 28.3427 28.1051 29.7774 28.7085 100288............................ 1.5054 1.0245 33.8141 28.7902 31.2667 31.1545 100289............................ 1.6862 1.0245 29.2915 29.6376 31.8991 30.3057 100290............................ 1.1911 0.9139 23.5080 27.1011 29.0093 26.4993 100291............................ 1.2462 0.9385

* 28.4722 28.1498 28.2965 100292............................ 1.3546 0.8749

* 26.7063 27.7643 27.2417 100293............................

***

* 32.7963

* 32.7963 100294............................

***

* 30.7557

* 30.7557 100295............................

***

* 26.1983

* 26.1983 100296............................ 1.3420 1.0023

* 29.3841 29.3841 100297............................

***

* 32.1504 32.1504 100298............................ 0.8097 0.9032

* 19.0284 19.0284 100299............................ 1.2650 0.9758

* 34.3125 34.3125 100300............................ 1.5491 0.9758

* 100301............................ 2.4311 0.8749

* 100302............................ 1.1202 0.9383

[[Page 24866]]

110001............................ 1.3403 0.8587 25.3102 26.4338 26.5634 26.1061 110002............................ 1.3617 0.9845 25.3897 26.4715 26.2215 26.0373 110003............................ 1.2936 0.7864 21.4002 22.7066 24.2076 22.7653 110004............................ 1.3585 0.8967 23.9911 24.9978 25.1820 24.7375 110005............................ 1.2330 0.9845 22.8999 28.1209 27.2810 26.2179 110006............................ 1.5291 1.0543 28.6090 28.3839

* 28.4953 110007............................ 1.5859 0.8671 23.8729 26.6396 26.3115 25.6309 110008............................ 1.3085 0.9845 27.1711 29.2947 30.9741 29.1802 110010............................ 2.2306 0.9845 29.7142 31.7185 33.2379 31.5593 110011............................ 1.2246 0.9845 26.0899 28.0598 28.5710 27.5776 110015............................ 1.0603 0.9845 26.6610 28.1274 28.8247 27.9582 110016............................ 1.2635 0.8594 21.7610 22.7263 24.3540 22.9370 110018............................ 1.1624 0.9845 28.2431 26.8016 30.1831 28.3506 110020............................ 1.3217 0.9845 26.8501 28.3822 27.5540 27.6137 110023............................ 1.2996 0.9845 27.3029 29.8061 29.4091 28.8898 110024............................ 1.4914 0.8987 25.7205 27.0225 27.9321 26.8777 110025............................ 1.4742 0.9768 26.1311 31.0703 30.2808 29.1365 110026............................ 1.1095 0.7864 21.2827 21.8018 22.8797 21.9817 110027............................ 1.0927 0.7864 20.2175 22.6058 25.5227 22.6306 110028............................ 1.7897 0.9600 28.1619 30.4641 31.4549 30.0483 110029............................ 1.8272 0.9845 24.8893 27.3618 29.2101 27.2811 110030............................ 1.3175 0.9845 26.4770 29.6841 29.9483 28.7919 110031............................ 1.2896 0.9845 24.7874 27.1989 29.5494 27.2201 110032............................ 1.1833 0.7864 21.9407 23.2586 25.1864 23.4269 110033............................ 1.4729 0.9845 28.3210 30.3415 32.4147 30.4690 110034............................ 1.7212 0.9600 26.9986 27.2338 28.7910 27.6793 110035............................ 1.7465 0.9845 27.4583 28.9408 30.1817 28.9116 110036............................ 1.8415 0.8987 26.8789 26.6664 27.4572 27.0225 110038............................ 1.5058 0.8458 21.2138 22.2720 22.9667 22.1527 110039............................ 1.3686 0.9600 24.7248 26.3503 26.2463 25.8073 110040............................ 1.0915 0.9845 19.7509 20.9487 23.9465 21.5965 110041............................ 1.2635 0.9845 23.4073 24.8864 26.1928 24.8269 110042............................ 1.0549 0.9845 28.6873 34.9954 33.4345 32.3594 110043............................ 1.7583 0.8987 26.6323 27.8477 28.8534 27.7746 110044............................ 1.1546 0.7864 20.9654 23.3039 24.3743 22.8665 110045............................ 1.0610 0.9845 24.9821 24.4275 27.7578 25.7221 110046............................ 1.1568 0.9845 23.8292 26.7464

* 25.2689 110050............................ 1.0878 0.8587 26.1319 27.5985 27.0646 26.9504 110051............................ 1.1326 0.7864 19.4276 20.1756 21.4871 20.4304 110054............................ 1.3876 0.9845 25.7085 28.9254 29.4622 28.1271 110059............................ 1.1627 0.7864 20.5565 23.2137 24.7765 22.7757 110064............................ 1.5562 0.9023 24.2739 24.1219 26.9345 25.1478 110069............................ 1.3180 0.9571 24.1669 26.2085 29.9100 26.8648 110071............................ 1.1303 0.7864 18.0224 21.3963 21.1989 20.2203 110073............................ 1.0754 0.7864 18.6336 18.5753 22.2470 19.7421 110074............................ 1.5617 1.0543 27.1207 27.9190 32.6801 29.0878 110075............................ 1.2369 0.8987 22.0935 23.7585 24.8206 23.5710 110076............................ 1.4782 0.9845 26.3506 28.7871 29.4324 28.2022 110078............................ 2.0225 0.9845 29.5779 29.9625 30.5184 30.0314 110079............................ 1.4284 0.9845 23.1024 26.8412 28.0337 25.8338 110080............................

***

* 22.3213 18.4714

* 20.3904 110082............................ 1.9490 0.9845 29.8366 30.8320 30.1059 30.2637 110083............................ 1.8986 0.9845 27.8245 30.4287 34.0590 30.7532 110086............................ 1.2924 0.7864 21.1508 21.6898 22.9935 21.9527 110087............................ 1.4777 0.9845 28.0471 28.1633 31.0389 29.1236 110089............................ 1.1256 0.7864 21.9509 23.9026 24.3270 23.4297 110091............................ 1.2981 0.9845 26.5523 29.5337 27.0969 27.7297 110092............................ 1.0712 0.7864 18.5527 20.8911 21.4146 20.2698 110095............................ 1.4672 0.8671 23.4846 26.3075 28.0497 25.9749 110100............................ 0.9766 0.8653 16.5600 16.2575 20.8152 17.8654 110101............................ 1.0211 0.7931 16.4269 19.4257 23.2580 19.5226

[[Page 24867]]

110104............................ 1.0874 0.7864 18.7951 20.3777 21.8924 20.4307 110105............................ 1.3393 0.7864 21.1077 23.1405 23.3989 22.5523 110107............................ 1.9642 0.9753 26.2526 28.9352 30.0994 28.5415 110109............................ 1.0213 0.7864 21.4279 23.0376 21.5988 22.0288 110111............................ 1.1558 0.9600 29.2189 25.1270 25.6830 26.4544 110112............................ 0.9103 0.7864 24.2464 22.7672 26.4049 24.5402 110113............................ 0.9648 0.9600 19.1752 21.3417 21.9483 20.8449 110115............................ 1.6873 0.9845 32.0198 31.5074 32.7917 32.1142 110121............................ 1.0432 0.8458 21.6637 26.2336 23.4538 23.8292 110122............................ 1.5380 0.8458 23.7589 25.1934 25.4416 24.7892 110124............................ 1.0505 0.7864 22.7058 22.9212 22.9564 22.8635 110125............................ 1.2986 0.9571 22.4238 23.7834 24.7325 23.6383 110128............................ 1.2616 0.8987 24.4596 25.7839 25.4173 25.2192 110129............................ 1.5741 0.9023 23.3631 25.9625 30.0382 26.3966 110130............................ 0.9401 0.7864 18.7549 19.1284 20.4320 19.4659 110132............................ 0.9896 0.7864 19.2307 20.2502 21.2623 20.2550 110135............................ 1.2755 0.7864 20.4412 22.5346 23.7098 22.3469 110136............................

***

* 15.8573 18.8212

* 17.2827 110142............................ 0.9496 0.8066 18.1980 21.3935 21.6229 20.4888 110143............................ 1.4028 0.9845 27.7055 28.6583 29.9107 28.7952 110146............................ 1.0440 0.9129 23.9067 27.0987 29.0166 26.6342 110149............................

***

* 27.1477 28.4040

* 27.8380 110150............................ 1.3057 0.9845 22.6624 25.3742 26.9867 24.9549 110153............................ 1.1345 0.9571 24.5368 25.7467 29.3255 26.5464 110161............................ 1.5056 0.9845 29.3201 30.4885 31.4996 30.4387 110163............................ 1.4445 0.8671 26.0764 28.2169 27.7657 27.3535 110164............................ 1.6473 0.9753 27.0600 28.8946 29.9927 28.6570 110165............................ 1.3818 0.9845 26.8378 27.0977 28.7885 27.5696 110166............................

***

* 26.8070

* 26.8070 110168............................ 1.8211 0.9845 27.0022 28.5700 29.7626 28.4639 110172............................ 1.3224 0.9845 29.1703 31.1234 31.3978 30.5995 110177............................ 1.7871 0.9600 26.7504 28.8356 29.7970 28.4770 110179............................

***

* 26.0759

* 26.0759 110183............................ 1.2702 0.9845 29.6132 28.6208 28.3576 28.8287 110184............................ 1.2372 0.9845 26.5240 28.3545 28.9228 28.0035 110186............................ 1.3737 0.9023 25.0298 27.4925 28.2840 26.9603 110187............................ 1.2184 0.9845 24.2933 25.2139 26.9609 25.5777 110189............................ 1.1273 0.9845 26.7654 26.1418 26.2773 26.3807 110190............................ 1.0375 0.8106 14.2518 23.3204 24.5194 20.0516 110191............................ 1.3326 0.9845 26.8277 27.7760 30.8738 28.4664 110192............................ 1.3983 0.9845 26.7852 28.8267 30.0811 28.6170 110193............................

***

* 27.3341 27.9161

* 27.6234 110194............................ 0.9362 0.7864 18.4776 19.1920 21.0803 19.6202 110198............................ 1.3960 0.9845 31.7748 31.0557 32.8394 31.8698 110200............................ 1.9208 0.9023 22.3249 24.9236 27.2957 24.7898 110201............................ 1.4602 0.9753 28.2232 31.0841 32.0685 30.4669 110203............................ 0.9675 0.9845 26.8768 29.7888 32.3439 29.6045 110205............................ 1.1514 0.8378 19.7408 22.0207 23.9713 21.9556 110209............................ 0.5322 0.7864 19.0450 21.1534 21.2405 20.5449 110212............................ 1.1996 0.8208 40.5120

* 40.5120 110214............................

***

* 37.1450

* 37.1450 110215............................ 1.2923 0.9845 25.7886 27.5566 29.5222 27.7244 110219............................ 1.4243 0.9845 27.0362 28.8814 32.1875 29.3856 110220............................

***

* 37.5741

* 37.5741 110221............................

***

* 28.0500

* 28.0500 110222............................

***

* 35.6189

* 35.6189 110223............................

***

* 25.3054 25.3054 110224............................

***

* 33.6431 33.6431 110225............................ 1.1643 0.9845

* 29.5367 29.5367 110226............................ 1.1727 0.9845

* 120001............................ 1.7822 1.1289 34.7715 34.1385 39.6365 36.0758

[[Page 24868]]

120002............................ 1.2099 1.0751 29.9913 32.3784 34.2093 32.2039 120004............................ 1.3321 1.1289 28.6527 30.0668 31.3533 30.0073 120005............................ 1.3153 1.0751 29.3405 31.1985 33.6910 31.4352 120006............................ 1.2715 1.1289 31.2285 31.6785 34.2215 32.3967 120007............................ 1.7204 1.1289 30.4247 30.2473 30.8768 30.5121 120010............................ 1.8846 1.1289 30.1659 29.5714 30.8509 30.1898 120011............................ 1.5402 1.1289 34.1643 37.1792 39.1930 36.8947 120014............................ 1.2834 1.0751 28.6416 30.3463 30.9833 30.0254 120016............................

***

* 19.6039

* 19.6039 120019............................ 1.1324 1.0751 30.3809 30.4257 33.0105 31.2828 120022............................ 1.9143 1.1289 26.6100 29.9527 32.5281 29.5900 120025............................

***

* 30.2367

* 30.2367 120026............................ 1.4053 1.1289 30.3293 32.4566 33.3760 32.1741 120027............................ 1.3450 1.1289 28.6717 28.7905 29.5804 29.0480 120028............................ 1.2954 1.1289 30.3794 32.4847 34.0426 32.3412 120029............................

***

* 44.6372 44.6372 130002............................ 1.4431 0.8780 23.6078 24.7871 25.0585 24.5110 130003............................ 1.3979 0.9620 27.6345 28.6158 28.6132 28.2893 130005............................

***

* 25.7523

* 25.7523 130006............................ 1.7739 0.9501 25.3221 27.2158 28.0040 26.8672 130007............................ 1.8211 0.9501 24.9562 28.7246 30.4947 27.9564 130013............................ 1.3826 0.9501 27.9209 30.9609 36.1511 31.7450 130014............................ 1.2242 0.9501 24.3885 27.2543 27.5904 26.3556 130018............................ 1.6969 0.9158 26.4125 27.3439 28.3984 27.3763 130021............................

***

* 16.1658

* 16.1658 130024............................ 1.1828 0.8301 23.3347 23.6212 24.8040 23.9295 130025............................ 1.2433 0.7879 20.1452 21.1998 22.7959 21.4284 130028............................ 1.4838 0.9158 26.3443 27.2195 28.3768 27.4425 130049............................ 1.6070 1.0220 26.9749 27.3597 29.0154 27.8217 130062............................

***

* 20.6642 25.6467 29.1889 24.9258 130063............................ 1.3933 0.9501 22.5904 26.0955 27.7566 25.3649 130065............................ 1.9742 0.9352

* 21.9792 30.4515 26.6732 130066............................ 2.0918 0.9679

* 28.9875 28.9875 130067............................ 0.5728 0.9352

* 21.3846 21.3846 130068............................ 2.6786 0.9679

* 140001............................ 1.1037 0.8717 22.3170 22.3001 22.2001 22.2725 140002............................ 1.3394 0.8885 24.6954 27.0165 27.4774 26.4099 140007............................ 1.3528 1.0455 28.3482 30.7378 31.4003 30.1858 140008............................ 1.4476 1.0455 28.5297 29.1767 31.7996 29.7868 140010............................ 1.5346 1.0455 35.1024 31.8806 38.1652 34.8498 140011............................ 1.1266 0.8355 22.4091 23.8575 25.8844 24.1276 140012............................ 1.1597 1.0455 28.6564 29.0336 31.8902 29.7936 140013............................ 1.4751 0.9374 23.3065 23.9269 25.0217 24.0534 140015............................ 1.4264 0.8885 23.0600 24.4687 24.6395 24.0656 140016............................ 1.0141

* 18.1242

* 18.1242 140018............................ 1.4726 1.0455 27.7548 26.3533 30.4549 28.1330 140019............................ 0.9079 0.8355 18.9228 21.3438 22.3154 20.8677 140024............................

***

* 17.5249

* 17.5249 140026............................ 1.1365 0.8643 23.0470 25.9669 26.0469 25.0148 140029............................ 1.5607 1.0455 28.6565 30.2688 34.0184 30.9961 140030............................ 1.5584 1.0455 29.7771 30.2776 31.6814 30.5817 140032............................ 1.2249 0.8885 24.0573 26.7310 27.5346 26.1088 140033............................ 0.7961 1.0455 25.6068 27.9993 29.5213 27.5598 140034............................ 1.1477 0.8885 23.0033 24.0470 24.4638 23.8456 140040............................ 1.2142 0.9217 22.2969 23.2293 24.5572 23.3448 140043............................ 1.2818 0.8898 26.7996 27.3469 29.8613 28.0415 140045............................

***

* 20.6548

* 20.6548 140046............................ 1.5062 0.8885 23.2127 24.7334 25.6221 24.5832 140048............................ 1.2927 1.0455 28.2222 29.3877 31.1842 29.5804 140049............................ 1.4736 1.0455 27.4009 29.0976 26.9354 27.8062 140051............................ 1.5046 1.0455 27.7901 30.9696 31.8207 30.1641

[[Page 24869]]

140052............................ 1.2921 0.8885 23.5662 25.9617 26.9889 25.4996 140053............................ 1.8971 0.8947 24.8455 27.4518 28.4493 26.9022 140054............................ 1.4490 1.0455 31.8564 33.1406 33.1984 32.7274 140058............................ 1.2533 0.8885 22.8423 24.6058 25.2553 24.2520 140059............................ 1.0745 0.8885 22.4652 22.6743 21.6222 22.2387 140061............................

***

* 20.8063

* 20.8063 140062............................ 1.3499 1.0455 34.7704 34.1230 35.0300 34.6455 140063............................ 1.4129 1.0455 27.8306 28.6559 30.3699 28.9237 140064............................ 1.1958 0.9217 22.0407 23.8639 25.7536 23.9574 140065............................ 1.4079 1.0455 29.4678 30.1856 31.2501 30.2861 140066............................ 1.0941 0.8885 21.9771 22.1524 22.0209 22.0493 140067............................ 1.8444 0.9374 25.3986 28.3506 29.8952 27.9255 140068............................ 1.2095 1.0455 27.3956 28.3938 26.2136 27.3581 140075............................ 1.3302 1.0455 27.9325 26.2626 35.9501 29.4586 140077............................ 1.0119 0.8885 19.1363 20.3999 21.6458 20.4041 140080............................ 1.4034 1.0455 23.2575 28.8791 29.8040 27.0165 140082............................ 1.5858 1.0455 25.6645 28.3429 30.4657 28.1091 140083............................ 0.9164 1.0455 26.2972 26.8919 28.2249 27.1579 140084............................ 1.3044 1.0455 29.2515 30.5036 30.7227 30.1514 140088............................ 1.9222 1.0455 32.4978 30.5450 32.1232 31.7009 140089............................ 1.2577 0.8355 23.3401 24.1066 24.9116 24.1079 140091............................ 1.7612 0.9320 26.8518 27.8536 28.2076 27.6623 140093............................ 1.2233 0.9250 25.3127 28.3298 28.6735 27.3134 140094............................ 1.0630 1.0455 27.9273 27.3841 27.1458 27.4606 140095............................ 1.1848 1.0455 27.6799 28.7617 30.7468 28.9831 140100............................ 1.4123 1.0455 37.0820 41.3374 37.4204 38.7591 140101............................ 1.2093 1.0455 28.5365 29.4081 28.9681 28.9900 140103............................ 1.1489 1.0455 23.3258 23.6406 24.0915 23.6943 140105............................ 2.4503 1.0455 27.4531 29.5274 29.6559 28.8375 140109............................ 1.2813

* 19.5675

* 19.5675 140110............................ 1.1015 1.0455 27.9844 28.6364 30.2949 28.9917 140113............................ 1.6269 0.9320 26.7969 29.5452 30.2650 28.8697 140114............................ 1.4992 1.0455 28.3014 28.2151 29.2174 28.5888 140115............................ 1.1220 1.0455 25.1498 26.0383 26.1931 25.7916 140116............................ 1.2809 1.0455 31.9902 34.5537 34.3854 33.6663 140117............................ 1.5470 1.0455 26.8802 27.7201 28.9000 27.8446 140118............................ 1.5344 1.0455 29.7570 32.5518 32.3262 31.5081 140119............................ 1.8434 1.0455 36.1419 34.2118 32.2183 34.0198 140120............................ 1.2653 0.9374 22.7375 23.9724 25.9262 24.2579 140122............................ 1.4641 1.0455 28.4188 30.5653 30.3888 29.7745 140124............................ 1.2574 1.0455 36.1327 35.7563 36.8811 36.2568 140125............................ 1.1737 0.8885 20.4014 22.7571 26.5780 23.2030 140127............................ 1.5914 0.9488 24.1658 25.6668 27.8334 25.8831 140130............................ 1.2375 1.0455 29.5247 32.6209 32.3345 31.5415 140133............................ 1.2957 1.0455 28.0339 31.0269 30.3222 29.7591 140135............................ 1.4311 0.8355 22.3264 23.3196 24.6627 23.4674 140137............................ 1.0306 0.8885 21.4699 23.4174 31.4330 24.5875 140141............................

***

* 21.7872

* 21.7872 140143............................ 1.1599 1.0455 26.2954 27.4499 26.1598 26.6232 140145............................ 1.0894 0.8885 23.4608 26.0875 25.2020 24.9373 140147............................ 1.1116 0.8355 19.8541 21.0686 21.1816 20.6906 140148............................ 1.7302 0.8947 24.7031 25.5677 27.0025 25.7602 140150............................ 1.7104 1.0455 35.2711 52.0970 35.5387 41.0090 140151............................ 0.8042 1.0455 23.4879 27.0312 26.0771 25.5353 140152............................ 1.1878 1.0455 27.6086 30.2209 29.8651 29.2052 140155............................ 1.3645 1.0455 28.9724 29.5734 32.7948 30.4667 140158............................ 1.3840 1.0455 27.0986 27.3721 30.9913 28.4461 140160............................ 1.2239 0.9659 24.5373 25.8684 28.2651 26.1623 140161............................ 1.0974 1.0455 23.1647 25.2898 28.8243 25.7885 140162............................ 1.5875 0.9488 27.4471 29.4121 32.1785 29.6154 140164............................ 1.8228 0.8885 23.7457 24.6009 25.9708 24.8069

[[Page 24870]]

140165............................

***

* 16.6304

* 16.6304 140166............................ 1.1618 0.8355 23.1005 26.4800 26.2861 25.2805 140167............................ 1.1617 0.8355 22.8911 22.8703 24.9899 23.5834 140172............................ 1.3657 1.0455 29.8568 32.1220 33.3088 31.7850 140174............................ 1.5727 1.0455 27.8131 30.5905 30.2862 29.6018 140176............................ 1.2302 1.0455 31.3490 32.9794 32.6124 32.3400 140177............................ 0.9043 1.0455 22.5610 26.4340 25.5687 24.9308 140179............................ 1.2690 1.0455 27.6376 29.3657 30.0402 29.0241 140180............................ 1.1754 1.0455 28.3629 27.8887 29.4333 28.5589 140181............................ 1.1327 1.0455 25.0101 25.0226 28.8391 26.2494 140182............................ 1.5032 1.0455 28.2211 30.1755 31.5975 29.8792 140184............................ 1.2950 0.8355 21.1802 25.2327 26.6072 24.4269 140185............................ 1.4647 0.8885 23.8531 25.2423 26.5377 25.2109 140186............................ 1.5405 1.0455 30.6951 29.8022 38.6436 32.7202 140187............................ 1.5457 0.8885 23.2892 24.8332 25.5863 24.5665 140189............................ 1.1672 0.8355 23.7198 22.5965 24.6993 23.6830 140190............................

***

* 19.8296

* 19.8296 140191............................ 1.3320 1.0455 25.8678 28.5836 31.2506 28.4103 140197............................ 1.2420 1.0455 23.0684 24.0463 24.9086 23.9560 140199............................ 1.0545

* 22.0315

* 22.0315 140200............................ 1.4398 1.0455 26.3379 28.8435 30.7340 28.6128 140202............................ 1.5519 1.0455 29.7870 32.7915 32.9414 31.9574 140206............................ 1.2672 1.0455 30.6561 29.7953 29.0219 29.8266 140207............................ 1.2156 1.0455 24.1048 26.0535 28.2239 26.0077 140208............................ 1.6599 1.0455 29.4708 29.5380 30.9464 29.9911 140209............................ 1.5590 0.9374 24.5376 26.3230 29.5947 26.7186 140210............................ 1.0674 0.8355 19.2640 20.6954 19.2050 19.6893 140211............................ 1.3080 1.0455 29.7054 30.3286 31.2117 30.4786 140213............................ 1.2474 1.0455 30.2945 31.6926 32.1006 31.3680 140217............................ 1.5469 1.0455 31.5324 32.1277 37.4373 33.6828 140223............................ 1.4766 1.0455 30.4923 31.7267 33.4712 31.9196 140224............................ 1.3766 1.0455 28.2177 29.6181 30.0109 29.2702 140228............................ 1.5676 0.9659 25.6419 27.9456 28.2837 27.2857 140231............................ 1.4308 1.0455 30.6410 30.0236 34.5759 31.7645 140233............................ 1.6659 1.0455 28.6305 29.7093 31.5127 29.9816 140234............................ 1.0449 0.8643 23.6928 24.5476 25.7284 24.6519 140239............................ 1.5972 0.9659 29.0092 31.1879 29.9224 30.0310 140240............................ 1.4146 1.0455 28.7310 31.5637 29.6215 29.9537 140242............................ 1.5035 1.0455 32.0522 34.6120 35.2330 33.9219 140250............................ 1.2383 1.0455 28.5971 29.6305 30.9236 29.7408 140251............................ 1.3945 1.0455 27.1687 28.0622 28.5295 27.9306 140252............................ 1.4015 1.0455 33.3351 34.4268 35.9410 34.5696 140258............................ 1.5168 1.0455 30.2639 34.2333 33.0067 32.5344 140275............................ 1.3109 0.8898 26.1473 27.8186 28.5054 27.4336 140276............................ 1.8663 1.0455 29.8325 31.6359 31.5673 31.0394 140280............................ 1.4652 0.8898 23.4447 24.9401 26.6521 24.9136 140281............................ 1.7579 1.0455 30.4838 33.3903 35.4009 33.0950 140285............................

***

* 20.7576

* 20.7576 140286............................ 1.1525 1.0455 29.1543 30.3237 30.9916 30.1576 140288............................ 1.5216 1.0455 29.3988 31.5197 31.5935 30.8906 140289............................ 1.3073 0.8885 22.6211 23.8452 25.6053 24.0376 140290............................ 1.3588 1.0455 31.7341 31.8135 32.5219 32.0520 140291............................ 1.6125 1.0455 29.8958 31.9052 33.4588 31.8392 140292............................ 1.1018 1.0455 27.6285 28.5094 31.4636 29.0642 140294............................ 1.1266 0.8355 23.4503 24.0750 26.1581 24.6191 140300............................ 1.1893 1.0455 34.8568 35.1494 41.7895 37.1471 140301............................ 1.1592 1.0455 31.7073 49.9507 36.3852 36.8862 140303............................ 2.2098 1.0455

* 29.6470

* 29.6470 150001............................ 1.1317 0.9723 29.6844 28.9075 31.8065 30.1183 150002............................ 1.4425 1.0455 25.0063 26.6222 27.6466 26.6689 150003............................ 1.7495 0.8682 25.3458 26.7585 26.9767 26.3732

[[Page 24871]]

150004............................ 1.4758 1.0455 26.8458 28.7336 30.9613 28.8233 150005............................ 1.2795 0.9723 27.2369 29.5371 30.5354 29.1851 150006............................ 1.3972 0.9488 26.4062 25.6265 27.1359 26.4178 150007............................ 1.3722 0.9468 26.6073 29.4971 30.0493 28.8173 150008............................ 1.3877 1.0455 26.6928 27.5703 27.0507 27.1181 150009............................ 1.4332 0.9045 22.2147 25.4496 25.7590 24.5202 150010............................ 1.4964 0.9468 26.8523 27.2272 28.4110 27.4598 150011............................ 1.2442 0.9723 24.3490 25.3178 26.7670 25.4609 150012............................ 1.5635 0.9649 27.3029 30.0348 31.2245 29.5420 150013............................

***

* 21.8465

* 21.8465 150015............................ 1.3255 0.8876 26.2434 28.0931 27.3806 27.2242 150017............................ 1.8579 0.9046 25.2342 26.3973 26.3375 26.0050 150018............................ 1.7216 0.9488 26.3289 27.3689 28.6052 27.4720 150021............................ 1.8099 0.9046 29.6967 28.9196 30.0025 29.5365 150022............................ 1.0830 0.8750 22.6773 23.1041 23.8966 23.1998 150023............................ 1.5634 0.8828 23.7159 26.9095 27.7498 25.8885 150024............................ 1.4799 0.9723 27.1589 28.1655 28.4136 27.8886 150026............................ 1.3156 0.9488 28.1127 28.6517 30.4957 29.1720 150027............................ 1.0482

* 17.4862

* 17.4862 150029............................ 1.4693 0.9649 26.9680 28.7187 29.9297 28.4268 150030............................ 1.1962 0.9723 26.9534 29.1493 29.3548 28.5129 150033............................ 1.5588 0.9723 27.9995 28.6838 29.7732 28.8056 150034............................ 1.4551 1.0455 26.0465 28.6429 28.0423 27.6123 150035............................ 1.5978 0.9246 26.6620 26.9700 27.8888 27.1974 150037............................ 1.3215 0.9723 28.5451 31.0935 29.0142 29.5229 150038............................ 1.1335 0.9723 28.8054 29.3156 33.0091 30.3929 150042............................ 1.3921 0.8828 23.0102 22.8786 25.1381 23.6707 150044............................ 1.3933 0.9045 23.7066 25.2137 25.2653 24.7681 150045............................ 1.0745 0.9046 25.2225 26.9818 27.5333 26.5864 150046............................ 1.4897 0.8828 21.9369 24.5593 26.5855 24.4151 150047............................ 1.7148 0.9046 25.8348 25.5194 25.8493 25.7349 150048............................ 1.3885 0.9654 27.1817 27.1233 28.1517 27.5020 150049............................ 1.3621

* 22.3370

* 22.3370 150051............................ 1.6351 0.9723 23.7061 26.5655 28.9114 26.4833 150052............................ 1.0751

* 20.6339

* 20.6339 150056............................ 1.9411 0.9723 28.2842 28.8727 29.3498 28.8452 150057............................ 2.0977 0.9723 24.8605 28.9529 30.3290 27.8808 150058............................ 1.5682 0.9649 27.5341 29.1444 29.1247 28.6422 150059............................ 1.5558 0.9723 28.5715 31.4987 31.3363 30.4971 150060............................

***

* 24.8544

* 24.8544 150061............................ 1.1276 0.8599 22.2822 21.3711 22.6744 22.1017 150062............................ 1.1339

* 24.6088

* 24.6088 150064............................ 1.2004 0.8599 23.7707 25.4987 28.7959 26.0974 150065............................ 1.2639 0.9723 25.9461 27.9283 30.2038 27.9980 150069............................ 1.1735 0.9654 25.2656 26.2028 26.0888 25.8557 150072............................ 1.1652 0.8700 20.5111 21.2120 21.7638 21.1631 150074............................ 1.4434 0.9723 25.2586 25.9321 28.5642 26.5896 150075............................ 1.0984 0.9046 24.0745 25.1568 25.7242 24.9786 150076............................ 1.2878 0.9488 28.1874 29.3249 30.1109 29.2163 150079............................ 1.1099

* 21.4067

* 21.4067 150082............................ 1.6791 0.8599 25.5860 28.3494 26.4526 26.8041 150084............................ 1.8404 0.9723 29.3905 31.1720 33.1783 31.1870 150086............................ 1.1730 0.9654 23.9404 25.1992 26.6732 25.3038 150088............................ 1.2755 0.9723 23.6253 27.2103 29.1480 26.6296 150089............................ 1.6030 0.8599 25.0449 24.7233 24.8038 24.8594 150090............................ 1.6395 1.0455 26.2899 30.4835 30.6398 29.1396 150091............................ 1.1639 0.9046 30.6209 30.4234 32.1616 31.1002 150097............................ 1.1292 0.9723 25.0367 27.7468 29.1332 27.3211 150100............................ 1.6890 0.8599 24.3530 25.7997 26.9731 25.6241 150101............................ 1.0674 0.9046 29.1657 29.0301 30.5475 29.5655 150102............................ 1.0330 0.9246 24.5923 25.7424 25.8716 25.4594

[[Page 24872]]

150104............................ 1.0855 0.9723 25.5872 28.2552 28.7782 27.5175 150106............................ 1.0158

* 20.9387

* 20.9387 150109............................ 1.4646 0.8682 23.5865 25.3367 26.8460 25.2374 150112............................ 1.4973 0.9723 26.5643 28.0068 29.8515 28.1779 150113............................ 1.2888 0.9723 24.8760 24.7960 25.9794 25.2152 150115............................ 1.4221 0.8599 19.3411 22.0747 22.5784 21.2668 150122............................ 1.3185 0.9723 26.0173

* 29.1651 27.6449 150124............................

***

* 21.3933

* 21.3933 150125............................ 1.5108 1.0455 26.7666 27.6535 29.3573 27.9334 150126............................ 1.4163 1.0455 26.9887 28.9454 29.4277 28.4460 150128............................ 1.4408 0.9723 26.4976 28.7810 29.4982 28.2798 150129............................ 1.1548 0.9723 29.9099 29.7398 31.4309 30.3982 150130............................ 1.6136

* 21.7400

* 21.7400 150132............................

***

* 25.6257 27.6560

* 26.6249 150133............................ 1.2465 0.9046 22.7292 25.1322 24.2528 24.0310 150134............................ 1.0184 0.9045 23.8525 26.3249 21.6507 23.7520 150136............................

***

* 26.2704

* 26.2704 150146............................ 1.1375 0.9046 29.3383 29.5256 30.3340 29.7675 150147............................ 1.5119 1.0455 22.8456 27.2339 26.1631 25.6991 150149............................ 1.0014 0.8599 23.6360 23.7026 24.9628 24.1402 150150............................ 1.3168 0.9046 25.5331 27.0542 26.7708 26.4923 150151............................

***

* 38.1445

* 38.1445 150152............................

***

* 44.7145

* 44.7145 150153............................ 2.4179 0.9723

* 32.1022 35.0601 33.7419 150154............................ 2.5731 0.9723

* 29.8514 29.8867 29.8697 150155............................

***

* 45.0121

* 45.0121 150156............................

***

* 25.9681

* 25.9681 150157............................ 1.6752 0.9723

* 32.3095 32.3095 150158............................ 1.2386 0.9723

* 150160............................ 2.0084 0.9723

* 150161............................ 1.4704 0.9723

* 150162............................ 1.7757 0.9723

* 150163............................ 1.1085 0.9045

* 160001............................ 1.2040 0.9227 25.1220 24.5108 25.7253 25.1337 160005............................ 1.2097 0.8480 21.8949 23.1034 24.7751 23.2876 160008............................ 1.0520 0.8480 20.7200 22.1402 22.4752 21.7844 160013............................ 1.2954 0.8659 23.7163 24.0956 24.4092 24.0732 160014............................

***

* 20.5882

* 20.5882 160016............................ 1.5631 0.9227 23.3619 24.5338 27.1450 24.9572 160020............................ 1.1531

* 19.5554

* 19.5554 160024............................ 1.5664 0.9162 26.2392 27.4158 29.3740 27.6163 160026............................

***

* 24.7424

* 24.7424 160028............................ 1.3103 0.9419 26.2948 27.8535 30.0834 28.2015 160029............................ 1.6376 0.9428 27.9277 28.7324 30.6688 29.0932 160030............................ 1.3828 0.9982 26.7068 28.7786 30.9401 28.8516 160031............................ 0.7988

* 19.7368

* 19.7368 160032............................ 1.0670 0.8715 23.4727 25.4662 26.2923 25.1089 160033............................ 1.7494 0.8898 24.6768 26.5315 27.2044 26.1333 160034............................ 1.0217

* 19.3503

* 19.3503 160039............................ 0.9129

* 22.1180

* 22.1180 160040............................ 1.2918 0.8891 23.9053 25.9032 26.8096 25.5667 160045............................ 1.6888 0.8689 25.4153 26.6463 27.5279 26.5336 160047............................ 1.3942 0.9419 25.2072 26.0227 28.1257 26.4461 160048............................

***

* 19.5831

* 19.5831 160050............................ 1.0566

* 24.5402

* 24.5402 160057............................ 1.2586 0.9142 23.0937 25.1272 25.6262 24.6658 160058............................ 1.9687 0.9428 27.1646 28.4167 28.9914 28.2022 160064............................ 1.6018 0.8891 28.6139 28.7668 28.4201 28.5965 160066............................ 0.9354

* 22.7709

* 22.7709 160067............................ 1.3642 0.8891 23.4060 24.8137 26.0201 24.7707 160069............................ 1.5288 0.8874 25.3402 27.4473 27.6151 26.8148

[[Page 24873]]

160079............................ 1.4776 0.8689 23.7234 24.7372 26.1612 24.8785 160080............................ 1.2820 0.8898 23.1837 25.8252 27.2360 25.4030 160081............................

***

* 23.1930

* 23.1930 160082............................ 1.7712 0.9162 26.4398 27.4718 28.7814 27.5576 160083............................ 1.6609 0.9162 28.2193 27.3004 28.3914 27.9723 160089............................ 1.2895 0.9142 22.6551 23.2149 23.2885 23.0561 160091............................

***

* 17.9862

* 17.9862 160101............................ 1.0822 0.9162 25.1000 25.0503 25.4729 25.2118 160104............................ 1.6559 0.8898 24.9134 28.1891 29.8108 27.8792 160110............................ 1.5339 0.8891 24.9434 26.6633 28.8124 26.8746 160112............................ 1.2909 0.8480 23.0672 24.7957 25.2879 24.4324 160117............................ 1.3812 0.8874 25.0278 25.4659 27.3401 25.9559 160118............................

***

* 19.7764

* 19.7764 160122............................ 1.0949 0.8480 22.5872 23.9177 24.4983 23.6840 160124............................ 1.1525 0.8480 23.1690 22.5482 24.2654 23.3247 160126............................ 1.0265

* 19.8323

* 19.8323 160146............................ 1.3905 0.9220 22.9897 22.6949 25.9575 23.8222 160147............................ 1.2917 0.9227 26.6438 28.6303 29.8976 28.4670 160153............................ 1.7355 0.9220 28.9881 29.9378 30.6170 29.8519 160154............................ 0.9478

* 170001............................ 1.1452 0.7989 21.9131 23.1260 23.8847 22.9700 170006............................ 1.3255 0.9040 21.9019 24.2068 27.1291 24.4623 170009............................ 1.0521 0.9321 29.2588 30.9025 29.6048 29.9146 170010............................ 1.2446 0.7989 24.0008 23.9707 25.5578 24.5520 170012............................ 1.6138 0.8761 24.7392 26.1367 27.1174 25.9599 170013............................ 1.6219 0.8761 25.0419 25.2476 26.7123 25.6576 170014............................ 1.0198 0.9321 23.5960 23.8135 24.1592 23.8605 170015............................

***

* 20.2368

* 20.2368 170016............................ 1.6404 0.8561 25.9482 25.8061 26.7533 26.1670 170017............................ 1.0741 0.9009 24.7771 26.9657 25.7301 25.8416 170019............................ 1.1990

* 22.0251

* 22.0251 170020............................ 1.5979 0.8761 23.1800 23.2757 24.1120 23.5234 170022............................ 1.1485

* 22.2878

* 22.2878 170023............................ 1.4202 0.8761 23.9808 24.0561 23.9805 24.0052 170027............................ 1.3965 0.7989 22.5103 23.1766 23.4023 23.0164 170033............................ 1.3534 0.8761 20.7864 21.9709 24.1874 22.2849 170039............................ 0.9441 0.9009 21.5203 26.9852 26.0906 24.6284 170040............................ 1.9811 0.9321 28.2856 28.4458 30.2460 29.0254 170049............................ 1.5233 0.9321 24.7895 25.2070 26.4091 25.4878 170052............................

***

* 18.5291

* 18.5291 170058............................ 1.1011 0.9321 23.3398 22.9210 26.5943 24.2597 170068............................ 1.2238 0.9141 22.6087 23.0635 23.8790 23.1876 170070............................

***

* 16.0162

* 16.0162 170074............................ 1.2234 0.7989 21.0565 23.7829 23.1854 22.7215 170075............................ 0.8299 0.7989 16.5444 19.7760 19.9316 18.7462 170085............................ 0.6104

* 170086............................ 1.5817 0.8561 24.0812 26.1362 26.3581 25.5514 170093............................

***

* 16.5553

* 16.5553 170094............................ 0.9370 0.7989 21.3887 21.5295 16.5371 19.6987 170098............................

***

* 20.1242

* 20.1242 170103............................ 1.2881 0.9009 22.8707 23.8042 24.1990 23.6448 170104............................ 1.4659 0.9321 26.9671 26.2990 27.5482 26.9346 170105............................ 1.0954 0.7989 21.4422 21.9606 22.7400 22.0339 170109............................ 1.0332 0.9321 23.2626 23.1088 23.8520 23.4043 170110............................ 0.8843 0.7989 22.9195 23.3260 23.9496 23.4209 170114............................ 0.9064

* 18.9158

* 18.9158 170120............................ 1.3879 0.9040 21.0499 22.0253 22.2797 21.7557 170122............................ 1.6841 0.9009 25.3982 26.6605 28.3325 26.7103 170123............................ 1.6957 0.9009 27.2239 27.6653 28.4687 27.7816 170133............................ 1.0455 0.9321 22.9309 23.1226 25.2821 23.8233 170137............................ 1.2780 0.7989 23.8862 24.7096 25.4425 24.7034

[[Page 24874]]

170142............................ 1.4027 0.8455 22.5778 23.9527 24.5814 23.7373 170143............................

***

* 20.4459

* 20.4459 170144............................

***

* 24.6259

* 24.6259 170145............................ 1.0836 0.7989 21.5756 23.2162 23.3953 22.7060 170146............................ 1.5040 0.9321 29.1358 29.8858 29.0538 29.3514 170147............................

***

* 21.4753 22.4973 24.3378 22.5659 170150............................ 1.1592 0.8165 18.5744 20.9448 19.5537 19.7042 170166............................ 0.9974 0.7989 19.2842 21.0762 22.6927 21.0426 170175............................ 1.4188 0.8761 23.9304 25.6281 26.7215 25.4230 170176............................ 1.5962 0.9321 26.2366 27.2332 29.0423 27.5653 170180............................

***

* 25.1368 32.5010 17.4887 26.4266 170182............................ 1.4423 0.9321 25.7443 27.3503 29.0642 27.4067 170183............................ 1.9419 0.9009 24.5539 25.8340 26.1875 25.5204 170185............................ 1.2362 0.9321 26.7797 27.8139 28.1777 27.6777 170186............................ 2.6637 0.9009 31.7896 32.8392 30.2636 31.6204 170187............................ 1.4879 0.7989 23.3702 22.8493 24.1467 23.4567 170188............................ 1.9751 0.9321 29.9751 30.6844 32.2575 31.0138 170190............................ 1.0179 0.8455 22.8729 22.9540 26.2542 24.0445 170191............................ 1.7210 0.7989 21.3069 22.1197 24.3772 22.6585 170192............................ 1.9138 0.9009 27.9704 26.2724 27.8171 27.3379 170193............................ 1.4210 0.8761 24.7429 20.6821 24.8461 23.2169 170194............................ 1.0788 0.9321 27.9903 29.9014 27.6979 28.5234 170195............................ 2.2822 0.9321

* 30.1001 29.5948 29.8108 170196............................ 2.3751 0.9009

* 33.9653 33.9653 180001............................ 1.2529 0.9654 25.4217 27.6917 29.7401 27.6436 180002............................ 1.0605 0.8095 22.9727 25.7862 26.5375 25.1104 180004............................ 1.0975 0.7812 19.5437 22.0797 20.8790 20.8280 180005............................ 1.1216 0.8706 24.5561 24.9779 25.6139 25.0800 180006............................

***

* 14.8011

* 14.8011 180007............................ 1.5270 0.9027 22.7606 25.7042 27.1922 25.2358 180009............................ 1.7023 0.8845 25.3837 26.4101 27.3217 26.4312 180010............................ 1.8869 0.9027 24.7256 25.6153 27.5042 25.9590 180011............................ 1.5431 0.8815 22.7364 25.5463 24.9907 24.4167 180012............................ 1.4916 0.9045 24.6642 25.6000 26.7267 25.6686 180013............................ 1.5075 0.9408 22.9512 23.7075 24.8114 23.8153 180016............................ 1.3308 0.9045 23.1832 24.8408 24.7149 24.2505 180017............................ 1.3241 0.7983 20.8630 21.8885 21.9702 21.5929 180018............................ 1.3149 0.7812 19.0992 20.9857 23.3022 21.1380 180019............................ 1.0936 0.9654 24.1342 24.0283 24.6269 24.2636 180020............................ 1.0484 0.7812 21.9494 24.6953 25.9626 24.2590 180021............................ 0.9695 0.7812 18.5966 20.7950 22.0692 20.5351 180024............................ 1.1161 0.9045 32.1824 31.1159 26.3521 29.7116 180025............................ 1.1404 0.9045 19.1543 22.6897 28.5920 23.5032 180026............................ 1.0693

* 18.2120

* 18.2120 180027............................ 1.2463 0.8116 23.8763 20.8303 21.7638 22.0496 180028............................ 0.9145

* 24.7967

* 24.7967 180029............................ 1.3855 0.8815 23.0536 25.6479 26.1493 24.9987 180035............................ 1.6206 0.9654 29.8438 31.0794 32.3484 31.1163 180036............................ 1.2432 0.8845 25.1154 25.2972 25.6952 25.3661 180037............................ 1.3242 0.9045 25.7361 26.3132 27.8489 26.6113 180038............................ 1.5454 0.8801 24.6348 26.0440 27.2813 25.9999 180040............................ 1.9659 0.9045 26.2125 27.9979 28.5206 27.6117 180043............................ 1.1551 0.7812 19.0617 20.9326 20.6423 20.2174 180044............................ 1.7151 0.8706 23.0971 24.4569 25.8053 24.4867 180045............................ 1.3294 0.9654 25.8349 27.4732 29.4298 27.6399 180046............................ 0.9468 0.9027 27.2244 27.1034 27.0962 27.1405 180047............................

***

* 21.8036

* 21.8036 180048............................ 1.2958 0.9045 21.6571 23.9230 24.3681 23.3115 180049............................ 1.4452 0.8815 23.3407 22.4769 24.3690 23.3958 180050............................ 1.1562 0.7840 22.6473 26.3604 25.9528 24.9966 180051............................ 1.2881 0.8223 21.3312 23.5299 24.3892 23.1284

[[Page 24875]]

180053............................ 0.9917 0.7812 19.1578 21.3044 22.1656 20.9703 180055............................ 1.1922

* 20.7237

* 20.7237 180056............................ 1.1792 0.8469 22.8910 24.3074 24.5323 23.9076 180063............................ 1.1034

* 17.9741

* 17.9741 180064............................ 1.1673 0.8132 16.2638 17.1009 20.1789 17.8235 180066............................ 1.0846 0.9408 24.9543 22.2713 23.7855 23.6483 180067............................ 2.0226 0.9027 25.4080 26.0238 27.9851 26.5261 180069............................ 1.0877 0.8706 22.3673 26.3701 26.5123 25.1423 180070............................ 1.1704 0.8052 20.1308 20.6741 20.2176 20.3429 180078............................ 1.1538 0.8706 26.2636 27.6806 28.2744 27.4277 180079............................ 1.1904 0.8076 19.7791 20.2100 23.5989 21.2535 180080............................ 1.2800 0.8043 21.7380 21.5818 23.7258 22.3548 180087............................ 1.2583 0.7812 18.4331 20.8841 22.0260 20.4628 180088............................ 1.6703 0.9045 27.5767 28.0916 28.6098 28.1048 180092............................ 1.1856 0.9027 22.5679 23.7909 23.7858 23.3986 180093............................ 1.6485 0.8127 20.5422 20.5807 21.4392 20.8528 180095............................ 1.0480 0.7812 17.9677 17.9146 21.5629 18.9607 180101............................ 1.1642 0.9027 25.4796 27.4506 28.1621 27.0742 180102............................ 1.5957 0.8116 18.4388 21.0896 25.2335 21.3174 180103............................ 2.1735 0.9027 26.9407 28.4583 28.7043 28.0357 180104............................ 1.5681 0.8116 24.9441 25.6157 25.9724 25.5137 180105............................ 0.8867 0.7812 19.7615 21.6002 23.1861 21.5257 180106............................ 0.8975 0.7812 17.8020 20.2884 20.7179 19.6699 180115............................ 0.9142 0.7812 20.9831 20.5539 20.3082 20.6168 180116............................ 1.2136 0.8116 22.7353 23.5354 25.8909 24.0619 180117............................ 0.9574 0.7812 21.1854 22.8469 24.7355 22.8804 180124............................ 1.3107 0.9408 23.1917 24.8292 25.4651 24.5479 180127............................ 1.3506 0.9045 23.4765 24.6774 26.3498 24.8205 180128............................ 0.9287 0.7812 20.8406 22.6056 23.8117 22.4352 180130............................ 1.6785 0.9045 26.0278 27.8900 29.1689 27.7419 180132............................ 1.4706 0.8815 23.7652 24.5105 25.3772 24.5770 180134............................ 0.9988

* 18.6779

* 18.6779 180138............................ 1.2338 0.9045 27.3400 28.1901 29.3488 28.3067 180139............................ 0.9711 0.7812 23.5363 23.3569 24.7565 23.8893 180141............................ 1.7986 0.9045 25.3042 25.3357 27.7799 26.1558 180143............................ 1.6391 0.9027 25.1613 28.1924 30.8722 28.2377 180144............................

***

* 29.5052

* 29.5052 180146............................

***

* 39.8522 39.8522 180147............................

***

* 31.1601 31.1601 180148............................

***

* 30.1239 30.1239 180149............................ 0.9790 0.7812

* 190001............................ 1.1333 0.7591 19.7516 22.1394 22.1542 21.3054 190002............................ 1.6405 0.8323 22.0056 23.3368 24.6968 23.3287 190003............................ 1.4815 0.8323 23.4977 25.8294 26.7813 25.3494 190004............................ 1.5567 0.7980 23.3290 25.3473 25.0771 24.6162 190005............................ 4.8105 0.8732 22.3208 22.6029 24.2903 23.0170 190006............................ 1.4353 0.8323 22.2467 22.7979 24.8816 23.2624 190007............................ 1.1757 0.7591 19.7528 21.8205 23.1401 21.5662 190008............................ 1.7630 0.7980 24.0111 24.6074 26.3623 24.9673 190009............................ 1.2905 0.7982 19.8404 21.1005 24.0685 21.5282 190010............................

***

* 21.6889

* 21.6889 190011............................ 0.9928 0.7872 19.7319 21.4052 21.6962 20.9421 190013............................ 1.4551 0.7787 20.8626 21.4573 23.7328 22.0203 190014............................ 1.1835 0.7591 22.4596 22.7151 22.6381 22.6119 190015............................ 1.3255 0.8732 22.8875 23.7789 25.1756 23.9762 190017............................ 1.3888 0.7775 21.5033 24.5390 24.7505 23.6069 190019............................ 1.7979 0.7982 23.7168 24.0468 25.4650 24.4147 190020............................ 1.2332 0.8014 21.6136 22.1967 23.4576 22.4009 190025............................ 1.3044 0.7591 20.8950 23.5007 24.6432 22.9599 190026............................ 1.6216 0.7982 22.5087 23.7702 24.1540 23.4852 190027............................ 1.6703 0.7787 21.2526 24.3006 26.7106 24.0302

[[Page 24876]]

190034............................ 1.2388 0.7779 19.6943 20.7334 21.2104 20.5402 190036............................ 1.7113 0.8732 24.8152 25.4164 25.6548 25.3040 190037............................ 0.6483 0.7787 18.6393 19.4071 20.7258 19.5618 190039............................ 1.6431 0.8732 25.6665 24.4386 26.1249 25.3976 190040............................ 1.3443 0.8732 26.7428 28.6297 28.0162 27.7945 190041............................ 1.4784 0.8615 24.6734 28.5376 28.9554 27.3327 190043............................

***

* 17.3477

* 17.3477 190044............................ 1.3215 0.7850 19.5567 20.9993 21.2561 20.6002 190045............................ 1.6092 0.8732 25.3854 25.8238 27.1982 26.1752 190046............................ 1.4988 0.8732 24.2128 23.8552 24.7362 24.2695 190048............................ 1.0173

* 19.6288

* 19.6288 190050............................ 1.0982 0.7635 19.1076 21.0259 20.9111 20.3638 190053............................ 1.1453 0.7691 16.4968 17.9788 18.5781 17.7244 190054............................ 1.3652 0.7676 20.1108 23.1471 22.7018 22.0096 190060............................ 1.4952 0.7787 23.6278 23.7393 22.6278 23.3255 190064............................ 1.6402 0.8014 23.3617 23.1358 23.7283 23.4081 190065............................ 1.6040 0.8014 23.7450 22.1880 23.1207 23.0049 190077............................ 0.9332

* 18.8409

* 18.8409 190078............................ 1.0564 0.7775 21.3786 22.2431 22.2313 21.9581 190079............................ 1.2248 0.8732 21.2546 24.0985 23.8184 23.0907 190081............................ 0.8766 0.7591 15.6146 20.0121 21.4422 18.9706 190086............................ 1.3003 0.7766 19.8823 22.0610 22.2872 21.4347 190088............................ 1.0986 0.8615 22.3480 23.8562 23.1624 23.1091 190090............................ 1.0652 0.7591 20.2045 23.1241 24.3261 22.5629 190095............................

***

* 18.0174

* 18.0174 190098............................ 1.7622 0.8615 24.6353 25.6854 25.7430 25.3592 190099............................ 1.0523 0.8014 20.4597 22.0610 23.2316 21.9191 190102............................ 1.5318 0.8323 25.2267 27.3126 26.9670 26.4739 190106............................ 1.1180 0.7982 21.7228 23.5376 26.6201 23.8308 190109............................ 1.2707

* 18.6524

* 18.6524 190111............................ 1.6579 0.8615 24.4998 25.5729 26.5701 25.5474 190114............................ 1.0545 0.7591 15.8031 17.2678 19.1533 17.4110 190115............................ 1.2581 0.8615 26.6295 28.2066 26.0782 26.9661 190116............................ 1.1767 0.7675 20.3845 22.3710 23.3978 22.0626 190118............................ 0.9130 0.8615 19.7024 22.8809 21.2519 21.3058 190122............................ 1.3212 0.8014 23.7082 22.0072 22.2352 22.6295 190124............................

***

* 24.6675 26.0032 27.7799 26.1591 190125............................ 1.6008 0.7872 23.9649 25.5463 24.8247 24.7613 190128............................ 1.1165 0.8014 27.9136 28.3257 29.6644 28.6603 190131............................ 1.2880 0.8014 25.1917 27.8465 28.6764 27.2755 190133............................ 0.9001 0.7692 13.6266 18.2045 22.4265 19.4499 190135............................

***

* 26.8238 27.7540 30.5687 28.1641 190140............................ 0.9712 0.7625 17.6936 18.9652 23.0383 19.9091 190144............................ 1.1643 0.8615 21.7547 22.9181 23.7865 22.8277 190145............................ 0.9240 0.7681 18.9678 19.9265 20.8537 19.9351 190146............................ 1.5652 0.8732 26.1792 27.4824 28.7186 27.4154 190149............................ 1.0427

* 18.8819

* 18.8819 190151............................ 0.9491 0.7591 18.6293 18.7467 18.8350 18.7414 190152............................ 1.5642 0.8732 27.6099 28.1334 30.8510 28.8848 190158............................

***

* 26.3042 26.4787 30.6477 27.6762 190160............................ 1.6099 0.7872 21.6740 22.9325 24.7806 22.9867 190161............................ 1.2439 0.7787 19.1022 22.6187 22.9017 21.4139 190162............................

***

* 25.0328 25.2953

* 25.1543 190164............................ 1.1710 0.8204 22.8599 25.2560 26.6165 24.9924 190167............................ 1.2685 0.8323 24.3185 26.4669 25.3251 25.3437 190175............................ 1.3812 0.8732 27.1531 26.0547 27.4234 26.8723 190176............................ 1.7573 0.8732 25.6997 25.8826 26.2601 25.9478 190177............................ 1.7189 0.8732 27.4621 27.7792 28.2738 27.8343 190182............................

***

* 28.4799 27.1682 29.8646 28.5185 190183............................ 1.1704 0.7980 19.8084 22.6928 22.0098 21.4396 190184............................ 1.0119 0.7766 23.9608 24.9476 24.1551 24.3727

[[Page 24877]]

190185............................

***

* 24.7912 25.6394 28.9749 26.4361 190190............................ 0.9347 0.7666 16.1195 24.3327 26.6988 22.8823 190191............................ 1.3282 0.8323 23.5734 24.1923 26.1592 24.6307 190196............................ 0.9301 0.8323 24.7135 24.0385 25.8459 24.8783 190197............................ 1.3888 0.7872 24.3735 25.8071 26.4794 25.5487 190199............................ 0.9962 0.8014 14.1409 27.3304 31.9843 22.9932 190200............................

***

* 27.5681 28.8173 27.4772 27.9970 190201............................ 1.2434 0.7787 24.5877 25.1010 24.4557 24.7118 190202............................ 1.4035 0.8014 24.7944 27.6084 29.6583 27.4867 190203............................

***

* 26.8795 28.1832 29.9743 28.2126 190204............................ 1.5156 0.8732 28.3684 28.1033 30.5137 28.9471 190205............................ 1.6777 0.8323 24.4540 26.6832 28.2453 26.4792 190206............................ 1.5774 0.8732 26.0139 26.7401 29.2352 27.2855 190208............................ 0.8622 0.7591 24.2588 28.7308 27.9789 27.1350 190218............................ 1.1036 0.8615 25.0356 26.7262 28.1014 26.6009 190236............................ 1.4949 0.8615 23.6824 24.7142 26.4588 24.9853 190241............................ 1.2210 0.7980 23.9700 25.2123 25.7878 25.0872 190242............................ 1.1667 0.8014 23.0072 24.8461 25.0011 24.3286 190245............................ 1.7065 0.7872 27.1786 25.5751 26.7636 26.5208 190246............................ 1.6693 0.7666

* 22.7824 22.7824 190247............................

***

* 32.7499

* 32.7499 190248............................

***

* 23.2220

* 23.2220 190249............................ 1.8972 0.8014

* 20.0468 25.2505 22.1285 190250............................ 2.1200 0.8732

* 31.5101 33.3274 32.3417 190251............................ 1.2888 0.8014

* 21.4464 23.8397 22.5827 190252............................

***

* 23.6924

* 23.6924 190253............................

***

* 22.8060 23.8029 23.3045 190254............................

***

* 32.9290

* 32.9290 190255............................ 0.7428 0.8323

* 22.2412 16.1597 18.3000 190256............................ 0.7572 0.8732

* 25.9565 25.9565 190257............................ 1.6034 0.7641

* 26.5480 26.5480 190258............................ 1.0329 0.8615

* 31.3715 26.1129 28.3727 190259............................ 1.8027 0.8323

* 26.5073 26.5073 190260............................

***

* 29.3937 29.3937 190261............................ 1.6302 0.7872

* 27.0423 27.0423 190262............................

***

* 30.3709 30.3709 190263............................ 2.4724 0.8323

* 26.1353 26.1353 190264............................

***

* 26.5809 26.5809 190265............................ 0.7095 0.7872

* 22.6214 22.6214 190266............................ 1.9489 0.8014

* 190267............................ 1.1620 0.8732

* 190268............................ 1.3593 0.8323

* 190270............................ 1.7989 0.8732

* 190272............................ 1.5539 0.8323

* 190273............................ 1.6476 0.8014

* 200001............................ 1.3871 0.9860 25.1144 25.2542 25.8813 25.4247 200002............................ 1.0767 0.8412 25.7478 25.7212 27.1134 26.1897 200008............................ 1.3366 1.0008 27.4412 27.7137 29.1729 28.1437 200009............................ 1.9757 1.0008 31.1056 30.7510 32.5792 31.4767 200012............................ 1.3501

* 25.7623

* 25.7623 200013............................

***

* 24.4131

* 24.4131 200018............................ 1.2572 0.8412 23.6337 23.5632 22.5017 23.1550 200019............................ 1.2471 1.0008 25.1367 25.6649 27.7886 26.2301 200020............................ 1.2349 1.0179 31.7083 32.6436 34.0918 32.8280 200021............................ 1.2518 1.0008 24.5519 27.1381 29.2049 27.0894 200024............................ 1.5842 0.9601 26.0080 27.5410 29.7792 27.8456 200025............................ 1.1474 1.0008 26.0573 26.3124 28.5747 27.0014 200027............................

***

* 26.3118

* 26.3118 200028............................

***

* 24.3271

* 24.3271 200031............................ 1.2585 0.8412 21.9489 21.2370 22.2140 21.8009 200032............................ 1.1124 0.8728 25.5227 26.3322 26.8986 26.2491

[[Continued on page 24879]]

From the Federal Register Online via GPO Access [wais.access.gpo.gov] ]

[[pp. 24879-24928]] Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates

[[Continued from page 24878]]

[[Page 24878]]

200033............................ 1.8739 0.9860 28.6479 29.3108 31.6996 29.9418 200034............................ 1.3348 0.9601 26.2926 27.0582 27.0093 26.8000 200037............................ 1.2314 0.8412 23.2333 24.1732 24.9410 24.1296 200039............................ 1.3026 0.9601 25.1196 25.1179 26.6405 25.6397 200040............................ 1.2321 1.0008 25.5405 25.9893 28.5564 26.8006 200041............................ 1.1532 0.8412 24.5532 24.9670 26.6764 25.4292 200050............................ 1.2564 0.9860 26.4992 27.6825 29.5020 27.9403 200052............................ 1.0964 0.8412 21.8726 22.5159 24.3571 22.9652 200063............................ 1.1435 0.9601 25.0167 25.8623 27.9736 26.3217 210001............................ 1.3542 0.9443 27.7561 28.2858 29.3435 28.4858 210002............................ 1.9660 1.0108 26.4992 32.3005 36.0667 31.3519 210003............................ 1.6629 1.0679 29.8684 34.1109 30.7342 31.5420 210004............................ 1.4235 1.0990 34.2392 33.6056 31.7115 33.1029 210005............................ 1.2775 1.0990 28.7557 28.9554 29.5819 29.1061 210006............................ 1.0872 1.0108 25.4081 25.9005 27.3618 26.2241 210007............................ 1.8897 1.0108 30.2548 31.8767 30.7107 30.9321 210008............................ 1.3824 1.0108 25.2833 24.3341 28.8840 26.1400 210009............................ 1.6952 1.0108 26.2360 27.7900 30.2658 28.0854 210010............................

***

* 25.7775

* 25.7775 210011............................ 1.3763 1.0108 27.5031 30.8575 31.5191 30.0101 210012............................ 1.6038 1.0108 27.4103 30.3078 31.1748 29.7268 210013............................ 1.2768 1.0108 25.1348 28.5328 28.9896 27.5055 210015............................ 1.2773 1.0108 28.2029 29.9261 32.2753 30.1829 210016............................ 1.7524 1.0990 32.2081 32.3506 33.5480 32.6959 210017............................ 1.1893 0.8917 23.2167 25.1890 26.8569 25.0995 210018............................ 1.1888 1.0990 29.1870 29.5533 29.6505 29.4657 210019............................ 1.7923 0.8917 26.1824 27.3731 28.7828 27.4738 210022............................ 1.3936 1.0990 33.8015 35.4727 37.3067 35.4764 210023............................ 1.4340 1.0178 30.4656 32.1812 32.9572 31.9405 210024............................ 1.7289 1.0108 29.5579 30.6359 32.9413 31.0661 210025............................ 1.2738 0.8917 26.0771 23.8552 24.8558 24.7696 210027............................ 1.5328 0.8917 26.0111 24.6343 24.4810 25.0054 210028............................ 1.0549 0.9273 25.9221 26.3469 26.7453 26.3458 210029............................ 1.2581 1.0108 27.9741 31.0266 31.8522 30.2804 210030............................ 1.2162 0.8917 29.5635 26.9763 32.2035 29.6025 210032............................ 1.1541 1.0752 26.1829 27.0727 27.9355 27.1027 210033............................ 1.1657 1.0108 29.0420 28.5534 29.2497 28.9509 210034............................ 1.3012 1.0108 28.4308 30.2908 32.3804 30.4301 210035............................ 1.2771 1.0679 26.1083 28.6484 27.3876 27.3991 210037............................ 1.1898 0.8917 27.0973 27.3287 27.8387 27.4523 210038............................ 1.2283 1.0108 29.5980 29.8121 32.3190 30.5512 210039............................ 1.1414 1.0679 27.6940 30.4991 32.4126 30.2663 210040............................ 1.2135 1.0108 29.3514 28.3559 29.2360 28.9742 210043............................ 1.2986 1.0178 27.5657 26.6524 32.6967 28.8479 210044............................ 1.3219 1.0108 28.8700 29.7339 30.3340 29.6364 210045............................ 0.9653 0.8917 15.6380 14.2223 16.3687 15.4676 210048............................ 1.2738 1.0108 28.4638 27.5043 26.0631 27.2649 210049............................ 1.2021 1.0108 26.9656 26.0900 27.0156 26.6995 210051............................ 1.3641 1.0679 29.2998 29.8892 30.4320 29.8760 210054............................ 1.2925 1.0679 26.2295 27.4328 27.7592 27.1401 210055............................ 1.1649 1.0679 29.9708 30.6941 31.4895 30.7115 210056............................ 1.2979 1.0108 28.6091 30.0810 32.3482 30.4741 210057............................ 1.3579 1.0990 32.2883 31.6787 32.8280 32.2611 210058............................ 1.0861 1.0108 29.7841 31.0873 31.6688 30.9534 210060............................ 1.1807 1.0679 28.5087 27.1764 29.9635 28.5560 210061............................ 1.2431 0.8917 23.6662 23.1645 25.0234 23.9963 220001............................ 1.2013 1.1256 29.0014 30.6070 31.2364 30.2908 220002............................ 1.3849 1.1256 30.3598 32.4356 33.6641 32.2134 220003............................ 1.1827

* 22.0549

* 22.0549 220006............................

***

* 30.8599 30.7673 33.6421 31.7227 220008............................ 1.2815 1.1256 30.1043 31.3385 34.5830 32.0429

[[Page 24879]]

220010............................ 1.2469 1.1256 29.7998 30.7804 31.9799 30.8557 220011............................ 1.1289 1.1256 34.4064 34.7655 36.5621 35.2403 220012............................ 1.5401 1.2617 35.7872 37.8763 39.7533 37.8795 220015............................ 1.1911 1.0236 28.3397 29.6315 32.4890 30.2084 220016............................ 1.1228 1.0236 28.0608 30.4813 31.3113 29.9507 220017............................ 1.2759 1.1710 29.7108 31.6170 33.2998 31.5458 220019............................ 1.0827 1.1256 23.2544 24.4009 25.7854 24.4946 220020............................ 1.2031 1.1256 26.5305 28.5288 31.0989 28.7645 220024............................ 1.2986 1.0236 27.3488 28.7342 31.9477 29.2908 220025............................ 1.0403 1.1256 23.0637 25.6478 30.4365 26.1068 220028............................

***

* 32.0980 31.7122 39.3268 34.1946 220029............................ 1.1325 1.1256 28.6970 30.6935 31.6352 30.3488 220030............................ 1.1318 1.0236 24.4289 26.8849 28.1322 26.5391 220031............................ 1.6575 1.1710 34.8183 36.8477 38.9417 36.9168 220033............................ 1.2129 1.1256 28.2539 31.8249 32.3475 30.8015 220035............................ 1.4185 1.1256 28.6238 31.4470 29.7381 29.8711 220036............................ 1.5118 1.1710 31.5184 33.1436 35.9106 33.5792 220046............................ 1.4766 1.0071 28.1396 30.4460 31.4997 30.0722 220049............................ 1.2129 1.1256 27.7518 30.4740 32.4636 30.2579 220050............................ 1.0822 1.0236 26.3768 28.3434 29.0272 27.9399 220051............................ 1.3072 0.9739 29.8380 30.2552 30.1012 30.0680 220052............................ 1.1348 1.1710 29.8577 32.4130 31.6356 31.2805 220058............................ 0.9616 1.1256 24.9642 25.7247 27.8893 26.1882 220060............................ 1.1736 1.1710 32.3362 32.5477 34.7327 33.2257 220062............................ 0.5719 1.1256 24.2779 25.0766 25.4179 24.9410 220063............................ 1.2562 1.1256 27.3968 30.2866 32.9101 30.2203 220065............................ 1.2427 1.0236 26.5513 27.6009 30.0468 28.0391 220066............................ 1.3446 1.0236 27.1317 27.8073 28.9742 27.9354 220067............................ 1.1851 1.1710 29.8911 30.2222 32.4000 30.8641 220070............................ 1.1334 1.1256 31.9283 33.1299 34.2574 33.1431 220071............................ 1.8646 1.1710 32.2936 36.5065 37.4053 35.4736 220073............................ 1.1771 1.1256 31.3566 34.2989 36.0252 33.8940 220074............................ 1.3059 1.1710 28.4930 30.5607 31.4701 30.1999 220075............................ 1.5111 1.1710 29.1588 30.9175 31.3628 30.4689 220076............................

***

* 29.7507 27.5148

* 28.6235 220077............................ 1.6760 1.0955 30.2684 31.7325 33.0291 31.6979 220080............................ 1.2069 1.1256 28.9835 29.9595 31.1248 30.0444 220082............................ 1.2848 1.1256 26.9841 30.0611 30.8211 29.3136 220083............................ 1.0840 1.1710 32.9143 34.5118 34.5698 33.9822 220084............................ 1.2047 1.1256 32.5711 30.9527 31.6948 31.7155 220086............................ 1.8174 1.1710 34.3667 34.2388 34.5669 34.3947 220088............................ 1.8786 1.1710 28.5462 35.8255 37.4460 33.3973 220089............................

***

* 31.1708 32.6305 34.7959 32.8331 220090............................ 1.1952 1.1256 30.8685 32.9011 33.8958 32.6221 220095............................ 1.1079 1.1256 27.4273 28.0673 30.1157 28.5485 220098............................ 1.1442 1.1256 28.8314 30.5869 31.5393 30.3882 220100............................ 1.3485 1.1710 29.6912 31.9859 34.6575 32.1939 220101............................ 1.2852 1.1256 33.1690 35.3464 37.5665 35.4542 220105............................ 1.2082 1.1256 31.9421 33.2625 32.8161 32.6900 220108............................ 1.1274 1.1710 30.6252 32.6131 33.8841 32.3642 220110............................ 2.0174 1.1710 36.6084 39.2167 41.0472 39.0591 220111............................ 1.2048 1.1710 31.1850 33.6167 34.8506 33.2566 220116............................ 1.9490 1.1710 32.9988 36.4149 38.8221 35.9865 220119............................ 1.0935 1.1710 30.1056 30.9965 32.0844 31.1223 220126............................ 1.1449 1.1710 28.7805 31.4882 32.5432 30.9197 220133............................

***

* 33.6003 29.4855 34.8935 32.6268 220135............................ 1.3229 1.2617 33.9866 36.0203 37.5164 35.8937 220153............................

***

* 19.8073 19.8073 220154............................ 0.9781 1.1710 28.6461

* 28.7843 28.7087 220162............................ 1.6507

* 220163............................ 1.5700 1.1256 33.6484 34.4874 37.4931 35.2930

[[Page 24880]]

220171............................ 1.7192 1.1256 30.4036 32.7414 35.9925 33.0852 220174............................ 1.2036 1.1256 31.7572 30.0406 30.9354 30.8546 220175............................ 1.2654

* 220176............................ 1.6837 1.1341

* 230002............................ 1.2951 1.0138 29.1410 32.9010 34.0440 32.0073 230003............................ 1.2255 0.9472 26.1278 27.5824 28.4694 27.4073 230004............................ 1.7409 0.9935 26.7206 29.3934 31.2926 29.2276 230005............................ 1.2575 0.9372 24.1902 25.8768 27.7463 25.8963 230006............................ 1.0740

* 23.8835

* 23.8835 230013............................ 1.3227 1.0272 23.7822 24.6511 27.2066 25.1217 230015............................ 1.1463 0.9196 24.6571 26.2782 27.2542 26.0748 230017............................ 1.7002 1.0505 29.5178 31.8821 32.5376 31.3890 230019............................ 1.6505 1.0272 28.4575 32.3401 34.3193 31.6359 230020............................ 1.7492 1.0138 29.2869 28.5646 29.4792 29.1157 230021............................ 1.5950 1.0151 24.9551 26.5659 28.6153 26.7251 230022............................ 1.3120 0.9933 23.3000 25.6683 30.1226 26.2395 230024............................ 1.6703 1.0138 30.0813 32.1483 32.5866 31.6095 230027............................ 1.0649

* 23.5511

* 23.5511 230029............................ 1.6011 1.0272 29.0935 32.3538 32.3835 31.2335 230030............................ 1.2717 0.8979 22.3174 23.8082 25.1077 23.7832 230031............................ 1.3725 1.0040 25.4679 29.7232 30.0088 28.2704 230034............................ 1.3787 0.8899 26.7967 24.4845 24.4133 25.2367 230035............................ 1.2605 0.9380 21.2317 24.8822 24.9648 23.8027 230036............................ 1.4572 0.9399 28.3622 29.3754 29.9622 29.2264 230037............................ 1.3454 1.0138 26.2000 28.9244 28.5469 27.9089 230038............................ 1.7903 0.9472 26.3480 28.2012 29.1247 27.9594 230040............................ 1.2075 0.9380 24.2349 25.5154 26.3754 25.4050 230041............................ 1.6026 0.9399 26.1760 27.8853 27.9569 27.3833 230042............................

***

* 26.2037

* 26.2037 230046............................ 1.9037 1.0504 30.3591 31.6235 32.2914 31.4688 230047............................ 1.4047 1.0092 28.1351 31.1771 31.7053 30.3603 230053............................ 1.6336 1.0138 29.8703 32.5711 32.1537 31.5469 230054............................ 1.8873 0.9339 24.9905 25.7591 26.0031 25.5906 230055............................ 1.2628 0.8899 25.4143 27.4349 28.4779 27.1071 230058............................ 1.1265 0.8899 24.0657 25.9291 27.1214 25.7327 230059............................ 1.5531 0.9472 25.5350 27.9091 28.5859 27.3987 230060............................ 1.2198 0.8899 25.5015 28.2874 27.0286 26.9332 230065............................

***

* 28.4631 32.6255

* 29.9929 230066............................ 1.3087 0.9935 27.4928 30.6184 30.2070 29.5125 230069............................ 1.1594 1.0138 29.5556 30.2663 31.3407 30.4158 230070............................ 1.6381 0.9127 24.2342 25.6778 26.8296 25.5681 230071............................ 0.8679 1.0272 26.3907 28.3064 29.6710 28.1425 230072............................ 1.3914 0.9472 24.4933 26.2838 27.4723 26.0939 230075............................ 1.3793 1.0090 27.6193 28.2540 30.8862 28.9422 230077............................ 1.9012 1.0272 27.6157 29.8538 30.5516 29.3453 230078............................ 1.0892 0.8899 23.9902 25.6809 25.7228 25.1288 230080............................ 1.3068 0.9399 21.2314 24.1573 24.5418 23.3433 230081............................ 1.1913 0.8899 23.0788 24.7374 26.4321 24.7713 230082............................ 1.6774

* 22.2165

* 22.2165 230085............................ 1.1930 1.0505 22.7313 23.4959 25.4277 23.9142 230087............................

***

* 16.9168

* 16.9168 230089............................ 1.3349 1.0138 28.7015 31.0522 32.8429 30.6482 230092............................ 1.3637 1.0138 26.3584 28.6829 29.3419 28.2028 230093............................ 1.2101 0.8959 26.4967 25.5804 27.4458 26.5307 230095............................ 1.3066 0.8899 21.3916 22.8681 25.1829 23.1772 230096............................ 1.1221 1.0151 28.7681 30.6024 31.7385 30.4262 230097............................ 1.7992 0.9380 26.5773 28.2526 29.8946 28.2263 230099............................ 1.2069 1.0138 26.4882 29.0221 29.3700 28.3176 230100............................ 1.1878 0.8899 21.8895 24.1881 25.2112 23.7860 230101............................ 1.2004 0.8899 24.3772 25.4839 28.4355 26.1552 230103............................

***

* 21.6609

[[Page 24881]]

230104............................ 1.5972 1.0138 30.5570 32.4634 32.4102 31.7987 230105............................ 1.8553 0.9399 27.2705 32.4583 30.5507 30.1271 230106............................ 1.1795 0.9472 24.3980 25.3243 27.8566 25.9485 230108............................ 1.1243 0.8899 18.4064 20.2539 24.4337 20.8956 230110............................ 1.2976 0.8899 28.7704 27.0040 25.7173 27.1019 230117............................ 1.8708 1.0505 29.4775 32.7994 33.0575 31.7174 230118............................ 1.0456 0.8899 22.3636 23.6110 24.8873 23.5918 230119............................ 1.3915 1.0138 30.2441 30.7488 31.9681 31.0533 230120............................ 1.1881

* 24.1485

* 24.1485 230121............................ 1.2797 0.9933 24.5220 26.4940 26.8351 25.9742 230130............................ 1.7334 1.0272 26.6076 30.1608 31.2720 29.4071 230132............................ 1.4190 1.1078 30.5318 32.3939 35.5753 32.8039 230133............................ 1.3873 0.8899 24.3174 23.9442 25.0634 24.4534 230135............................ 1.4715 1.0138 25.8407 25.9583 23.6004 25.1117 230141............................ 1.6569 1.1078 28.6326 31.6152 33.8730 31.3710 230142............................ 1.2441 1.0138 26.9433 27.8377 29.7407 28.1855 230143............................

***

* 21.4083

* 21.4083 230144............................ 2.3494 1.0504

* 230146............................ 1.3935 1.0138 26.3432 26.8156 27.2610 26.8176 230151............................ 1.3152 1.0272 28.2243 27.4546 29.8352 28.4827 230153............................

***

* 22.8644

* 22.8644 230156............................ 1.6276 1.0504 31.1909 32.3755 33.9016 32.4963 230165............................ 1.6917 1.0138 28.9636 29.6376 31.4221 30.0161 230167............................ 1.6184 1.0053 27.4562 29.8071 31.0585 29.4605 230169............................

***

* 31.8442

* 31.8442 230172............................ 1.1867

* 25.7402

* 25.7402 230174............................ 1.2752 0.9472 27.6920 30.0563 29.7361 29.1540 230176............................ 1.2857 1.0138 27.3605 28.1498 25.8188 27.0655 230180............................ 1.1332 0.8899 24.7358 26.0707 24.9693 25.2513 230184............................

***

* 23.6706 34.6295

* 25.2502 230186............................

***

* 26.2282

* 26.2282 230189............................

***

* 23.0100

* 23.0100 230190............................ 0.8738 1.0505 29.9603 30.7875 33.8238 31.5782 230193............................ 1.2840 1.0040 23.3565 25.1626 26.4717 25.0021 230195............................ 1.4440 1.0092 28.2892 29.5656 30.9245 29.6342 230197............................ 1.5802 1.1078 30.0367 32.0063 33.6990 31.9260 230204............................ 1.3301 1.0092 29.1466 31.5615 32.2850 31.0158 230207............................ 1.3447 1.0272 24.5201 25.4268 25.2547 25.0743 230208............................ 1.1990 0.9380 21.9651 23.7523 24.3741 23.3710 230212............................ 0.9926 1.0504 29.7981 31.9818 32.8564 31.5064 230216............................ 1.5508 1.0040 27.5230 29.0147 29.2047 28.5834 230217............................ 1.3812 0.9933 28.6074 30.1136 31.9706 30.2655 230222............................ 1.3799 0.9399 26.9724 29.9341 30.6473 29.2057 230223............................ 1.2979 1.0272 29.2854 28.6745 29.8419 29.2657 230227............................ 1.4986 1.0092 29.5798 30.8218 33.6697 31.2203 230230............................ 1.5219 1.0053 27.9607 29.8763 31.1701 29.6591 230235............................ 1.0691

* 21.8777

* 21.8777 230236............................ 1.5046 0.9472 28.4754 31.3110 30.8531 30.2122 230239............................ 1.2710 0.8899 22.1040 21.0814 22.1569 21.7756 230241............................ 1.2149 1.0040 27.4890 27.6106 28.5505 27.9009 230244............................ 1.4355 1.0138 26.4326 29.6283 30.0355 28.6450 230254............................ 1.5080 1.0272 28.1216 29.2653 29.5865 28.9731 230257............................ 0.9510 1.0092 27.8198 29.6712 30.6373 29.3897 230259............................ 1.2666 1.0504 26.8677 27.4217 27.5982 27.2972 230264............................ 1.8606 1.0092 19.2398 22.7768 28.5389 23.0403 230269............................ 1.5016 1.0272 28.8187 31.3226 31.3773 30.6050 230270............................ 1.2640 1.0138 27.8488 28.5372 28.8505 28.4218 230273............................ 1.5123 1.0138 29.9307 31.9862 31.5372 31.1375 230275............................ 0.4718 0.9127 23.1095 23.8104 25.2117 24.0696 230277............................ 1.4037 1.0272 29.1973 29.8372 31.4001 30.1455 230279............................ 0.4947 1.0138 24.7673 27.2816 27.9709 26.6920

[[Page 24882]]

230283............................

***

* 26.2622 33.5531

* 27.8105 230289............................

***

* 29.7721

* 29.7721 230291............................

***

* 30.9656

* 30.9656 230292............................

***

* 31.8943

* 31.8943 230294............................

***

* 31.6195

* 31.6195 230295............................

***

* 27.1298

* 27.1298 230296............................

***

* 34.2091 34.2091 230297............................ 1.6725 1.0092

* 230299............................ 0.7569 1.0092

* 230300............................ 2.9372 1.0092

* 240001............................ 1.5321 1.0961 31.5753 33.1499 34.9488 33.2343 240002............................ 1.8802 1.0151 28.9860 31.6000 33.5414 31.3640 240004............................ 1.5917 1.0961 30.8072 32.7010 32.0885 31.8534 240006............................ 1.0930 1.0761 30.1949 31.0777 34.0824 31.7954 240010............................ 2.0488 1.0761 31.3733 33.4668 33.9391 32.9198 240013............................

***

* 28.3860

* 28.3860 240014............................ 1.0233 1.0961 29.8623 29.8905 31.5902 30.4899 240016............................ 1.2758

* 26.7814

* 26.7814 240017............................ 1.1862

* 24.4417 24.3596

* 24.4015 240018............................ 1.2795 1.0085 25.6236 28.1432 29.6619 27.8174 240019............................ 1.0510 1.0151 28.6723 33.7546 32.9757 31.6807 240020............................ 1.0696 1.0961 31.2443 31.3874 33.4700 32.0413 240021............................ 1.0320

* 27.1236

* 27.1236 240022............................ 1.0296 0.9212 25.2066 26.1920 27.4384 26.3075 240027............................ 0.9334

* 18.2482

* 18.2482 240029............................ 0.9036

* 25.3568

* 25.3568 240030............................ 1.3356 1.0390 24.7154 26.5508 27.1291 26.1210 240031............................

***

* 26.7778

* 26.7778 240036............................ 1.6917 1.0961 28.0812 32.7028 34.2927 31.6446 240038............................ 1.5420 1.0961 31.0779 31.9891 33.2977 32.1250 240040............................ 1.0727 1.0151 27.4895 27.5074 29.2269 28.0678 240043............................ 1.2145 0.9212 21.8684 23.3489 24.2153 23.1696 240044............................ 1.0574 0.9883 22.0973 25.0988 26.8667 24.6227 240047............................ 1.5016 1.0151 28.8289 28.6406 29.7813 29.0973 240050............................ 1.1126 1.0961 26.4854 27.5553 31.2060 28.4938 240052............................ 1.2197 0.9212 26.4256 28.7206 29.4594 28.2281 240053............................ 1.4802 1.0961 29.5315 31.4324 33.1815 31.4253 240056............................ 1.2486 1.0961 31.6623 33.1728 33.9981 32.9754 240057............................ 1.8365 1.0961 30.6258 30.7703 33.6438 31.6657 240059............................ 1.1404 1.0961 29.7916 31.0911 33.3840 31.4927 240061............................ 1.8183 1.0761 30.6383 33.1799 32.1083 31.9962 240063............................ 1.6444 1.0961 32.3487 33.7895 35.3585 33.8590 240064............................ 1.1841 1.0020 29.9662 34.3757 27.2367 30.4831 240066............................ 1.5085 1.0961 33.4532 35.3441 36.1920 35.0530 240069............................ 1.2060 1.0761 28.9496 29.3718 31.1575 29.8505 240071............................ 1.1294 1.0761 28.0586 28.6950 31.7403 29.4814 240075............................ 1.1560 1.0390 26.1956 27.5039 29.1165 27.5981 240076............................ 1.0348 1.0961 29.8561 30.6936 33.0908 31.3206 240078............................ 1.7539 1.0961 32.3235 32.5785 35.5096 33.5022 240080............................ 1.9135 1.0961 31.6828 32.5725 34.9990 33.0567 240083............................ 1.2282

* 26.6582

* 26.6582 240084............................ 1.1715 1.0151 26.8141 26.5975 26.6137 26.6743 240088............................ 1.2868 1.0390 28.0825 28.0603 30.7452 28.9706 240093............................ 1.4141 1.0961 25.5805 27.2928 29.1386 27.3669 240100............................ 1.3062 0.9212 27.6299 30.8391 31.5746 30.0094 240101............................ 1.1577 0.9212 25.5355 25.6963 26.8837 26.0839 240103............................

***

* 22.7077

* 22.7077 240104............................ 1.1355 1.0961 31.4306 31.6511 34.8590 32.7610 240106............................ 1.6068 1.0961 29.3455 30.5927 33.3656 31.1028 240109............................ 0.8676

* 16.5051

* 16.5051 240115............................ 1.5324 1.0961 31.3869 32.0107 33.7716 32.4047

[[Page 24883]]

240117............................ 1.1786 0.9805 23.6230 24.5750 27.6916 25.3192 240123............................

***

* 21.7500

* 21.7500 240128............................

***

* 21.5791 23.3334

* 22.4504 240132............................ 1.2801 1.0961 31.7139 32.1233 34.6782 32.8020 240141............................ 1.1202 1.0961 26.4016 31.4468 32.3861 30.2635 240143............................ 0.8966

* 21.7416

* 21.7416 240152............................

***

* 29.6196

* 29.6196 240162............................

***

* 22.2722

* 22.2722 240166............................ 1.1548 0.9212 25.7509 27.6987 29.6615 27.8068 240187............................ 1.3295 1.0961 27.8811 27.8844 29.6502 28.5206 240196............................ 0.8200 1.0961 30.7720 31.5965 34.1199 32.1844 240206............................ 0.8831 1.4406

* 240207............................ 1.1958 1.0961 31.7665 32.5589 34.9881 33.1636 240210............................ 1.2897 1.0961 32.1564 32.7123 34.4858 33.1223 240211............................ 0.9769 0.9598 18.8503 22.5430 29.3644 22.2558 240213............................ 1.3950 1.0961 32.7532 33.8680 35.9799 34.2403 250001............................ 1.9054 0.8273 22.7827 23.5222 24.5227 23.6272 250002............................ 0.9546 0.7971 23.3844 23.4063 25.4201 24.0840 250004............................ 1.9123 0.8951 24.1065 24.7907 25.8710 24.9580 250006............................ 1.1113 0.8951 24.0191 24.4282 25.9197 24.8139 250007............................ 1.2347 0.8618 25.8710 24.8929 27.7647 26.1856 250009............................ 1.2422 0.8432 22.2323 23.0352 23.4128 22.8968 250010............................ 0.9918 0.7915 19.4402 21.4322 21.8643 20.9156 250012............................ 0.9475 0.9291 20.2922 21.5540 23.3688 21.7206 250015............................ 1.1234 0.7915 20.7555 22.0067 22.2776 21.6577 250017............................ 1.0264 0.7915 21.3950 22.7660 33.6797 25.4557 250018............................ 0.8932 0.7915 16.6292 17.1276 17.9011 17.2147 250019............................ 1.5216 0.8618 23.9741 25.7376 26.2315 25.3074 250020............................ 0.9941 0.7915 21.4019 22.1851 23.7217 22.4960 250021............................

***

* 20.3564

* 20.3564 250023............................ 0.8676 0.8223 16.2418 18.0108 18.4674 17.5916 250025............................ 1.0998 0.7915 20.5258 22.5621 23.1721 22.1086 250027............................ 0.9597 0.7915 17.3481 24.4937 26.9874 22.7342 250031............................ 1.3175 0.8273 21.4326 24.8139 55.6623 27.5006 250034............................ 1.5394 0.8951 24.3189 26.1887 27.0455 25.8383 250035............................ 0.8591 0.7915 17.2046 20.1622 19.6892 19.0949 250036............................ 1.0384 0.8544 19.1975 20.3625 19.7915 19.8090 250037............................ 0.9020

* 17.4012

* 17.4012 250038............................ 0.9401 0.8273 18.9050 22.2571 26.9582 22.1495 250039............................ 0.9692

* 17.3155

* 17.3155 250040............................ 1.4830 0.8223 23.2285 24.5962 27.3356 25.0598 250042............................ 1.2092 0.8951 23.4135 25.6807 26.1154 25.0557 250043............................ 1.0145 0.7915 19.8097 18.8979 20.8820 19.8715 250044............................ 1.0512 0.7971 23.3862 24.0508 24.9245 24.1146 250045............................ 0.8706

* 26.3831

* 26.3831 250048............................ 1.6243 0.8273 22.9765 25.2092 24.7651 24.3109 250049............................ 0.8732 0.7915 17.7005 19.1044 20.4694 19.2002 250050............................ 1.1890 0.7915 19.1467 20.8084 21.1669 20.4034 250051............................ 0.8083 0.7915 10.6095 14.3741 13.9457 12.9300 250057............................ 1.1224 0.7915 20.1900 22.7601 24.3633 22.3987 250058............................ 1.2423 0.7915 18.1704 19.2502 18.9952 18.8123 250059............................ 0.9230 0.7915 19.2976 23.8997 26.7379 23.0872 250060............................ 0.7986 0.7915 16.8247 28.1431 25.4705 22.9625 250061............................ 0.9038 0.7915 12.8174 17.8267 18.7359 16.2197 250067............................ 1.0777 0.7915 21.6911 23.1193 25.2181 23.3708 250069............................ 1.4806 0.8166 22.8162 22.6353 22.4221 22.6169 250072............................ 1.6976 0.8273 24.6587 25.8399 25.5321 25.3433 250077............................ 0.9345 0.7915 14.7632 18.3735 19.0379 17.4294 250078............................ 1.6953 0.8223 20.9354 22.1243 22.8399 21.9357 250079............................ 0.8536 0.8273 38.0032 45.5166 43.0813 42.6359 250081............................ 1.3342 0.8166 24.7031 23.9995 25.6789 24.7909

[[Page 24884]]

250082............................ 1.4651 0.7959 19.6966 23.0287 23.5384 22.0708 250084............................ 1.2101 0.7915 18.5775 19.6492 19.1096 19.1057 250085............................ 1.0005 0.7915 19.7008 22.5513 24.2875 22.2560 250093............................ 1.1880 0.7915 21.3237 23.0984 23.9098 22.7648 250094............................ 1.7339 0.8223 22.7312 24.1422 24.7709 23.8832 250095............................ 1.0360 0.7915 21.3511 21.7488 23.6079 22.2424 250096............................ 1.1761 0.8273 22.6298 24.9187 26.3717 24.6250 250097............................ 1.6174 0.8014 20.1687 21.8139 22.0204 21.3427 250099............................ 1.2805 0.8273 19.5797 21.1269 21.9028 20.8103 250100............................ 1.4738 0.8166 24.2209 25.6846 27.0283 25.6565 250101............................

***

* 19.3543

* 19.3543 250102............................ 1.5948 0.8273 24.2868 24.6652 25.4029 24.7878 250104............................ 1.4895 0.8166 22.6591 23.4303 24.4287 23.5414 250105............................ 0.9250

* 18.1195

* 18.1195 250107............................ 0.5882

* 17.8999

* 17.8999 250112............................ 0.9900 0.7915 21.2824 24.3069 26.3311 23.9682 250117............................ 1.1064 0.8223 23.3673 22.2450 23.7325 23.1044 250120............................

***

* 23.4277 24.6370 26.6502 24.9393 250122............................ 1.1114 0.7915 24.5854 27.2795 27.4403 26.3821 250123............................ 1.3317 0.8618 24.5115 26.6221 27.9144 26.3804 250124............................ 0.8188 0.8273 17.2181 20.4394 20.5596 19.3903 250125............................ 1.2236 0.8618 27.7077 27.5158 26.8377 27.3634 250126............................ 0.9502 0.7915 21.7112 24.4126 25.6980 23.8290 250127............................ 0.8851 1.4406

* 250128............................ 0.9292 0.8308 17.6269 17.7624 21.7827 19.2616 250134............................ 0.8844 0.8273 25.8369 22.2167 21.0199 22.9407 250136............................ 1.0311 0.8273 23.0637 22.9468 25.2250 23.7174 250138............................ 1.3295 0.8273 23.8861 24.3018 25.2632 24.4952 250141............................ 1.5450 0.9291 27.6158 28.5922 30.5462 28.9990 250146............................ 0.7934

* 18.6486

* 18.6486 250149............................ 0.8346 0.7915 15.0641 16.8796 17.2245 16.4086 250151............................ 0.4710 0.7915 17.2205 18.8846 22.8221 18.4859 250152............................ 0.8555 0.8273 25.7837 26.9334 26.4561 26.3576 250153............................

***

* 29.0461

* 29.0461 250155............................

***

* 22.5728

* 22.5728 250156............................

***

* 16.8646 16.8646 250157............................

***

* 29.6366 29.6366 250160............................ 1.4401 0.8308

* 250161............................ 2.1565 0.8273

* 260001............................ 1.6521 0.9318 25.9250 27.9230 29.5231 27.7476 260002............................

***

* 26.4879

* 26.4879 260004............................ 0.9694 0.8145 16.9422 20.3217 21.3539 19.5722 260005............................ 1.5541 0.8885 26.5773 27.7855 27.9465 27.4311 260006............................ 1.4864 0.8145 26.7587 30.3440 27.3734 28.2406 260008............................

***

* 18.9522

* 18.9522 260009............................ 1.1616 0.9321 22.1816 24.2360 25.7517 24.0687 260011............................ 1.5006 0.8706 22.7062 25.6387 27.5729 25.2802 260012............................

***

* 20.3061

* 20.3061 260013............................

***

* 20.5007

* 20.5007 260015............................ 1.0081 0.8507 22.5409 24.6139 25.0595 24.0549 260017............................ 1.3305 0.8706 22.7022 23.5713 24.9740 23.7836 260018............................ 1.0396

* 17.0434

* 17.0434 260020............................ 1.7371 0.8885 26.0407 27.4730 29.3071 27.6646 260021............................ 1.3993 0.8885 27.6329 29.3646 31.7013 29.4504 260022............................ 1.4087 0.8480 22.8085 23.3393 24.8696 23.6522 260023............................ 1.3563 0.8885 21.2077 24.3192 25.4291 23.5894 260024............................ 1.1337 0.8145 18.4829 19.4952 19.2179 19.0576 260025............................ 1.3611 0.8885 22.4645 22.2451 24.0348 22.9414 260027............................ 1.6424 0.9321 25.3348 26.3590 29.3205 26.9768 260032............................ 1.8499 0.8885 23.9478 25.6763 25.8890 25.1792 260034............................ 0.9779 0.9321 24.1143 25.0573 27.1644 25.5181

[[Page 24885]]

260035............................

***

* 17.8741

* 17.8741 260036............................

***

* 22.1913

* 22.1913 260040............................ 1.6639 0.9196 23.3566 24.3938 28.5815 25.2261 260047............................ 1.4482 0.8706 24.4185 25.4978 26.6318 25.5311 260048............................ 1.1759 0.9321 24.3906 27.6117 28.2868 26.7437 260050............................ 1.1594 0.8831 23.6849 25.0506 26.2320 25.0309 260052............................ 1.3110 0.8885 24.5165 26.0052 27.6348 26.0327 260053............................ 1.0761

* 21.6607

* 21.6607 260057............................ 1.0699 0.9321 19.3335 20.9639 21.5895 20.6144 260059............................ 1.1568 0.8272 19.7243 22.6922 22.3875 21.6445 260061............................ 1.1351 0.8145 21.5264 22.4766 22.8581 22.2790 260062............................ 1.2507 0.9321 26.4539 28.1661 28.4951 27.7044 260064............................ 1.3834 0.8545 19.0543 22.2395 23.5352 21.5798 260065............................ 1.7778 0.9196 23.0015 27.1014 29.3548 26.5318 260067............................ 0.9311

* 17.6256

* 17.6256 260068............................ 1.7969 0.8545 24.9504 26.0295 27.3717 26.1290 260070............................ 0.9563 0.8145 18.4779 24.6331 21.9646 21.9639 260073............................

***

* 21.6214

* 21.6214 260074............................ 1.2375 0.8545 24.8655 25.6218 28.0454 26.1516 260077............................ 1.6221 0.8885 25.5782 26.7466 27.7359 26.6839 260078............................ 1.2835 0.8145 19.0802 20.1983 21.1532 20.1475 260080............................ 0.9195 0.8145 14.7774 17.9107 18.6028 17.0061 260081............................ 1.5691 0.8885 26.3969 28.1182 29.1725 27.9063 260085............................ 1.5670 0.9321 25.6302 26.6718 28.0298 26.7543 260086............................ 0.9570

* 19.1702

* 19.1702 260091............................ 1.5269 0.8885 27.2407 28.0537 28.5213 27.9452 260094............................ 1.7017 0.8943 23.2544 24.1473 23.8642 23.7598 260095............................ 1.3903 0.9321 25.5668 24.2698 27.3917 25.6438 260096............................ 1.4990 0.9321 27.5592 29.7312 30.7246 29.3745 260097............................ 1.2006 0.8440 21.3957 25.0624 25.5604 24.1093 260102............................ 0.9518 0.9321 24.2368 27.2145 26.7618 26.1063 260104............................ 1.5655 0.8885 26.2867 28.6247 28.0218 27.6808 260105............................ 1.8539 0.8885 28.8849 29.8848 29.4761 29.4215 260107............................ 1.2949 0.9321 26.7781 25.8177 27.8030 26.7722 260108............................ 1.8342 0.8885 24.9880 26.6374 27.0748 26.2654 260110............................ 1.6392 0.8885 23.7978 24.7656

* 24.2985 260113............................ 1.1068 0.8355 20.9644 21.2072 21.8850 21.3616 260115............................ 1.1392 0.8885 21.9858 23.1396 24.6379 23.3009 260116............................ 1.0986 0.8145 18.5076 21.3503 20.7451 20.1801 260119............................ 1.3299 0.8507 24.9937 27.9769 31.5417 28.0654 260122............................

***

* 20.8015

* 20.8015 260127............................ 0.9486

* 21.8533

* 21.8533 260137............................ 1.7247 0.9318 22.7431 24.3273 28.2386 25.0868 260138............................ 1.9895 0.9321 28.5610 30.4410 30.7179 29.9246 260141............................ 1.8510 0.8545 22.4886 24.1555 25.5660 24.0282 260142............................ 1.0871 0.8145 20.3993 21.5923 21.7584 21.2691 260147............................ 0.9229 0.8145 18.5153 21.4235 22.1878 20.7802 260159............................

***

* 23.7427 22.6276 23.9520 23.4461 260160............................ 1.0728 0.8145 21.0544 23.8257 25.5072 23.4620 260162............................ 1.3823 0.8885 25.1423 27.0236 28.4645 26.9318 260163............................ 1.1437 0.8145 20.1949 21.6408 21.5551 21.0992 260164............................ 1.3771

* 19.7068

* 19.7068 260166............................ 1.2260 0.9321 27.0237 29.1225 28.4735 28.1987 260175............................ 1.0782 0.9321 22.6171 25.1817 24.6035 24.1897 260176............................ 1.7016 0.8885 27.4244 29.3034 31.1025 29.3195 260177............................ 1.2061 0.9321 26.1178 27.0185 28.7735 27.3063 260178............................ 1.8406 0.8545 22.2251 25.4782 27.1192 25.2033 260179............................ 1.5483 0.8885 26.1419 26.6069 28.1578 26.9703 260180............................ 1.5417 0.8885 26.7461 28.2931 29.3792 28.1552 260183............................ 1.6671 0.8885 26.0418 27.5577 29.2666 27.6346 260186............................ 1.5449 0.8706 25.3148 26.9797 28.8584 27.0989

[[Page 24886]]

260190............................ 1.1940 0.9321 26.4505 27.9137 30.5095 28.3280 260191............................ 1.3655 0.8885 23.3856 24.6973 26.3196 24.8420 260193............................ 1.1900 0.9321 26.2979 26.8922 28.1060 27.0944 260195............................ 1.2147 0.8145 22.3959 22.6870 24.0387 23.0815 260198............................ 0.9613 0.8885 27.5996 28.0021 27.2554 27.6065 260200............................ 1.2655 0.8885 24.8624 28.2453 27.4813 26.8911 260207............................ 1.1543 0.9196 19.7294 22.6109 22.9594 22.0277 260209............................ 1.1051 0.8706 23.2430 25.0098 25.0733 24.4643 260210............................ 1.2690 0.8885 25.3781 26.8745 30.6046 27.6608 260211............................ 1.5777 0.9321 33.9109 40.9821 35.9066 37.0319 260213............................

***

* 34.8944 34.8944 260214............................ 1.2355 0.9321

* 260215............................ 0.8925

* 260216............................ 1.1874 0.9321

* 260217............................ 1.9096 0.8145

* 270002............................ 1.1595 0.8337 22.7322 24.0534 25.2902 24.0315 270003............................ 1.3079 0.8765 26.4843 28.8700 29.2082 28.2134 270004............................ 1.6792 0.8877 23.5454 26.1319 26.7037 25.4969 270011............................ 1.0335 0.8337 22.1394 22.7061 24.4678 23.0847 270012............................ 1.5539 0.8765 25.2873 25.2914 26.5782 25.7174 270014............................ 1.9641 0.8737 26.2025 25.8231 27.4790 26.5061 270017............................ 1.3145 0.8737 27.5483 26.5404 27.4092 27.1700 270021............................

***

* 21.7056

* 21.7056 270023............................ 1.5491 0.8737 26.7576 25.5682 26.2592 26.1753 270032............................ 1.0285 0.8337 19.6212 20.3469 20.4332 20.1360 270036............................

***

* 20.4241

* 20.4241 270049............................ 1.7523 0.8877 26.3996 27.1634 28.6651 27.4207 270051............................ 1.5590 0.8337 26.6619 26.5621 24.8924 25.9335 270057............................ 1.2521 0.8337 24.2980 25.5811 27.1840 25.7302 270060............................

***

* 17.7564

* 17.7564 270074............................ 0.9141 1.4406

* 270081............................ 0.9750 0.8573 17.4862 19.5612 20.0422 18.9880 270086............................ 1.0637 0.8765

* 21.0808 20.7990 20.9439 270087............................ 1.2165 0.8337

* 25.9772 24.8182 25.3750 280003............................ 1.7455 0.9836 29.3921 30.6124 29.8995 29.9681 280009............................ 1.8639 0.9603 26.7678 27.0705 29.3561 27.7370 280013............................ 1.7316 0.9419 26.1908 27.0250 27.9514 27.0724 280020............................ 1.7365 0.9836 26.5068 27.3284 32.3886 28.7653 280021............................ 1.1556

* 22.0489

* 22.0489 280023............................ 1.3658 0.9603 22.3230 26.7980 29.5116 26.0300 280030............................ 1.8923 0.9419 30.7481 29.5102 30.6995 30.3315 280032............................ 1.2987 0.9603 23.6462 24.3995 24.7535 24.2695 280040............................ 1.6382 0.9419 26.9827 28.7207 29.5254 28.4311 280054............................ 1.1439

* 23.5665

* 23.5665 280057............................ 0.8567

* 20.4830

* 20.4830 280060............................ 1.6740 0.9419 26.2139 27.7496 30.3288 28.0764 280061............................ 1.3931 0.9049 24.9482 26.0208 26.4808 25.8452 280065............................ 1.2398 0.9747 26.0135 28.0581 27.9710 27.3272 280077............................ 1.3381 0.8905 25.5624 27.0860 28.2199 26.9868 280081............................ 1.7001 0.9419 26.0541 28.7464 31.1636 28.6498 280105............................ 1.2700 0.9419 26.7555 27.8599 24.0173 26.1446 280108............................ 1.0629

* 23.2503

* 23.2503 280111............................ 1.1871 0.8848 23.4770 24.5617 27.4621 25.3069 280117............................ 1.1227

* 24.1521

* 24.1521 280119............................ 0.8644 1.4406

* 280123............................ 0.9968 0.8966

* 15.4047 22.2049 17.7468 280125............................ 1.5933 0.8848 21.7657 22.1345 23.2889 22.4198 280127............................ 1.7915 0.9836

* 29.3684 25.6815 27.2620 280128............................ 2.9058 0.9836

* 28.5422 28.8725 28.7209 280129............................ 1.9022 0.9419

* 27.8784 27.8784 280130............................ 1.3728 0.9419

* 30.5784 30.5784

[[Page 24887]]

290001............................ 1.8544 1.1062 31.1981 36.3129 35.5076 34.2980 290002............................ 0.9059 0.9688 18.3469 17.3876 24.0115 19.4175 290003............................ 1.8294 1.1431 28.1625 30.3373 32.8160 30.4044 290005............................ 1.4257 1.1431 27.6697 28.3366 31.4494 28.9962 290006............................ 1.1856 1.0851 27.9501 31.7301 31.9783 30.5921 290007............................ 1.6373 1.1431 37.5559 38.1938 39.6409 38.4737 290008............................ 1.2052 0.9688 27.9714 27.3019 30.8413 28.7097 290009............................ 1.7177 1.1062 29.8019 36.2724 32.3330 32.7004 290010............................

***

* 23.9655

* 23.9655 290012............................ 1.3586 1.1431 31.0843 32.3966 35.7987 33.1284 290016............................

***

* 26.1925

* 26.1925 290019............................ 1.4100 1.0851 28.6158 29.3650 30.5954 29.5666 290020............................ 0.9879 0.9688 21.6993 23.2103 27.7976 23.8850 290021............................ 1.7397 1.1431 33.2116 32.7894 36.5004 34.2290 290022............................ 1.6627 1.1431 29.4422 29.9717 33.3048 30.8956 290027............................ 0.8977 0.9688 15.1448 23.9959 23.9599 21.2093 290032............................ 1.4275 1.1062 31.7105 31.6711 34.3860 32.5896 290039............................ 1.5604 1.1431 31.2941 32.1423 34.9629 32.8645 290041............................ 1.3801 1.1431 33.9877 34.2436 37.4249 35.3803 290042............................

***

* 22.4809 22.4809 290044............................

***

* 37.1662

* 37.1662 290045............................ 1.5925 1.1431 30.9612 33.1512 34.4159 32.9841 290046............................ 1.3247 1.1431

* 38.6235 38.6235 290047............................ 1.4996 1.1431

* 33.4701 33.4701 290049............................ 1.3670 0.9688

* 26.1159 26.1159 290051............................ 1.6067 0.9688

* 290052............................ 0.8797 0.9688

* 300001............................ 1.5438 1.1266 27.5032 29.2260 29.8127 28.8790 300003............................ 2.1029 1.1266 33.3560 34.7900 37.0864 35.1213 300005............................ 1.4046 1.1266 25.6699 27.8000 27.8412 27.1335 300006............................

***

* 23.3200

* 23.3200 300010............................

***

* 27.5028

* 27.5028 300011............................ 1.2842 1.1266 28.4044 30.9403 31.8926 30.4452 300012............................ 1.3771 1.1266 30.5198 30.4972 31.2638 30.7723 300014............................ 1.1567 1.1266 27.5151 29.7667 29.1829 28.8585 300017............................ 1.3103 1.1266 29.6957 29.9560 31.6688 30.4410 300018............................ 1.4114 1.1266 29.7209 29.4270 31.7886 30.3782 300019............................ 1.2727 1.1266 25.9656 27.5672 28.2267 27.2944 300020............................ 1.1629 1.1266 28.6723 30.8491 31.0585 30.2190 300023............................ 1.3399 1.1266 28.6309 31.0040 31.2712 30.3856 300029............................ 1.7610 1.1266 29.0806 29.8117 31.4416 30.1530 300034............................ 1.9071 1.1266 29.7484 30.7676 31.6879 30.7462 310001............................ 1.7811 1.3215 35.3612 41.7460 39.3376 38.8070 310002............................ 1.8123 1.2993 37.3461 37.9183 37.9222 37.7187 310003............................ 1.1430 1.3215 32.8935 36.2346 39.0744 36.1389 310005............................ 1.3201 1.1681 29.0084 32.1319 33.6294 31.6189 310006............................ 1.2212 1.3215 27.4545 28.4771 28.7318 28.2233 310008............................ 1.3025 1.3215 31.2579 32.6788 33.3151 32.4229 310009............................ 1.3174 1.2993 32.7384 33.6940 33.6147 33.3544 310010............................ 1.2786 1.0879 28.5852 33.9552 33.6979 32.1224 310011............................ 1.2517 1.0749 30.8612 31.2907 33.3167 31.8219 310012............................ 1.6584 1.3215 34.6882 38.3590 39.8553 37.6612 310013............................ 1.3584 1.2993 30.6248 31.0447 35.6324 32.2990 310014............................ 1.9437 1.0778 29.7204 30.0793 32.9002 30.9524 310015............................ 1.9917 1.2993 36.4776 36.8818 39.2914 37.5855 310016............................ 1.3455 1.3215 33.9862 35.6155 38.2693 36.0382 310017............................ 1.3323 1.2993 30.9233 32.2434 35.7519 32.9534 310018............................ 1.1951 1.2993 30.3381 30.3234 32.9700 31.1742 310019............................ 1.5537 1.3215 29.6592 30.3518 30.6364 30.2332 310020............................ 1.5411 1.3215 30.6722 33.5516 38.4379 35.7904 310021............................ 1.6686 1.1578 31.3410 32.1929 31.6553 31.7275

[[Page 24888]]

310022............................ 1.2932 1.0522 28.2024 30.4043 31.1924 29.9525 310024............................ 1.2738 1.1681 30.9171 33.3415 33.8601 32.7346 310025............................ 1.3587 1.3215 31.1274 34.3687 32.2621 32.6290 310026............................ 1.1830 1.3215 27.5171 29.1588 30.1373 28.9603 310027............................ 1.3922 1.1681 28.8314 29.7793 31.5949 30.0511 310028............................ 1.1686 1.1681 31.3849 32.2977 33.9891 32.5798 310029............................ 1.9312 1.0522 30.7707 32.9246 33.6690 32.4532 310031............................ 3.0093 1.1131 33.9685 37.0668 38.5892 36.5339 310032............................ 1.3412 1.0752 27.5232 30.7865 33.0210 30.4618 310034............................ 1.3882 1.1131 29.9162 31.7012 32.7508 31.4426 310037............................ 1.3836 1.3215 35.0329 38.5415 38.2849 37.2929 310038............................ 1.9989 1.2993 33.4822 35.9190 36.3324 35.3010 310039............................ 1.2659 1.2993 28.8292 31.4278 33.2087 31.1027 310040............................ 1.3296 1.3215 34.1113 33.8535 37.7941 35.2736 310041............................ 1.3039 1.1131 32.8085 32.8390 33.9785 33.1810 310042............................

***

* 30.7357 34.4986

* 32.5359 310044............................ 1.3429 1.0879 31.3205 31.9678 33.7598 32.3234 310045............................ 1.6626 1.3215 34.1060 36.7862 38.4412 36.4048 310047............................ 1.3101 1.2095 32.7880 34.1520 37.6016 34.9123 310048............................ 1.3620 1.1578 30.2025 32.9681 33.9471 32.4207 310049............................

***

* 27.8565

* 27.8565 310050............................ 1.2631 1.2993 27.3033 29.1732 32.3677 29.5223 310051............................ 1.4207 1.1681 33.7168 35.0121 38.1175 35.6230 310052............................ 1.3148 1.1131 30.8036 32.5778 33.5833 32.3042 310054............................ 1.3494 1.2993 34.1860 34.4431 36.9103 35.1809 310057............................ 1.3560 1.0652 29.5221 31.1268 31.8882 30.8455 310058............................ 1.1001 1.3215 28.0815 27.1555 30.4060 28.5493 310060............................ 1.2254 1.0024 25.1575 27.3415 27.8235 26.8641 310061............................ 1.2038 1.0652 28.2129 31.6648 39.0527 32.6386 310063............................ 1.3573 1.1681 31.4884 31.9247 33.8500 32.3995 310064............................ 1.5574 1.2095 33.4440 35.7607 38.6296 36.0384 310069............................ 1.2293 1.0752 28.1681 31.7642 34.4614 31.6133 310070............................ 1.4396 1.2993 33.2310 34.3225 36.3246 34.6566 310073............................ 1.9339 1.1131 32.0328 32.6733 34.2852 33.0130 310074............................ 1.4038 1.3215 29.4834 40.3494 39.6126 36.4273 310075............................ 1.3460 1.1131 31.6869 31.5226 32.5325 31.9056 310076............................ 1.6950 1.2993 36.4280 38.0643 37.5145 37.3322 310077............................

***

* 32.6644 34.6085

* 33.6290 310078............................

***

* 29.8014 30.5761

* 30.1919 310081............................ 1.2439 1.0778 26.6136 30.1561 31.0670 29.3003 310083............................ 1.2968 1.2993 28.2392 30.3580 31.9125 30.1899 310084............................ 1.2502 1.1131 32.9001 33.5941 32.6073 33.0241 310086............................ 1.2173 1.0522 29.3058 29.5566 29.8937 29.5898 310088............................ 1.1945 1.2095 26.4966 29.9929 30.3513 28.9184 310090............................ 1.2500 1.1681 30.8941 32.8191 33.4603 32.3294 310091............................ 1.1866 1.0752 27.7204 29.3969 31.9736 29.6731 310092............................ 1.4214 1.0879 29.4998 29.7958 32.7029 30.6404 310093............................ 1.2379 1.2993 28.0401 29.1288 30.2858 29.1452 310096............................ 2.0679 1.2993 34.4275 34.1524 35.0725 34.5578 310105............................ 1.2685 1.3215 31.9769 30.1069 32.5642 31.5185 310108............................ 1.3924 1.2993 30.1002 33.0172 34.2946 32.4532 310110............................ 1.3064 1.0879 31.2164 33.2246 33.4787 32.6988 310111............................ 1.2383 1.1131 30.7475 31.8393 34.8278 32.5301 310112............................ 1.3378 1.1131 30.4192 31.2372 32.2812 31.3132 310113............................ 1.2461 1.1131 29.6079 31.0436 33.6769 31.5139 310115............................ 1.3278 1.0024 29.6020 29.5320 32.8144 30.7156 310116............................ 1.2564 1.3215 25.6976 29.2748 29.8219 28.1707 310118............................ 1.2957 1.3215 28.8797 31.1803 31.2285 30.4796 310119............................ 1.9246 1.2993 37.7876 43.1238 41.5679 40.9083 310120............................ 1.1067 1.1681 31.4111 29.2535 33.3847 31.2917 310122............................

***

* 41.9008 41.9008

[[Page 24889]]

310123............................

***

* 37.1088 37.1088 310124............................

***

* 41.8807 41.8807 310125............................

***

* 36.2250 36.2250 310126............................ 1.5770 1.1681

* 310127............................ 2.1663 1.0652

* 320001............................ 1.6846 0.9740 26.9434 29.6182 30.0055 28.9118 320002............................ 1.4659 1.0689 30.5158 32.0477 33.1322 31.9531 320003............................ 1.1337 1.0376 28.1402 27.6222 31.4451 29.2080 320004............................ 1.3346 0.8965 24.9481 24.7803 26.2118 25.3020 320005............................ 1.3975 0.9740 23.8264 24.7543 28.7944 25.7110 320006............................ 1.3191 0.9740 24.2812 26.9080 28.0944 26.5127 320009............................ 1.5658 0.9740 22.8293 32.0116 27.1448 26.7952 320011............................ 1.1525 0.9302 24.2279 25.6693 27.9505 25.9804 320013............................ 1.1100 1.0376 28.9276 22.8283 30.3766 26.8594 320014............................ 1.0803 0.8965 24.5310 27.2806 28.7043 26.9250 320016............................ 1.1846 0.8965 23.5040 25.0835 27.1469 25.3042 320017............................ 1.1945 0.9740 25.0286 31.6357 33.3482 30.1538 320018............................ 1.4713 0.8990 23.2360 26.5109 25.9235 25.0329 320019............................ 1.5781 0.9740 31.5192 27.8067 35.0213 30.9859 320021............................ 1.6048 0.9740 27.2357 26.9918 28.8474 27.7575 320022............................ 1.1613 0.8965 23.7160 23.9595 25.3696 24.3630 320030............................ 1.0965 0.8965 22.1971 21.0378 24.4482 22.6073 320033............................ 1.1954 1.0376 27.6393 31.7114 30.1473 29.8085 320037............................ 1.2522 0.9740 23.3999 24.9657 25.2866 24.5732 320038............................ 1.2773 0.8965 20.1533 21.7022 32.7170 25.2881 320046............................

***

* 24.3534

* 24.3534 320057............................ 0.8707 1.4406

* 320058............................ 0.7716 1.4406

* 320059............................ 0.8741 1.4406

* 320060............................ 0.9480 1.4406

* 320061............................ 0.8805 1.4406

* 320062............................ 0.8907 1.4406

* 320063............................ 1.3149 0.9527 24.4696 25.0031 26.0095 25.1843 320065............................ 1.3098 0.9527 26.6603 27.3163 25.7921 26.5970 320067............................ 0.8747 0.8965 23.7745 24.9865 24.6963 24.5130 320069............................ 1.1001 0.8965 20.9167 22.4128 23.9847 22.4801 320070............................ 0.9497 1.4406

* 320074............................ 1.1777 0.9740 22.2175 31.1333 28.4393 27.5521 320079............................ 1.0738 0.9740 25.2105 26.1188 27.6850 26.3851 320083............................ 2.5853 0.9740 28.2114 26.6921 31.4628 28.8401 320084............................ 0.9586 0.8965 17.2511 17.5788 22.7674 19.1162 320085............................ 1.7001 0.8990 24.8752 27.9944 27.4093 26.8652 330001............................

***

* 33.4718

* 33.4718 330002............................ 1.4716 1.3215 31.1924 30.9600 32.1948 31.4363 330003............................ 1.3901 0.8672 22.9945 24.4326 25.2199 24.2253 330004............................ 1.2791 1.0644 26.0445 28.0594 29.9032 27.9539 330005............................ 1.5858 0.9586 29.0124 30.3200 31.5013 30.2919 330006............................ 1.2547 1.3215 31.5370 33.6284 34.1959 33.1177 330008............................ 1.1969 0.9586 21.8198 23.4429 25.1985 23.4724 330009............................ 1.2178 1.3215 35.4986 36.2820 34.8184 35.5246 330010............................ 0.9609 0.8482 19.6920 20.7476 19.2838 19.8627 330011............................ 1.3855 0.9072 21.8008 25.1308 27.4732 24.7762 330013............................ 1.8823 0.8672 24.5162 26.4578 26.8359 25.9711 330014............................ 1.3016 1.3215 38.8123 42.1759 45.7594 42.1079 330016............................

***

* 28.4391 22.0493 23.0754 24.0041 330019............................ 1.2360 1.3215 34.8266 38.5368 39.7366 37.6971 330023............................ 1.5534 1.2380 31.6208 35.9428 35.4371 34.4826 330024............................ 1.8516 1.3215 37.8398 42.7691 43.2449 41.1310 330025............................ 1.0757 0.9586 20.2776 21.2565 23.2412 21.5971 330027............................ 1.3299 1.2993 39.0717 42.8000 45.1871 42.3247 330028............................ 1.4253 1.3215 34.2709 36.6498 36.2872 35.6905

[[Page 24890]]

330029............................ 0.4640 0.9586 19.1589 23.2039 24.0652 21.4784 330030............................ 1.2459 0.8899 22.9937 24.6175 24.7514 24.0792 330033............................ 1.1944 0.8645 22.5680 24.5510 24.8008 23.9488 330036............................ 1.1736 1.3215 28.9409 29.1884 30.3728 29.5020 330037............................ 1.1939 0.8899 20.6904 22.3689 21.9242 21.6478 330041............................ 1.3232 1.3215 36.0286 37.4883 36.9921 36.8224 330043............................ 1.3836 1.2791 34.7480 39.1643 37.6666 37.1976 330044............................ 1.3066 0.8440 24.1907 26.5669 28.2003 26.3311 330045............................ 1.3331 1.2791 36.1893 38.1269 40.0305 38.1670 330046............................ 1.3803 1.3215 44.8494 50.3152 47.4949 47.5038 330047............................ 1.1860 0.8482 24.0678 24.3932 24.9779 24.4959 330049............................ 1.5206 1.2380 29.2904 29.8350 34.8972 31.4643 330053............................ 1.0498 0.8899 18.5289 20.6272 21.8755 20.3411 330055............................ 1.5727 1.3215 38.4839 41.5934 42.1979 40.8295 330056............................ 1.4393 1.3215 37.8444 36.0136 38.8876 37.5779 330057............................ 1.7325 0.8672 24.4680 26.4989 27.7098 26.2555 330058............................ 1.2589 0.8899 21.3727 22.2524 21.7018 21.7824 330059............................ 1.5266 1.3215 39.7387 41.7343 44.9131 42.1510 330061............................ 1.1887 1.3215 33.2848 36.0587 37.8810 35.7856 330062............................ 2.5188

* 21.0464

* 21.0464 330064............................ 1.1807 1.3215 36.4276 38.0437 38.2307 37.5268 330065............................ 1.0348 0.9586 23.9128 25.3043 24.3986 24.5180 330066............................ 1.2793 0.8672 24.7941 29.1780 25.8149 26.6311 330067............................ 1.4313 1.2380 26.4243 27.8900 29.2544 27.8289 330072............................ 1.3663 1.3215 36.4336 37.8505 39.6955 37.9159 330073............................ 1.0847 0.8899 20.1490 22.5592 23.0765 21.9326 330074............................ 1.2115 0.8899 21.4274 22.6629 23.5142 22.5510 330075............................ 1.1310 0.9912 22.4188 23.1592 23.4332 23.0114 330078............................ 1.4633 0.9586 23.3981 25.8073 27.2852 25.5265 330079............................ 1.3908 0.9431 22.5237 24.6054 24.9934 24.0663 330080............................ 1.1615 1.3215 39.1724 39.1417 38.9393 39.0845 330084............................ 1.0885 0.8440 21.5455 22.5573 25.6859 23.2864 330085............................ 1.1343 0.9577 23.9568 25.3285 26.6208 25.3039 330086............................ 1.3317 1.3215 29.1784 32.7675 35.4708 32.6068 330088............................ 1.0150 1.2791 31.3973 34.0789 35.3841 33.6057 330090............................ 1.4726 0.8440 23.6174 25.5351 26.8715 25.3561 330091............................ 1.3639 0.9586 23.8063 25.9378 27.0011 25.6211 330094............................ 1.2532 0.9231 23.0001 25.7116 26.9119 25.1924 330095............................

***

* 31.9873

* 31.9873 330096............................ 1.2270 0.8440 22.0337 22.7189 23.4149 22.7206 330097............................ 1.0476

* 20.3189

* 20.3189 330100............................ 1.0853 1.3215 34.4621 38.3333 39.6209 37.5339 330101............................ 1.9268 1.3215 38.7503 40.1929 43.7932 40.9960 330102............................ 1.3805 0.9586 24.8184 25.3879 26.6873 25.6615 330103............................ 1.1459 0.8440 21.1452 22.8242 24.5566 22.8013 330104............................ 1.3468 1.3215 32.8818 33.7537 34.3166 33.6767 330106............................ 1.7224 1.2993 41.4561 43.8210 45.9263 43.7752 330107............................ 1.2622 1.2791 31.3888 34.9047 35.7373 34.0849 330108............................ 1.1634 0.8440 22.2607 23.2919 23.9344 23.1799 330111............................ 1.0675 0.9586 20.9387 20.3473 40.4318 24.2734 330115............................ 1.1809 0.9912 23.3043 25.2373 23.0235 23.8663 330119............................ 1.7982 1.3215 39.1114 39.0528 42.2871 40.1393 330125............................ 1.7876 0.8899 26.7119 27.2920 28.0831 27.3803 330126............................ 1.3169 1.2993 31.6370 35.2257 36.5676 35.2858 330127............................ 1.3510 1.3215 44.6103 45.3680 45.2974 45.0865 330128............................ 1.2215 1.3215 37.7166 39.5197 41.7780 39.6521 330132............................ 1.1465 0.8561 17.4946 21.0479 21.7624 20.0513 330133............................ 1.3487 1.3215 36.6962 39.3837 38.5211 38.1371 330135............................ 1.1424 1.0853 29.0837 27.9132 32.0511 29.6957 330136............................ 1.5153 0.9577 24.2010 25.8531 26.6667 25.5991 330140............................ 1.8341 0.9912 25.7573 27.6183 29.3429 27.5920

[[Page 24891]]

330141............................ 1.3225 1.2791 34.8902 39.4701 38.2473 37.6083 330144............................ 1.0373 0.8440 20.9935 22.9561 23.3863 22.4512 330151............................ 1.1211 0.8440 19.1841 21.7665 19.7949 20.1954 330152............................ 1.2983 1.3215 36.5136 37.6721 38.2040 37.4693 330153............................ 1.7286 0.8672 24.5219 26.4386 28.4427 26.4924 330154............................ 1.7054

* 330157............................ 1.3498 0.9577 25.2312 26.5686 27.1422 26.3135 330158............................ 1.5257 1.3215 32.2990 38.2033 41.6972 37.3734 330159............................ 1.3649 0.9912 28.9094 28.2774 31.7829 29.5878 330160............................ 1.5299 1.3215 34.1960 36.6208 39.4136 36.7564 330162............................ 1.2873 1.3215 32.1783 34.9460 37.6198 34.8798 330163............................ 1.1299 0.9586 24.0200 27.1933 28.3889 26.5653 330164............................ 1.4611 0.8899 28.8481 27.7217 27.4988 28.0125 330166............................ 1.0839 0.8440 19.4360 20.4680 20.7114 20.1915 330167............................ 1.7102 1.2993 34.4748 36.7653 39.1206 36.7231 330169............................ 1.3871 1.3215 39.3361 45.3774 46.4890 43.5617 330171............................

***

* 30.0122 30.4005 35.1552 31.6496 330175............................ 1.1110 0.8681 22.2067 23.8509 23.3990 23.1608 330177............................ 0.9871 0.8440 19.6100 20.6338 22.9802 21.0952 330180............................ 1.2281 0.8672 22.1920 24.3761 25.4142 23.9988 330181............................ 1.2689 1.2993 38.5351 41.4104 42.2619 40.7706 330182............................ 2.3122 1.2993 39.6038 40.9014 40.8712 40.4724 330184............................ 1.4040 1.3215 34.4044 35.8102 39.0405 36.4609 330185............................ 1.2787 1.2791 32.3466 36.3155 37.9564 35.6879 330188............................ 1.2378 0.9586 23.9210 25.1153 27.5982 25.5241 330189............................ 1.3891 0.8672 21.6229 22.3484 22.4386 22.1392 330191............................ 1.2684 0.8672 24.0232 25.5656 26.4297 25.3758 330193............................ 1.3149 1.3215 37.1807 39.9327 38.9508 38.7084 330194............................ 1.7330 1.3215 43.9910 45.5639 46.8833 45.5303 330195............................ 1.7148 1.3215 40.0206 39.7802 41.7863 40.5425 330196............................ 1.2484 1.3215 33.2171 36.7178 38.2483 36.0767 330197............................ 1.0598 0.8440 23.4290 26.8921 25.9860 25.4379 330198............................ 1.3670 1.2993 30.5485 33.4930 34.8948 33.0511 330199............................ 1.1951 1.3215 35.0059 38.6407 40.3929 37.9482 330201............................ 1.5880 1.3215 39.3682 37.2064 42.6689 39.7174 330202............................ 1.2474 1.3215 38.0129 37.4150 37.4138 37.6069 330203............................ 1.4679 0.9912 26.5882 32.1207 34.0475 30.8848 330204............................ 1.3409 1.3215 37.6849 39.6393 41.9936 39.7972 330205............................ 1.1766 1.0853 32.1618 31.9510 33.9404 32.7289 330208............................ 1.1551 1.3215 29.6282 32.1256 33.5256 31.7765 330209............................

***

* 29.7988 30.2038

* 30.0002 330211............................ 1.1593 0.8440 22.9966 24.4470 25.8735 24.4782 330212............................

***

* 27.2232

* 27.2232 330213............................ 1.1110 0.8440 22.5191 24.4049 27.4887 24.8464 330214............................ 1.9082 1.3215 37.8500 41.8719 41.2768 40.2400 330215............................ 1.3064 0.8774 22.6744 23.7361 23.9564 23.4614 330218............................ 1.0749 0.9912 24.1106 26.9638 26.9959 26.0466 330219............................ 1.7271 0.9586 29.3644 29.8889 32.5646 30.5813 330221............................ 1.3239 1.3215 36.5539 39.2080 40.0488 38.6287 330222............................ 1.2884 0.8672 23.9746 25.8507 27.7182 25.9131 330223............................ 1.0004 0.8440 19.4229 23.3669 26.1256 22.8479 330224............................ 1.3202 1.0644 25.7850 27.9231 29.0864 27.6364 330225............................ 1.2316 1.2993 29.2719 32.3585 35.7735 32.4753 330226............................ 1.3388 0.8899 21.8977 24.5646 24.8456 23.8231 330229............................ 1.1912 0.8440 20.6095 21.9356 23.0562 21.8540 330230............................ 1.0097 1.3215 33.3175 37.1298 38.6523 36.3361 330231............................ 1.0931 1.3215 36.9619 40.6697 44.9376 40.8957 330232............................ 1.1619 0.8672 24.4531 26.3313 27.4623 26.1064 330233............................ 1.4121 1.3215 45.5132 47.3497 52.7025 48.3771 330234............................ 2.3848 1.3215 40.6314 48.2306 49.3194 45.8234 330235............................ 1.1939 0.9577 23.3866 27.7031 29.4294 26.7553

[[Page 24892]]

330236............................ 1.5608 1.3215 35.6347 40.2386 42.8923 39.6820 330238............................ 1.2614 0.8899 20.8639 21.7435 21.7652 21.4610 330239............................ 1.2560 0.8440 21.5397 22.3854 23.6653 22.5395 330240............................ 1.2133 1.3215 39.9450 43.5753 40.4972 41.3029 330241............................ 1.8038 0.9912 29.0882 30.2304 32.6139 30.7098 330242............................ 1.3307 1.3215 33.6926 37.4870 36.8969 35.9769 330245............................ 1.8750 0.8440 22.8003 26.1811 27.4329 25.5153 330246............................ 1.3359 1.2791 34.6329 37.1611 35.7391 35.8256 330247............................ 0.8986 1.3215 32.2300 35.4980 39.0193 35.4567 330249............................ 1.3518 0.9912 22.9834 25.3246 23.8548 24.0420 330250............................ 1.3308 0.9589 25.1664 27.1606 29.0058 27.1464 330259............................ 1.4194 1.2993 31.9152 35.1514 36.5831 34.5776 330261............................ 1.2665 1.3215 30.7942 33.7834 40.2554 34.7041 330263............................ 1.0289 0.8440 22.4675 23.8738 24.1312 23.5399 330264............................ 1.2912 1.0853 30.0139 30.4701 30.1809 30.2033 330265............................ 1.1849 0.8899 20.4635 21.6477 23.9070 21.9772 330267............................ 1.3602 1.3215 31.5478 32.8541 34.9869 33.1372 330268............................ 0.9192 0.8440 20.9720 25.3567 23.8791 23.3606 330270............................ 2.0325 1.3215 42.2111 57.3596 55.2076 51.3946 330273............................ 1.3982 1.3215 30.4720 37.0157 34.5032 34.0363 330276............................ 1.0979 0.8440 22.2353 24.3300 26.0917 24.2198 330277............................ 1.1791 0.9715 25.3582 26.4535 30.9561 27.3784 330279............................ 1.5215 0.9586 25.2130 27.4539 29.4540 27.4527 330285............................ 1.9980 0.8899 27.9018 30.1928 31.1219 29.7572 330286............................ 1.3653 1.2791 33.3552 35.5895 36.8535 35.2974 330290............................ 1.7316 1.3215 36.9981 39.4690 40.3862 38.9177 330304............................ 1.3060 1.3215 34.5761 36.2845 37.3516 36.1507 330306............................ 1.4126 1.3215 35.6640 36.3552 38.7631 36.9884 330307............................ 1.3336 0.9715 27.5699 29.2529 29.5522 28.8425 330314............................

***

* 25.5597 26.2719 28.1362 26.6009 330316............................ 1.2421 1.3215 34.8623 34.8567 37.1744 35.6156 330331............................ 1.2559 1.2993 36.1630 39.8402 41.2652 39.1610 330332............................ 1.2705 1.2993 33.3050 35.1646 37.0082 35.2111 330333............................

***

* 26.1917

* 26.1917 330338............................

***

* 31.3761 37.7497

* 34.6182 330339............................ 0.7038 0.8672 22.6569 23.5786 24.3064 23.5064 330340............................ 1.2556 1.2791 33.9358 37.9000 36.0162 35.9189 330350............................ 1.4768 1.3215 36.6250 41.1339 43.9324 40.6020 330353............................ 1.2410 1.3215 37.6549 45.9692 45.0917 43.0066 330354............................ 2.1053

* 330357............................ 1.2623 1.3215 35.5975 38.2286 40.3814 37.9050 330372............................ 1.2696 1.2993 32.6721 36.1840 35.1250 34.7426 330385............................ 1.1071 1.3215 46.3221 48.6175 49.0841 47.9726 330386............................ 1.2194 1.1578 27.9943 29.9366 33.3181 30.4738 330389............................ 1.7372 1.3215 34.7669 37.1862 38.6409 36.8607 330390............................ 1.2371 1.3215 36.0573 36.3842 35.5521 35.9765 330393............................ 1.7369 1.2791 34.8095 38.0619 39.2461 37.4154 330394............................ 1.6366 0.9072 25.2229 27.3388 28.4575 27.0150 330395............................ 1.4366 1.3215 37.3096 36.3921 37.5757 37.0853 330396............................ 1.5239 1.3215 35.0297 37.4998 39.4882 37.3251 330397............................ 1.4326 1.3215 38.4741 37.5682 41.4413 39.1429 330399............................ 1.0763 1.3215 32.3688 34.7394 37.1175 34.7258 330401............................ 1.3610 1.2791 40.6249 37.8559 40.4446 39.6483 330403............................ 0.9812 0.8899 23.1886 25.5163 25.2928 24.6329 330404............................ 0.8616 1.3215

* 330405............................ 0.8688 1.3215

* 330406............................ 0.8701 0.8672

* 340001............................ 1.5147 0.9512 25.0041 28.3988 29.5669 27.7156 340002............................ 1.8220 0.9209 27.3349 28.4860 29.6875 28.5183 340003............................ 1.1852 0.8608 23.3066 24.1602 26.0869 24.5118 340004............................ 1.4192 0.9083 25.4474 26.6404 27.5270 26.5361

[[Page 24893]]

340005............................ 0.9877

* 22.3814

* 22.3814 340008............................ 1.1889 0.9348 26.6314 26.7443 27.7190 27.0539 340010............................ 1.3717 0.9373 24.5666 27.2105 28.7525 26.8565 340011............................ 1.1370 0.8608 19.9484 19.7441 22.0042 20.5589 340012............................ 1.2498 0.8608 22.7189 23.2288 24.7564 23.5968 340013............................ 1.2487 0.9348 23.0261 23.9492 26.3599 24.4158 340014............................ 1.5497 0.9083 25.1872 27.4888 27.8361 26.8911 340015............................ 1.3640 0.9348 26.2276 28.0585 28.3916 27.5637 340016............................ 1.2883 0.8608 23.0359 25.6454 27.3478 25.3411 340017............................ 1.3186 0.9209 23.8229 25.7780 27.4678 25.6896 340018............................

***

* 23.7243

* 23.7243 340020............................ 1.2004 0.8751 23.7995 26.4465 27.5449 25.9051 340021............................ 1.3001 0.9348 26.0995 29.4864 29.3819 28.3674 340023............................ 1.3623 0.9386 24.4896 26.4225 26.3102 25.7592 340024............................ 1.1037 0.8779 22.2522 23.6638 26.3988 24.1337 340025............................ 1.3303 0.9209 21.2276 23.5881 24.0074 22.9989 340027............................ 1.1601 0.9272 23.6326 25.5973 26.3812 25.2702 340028............................ 1.5219 0.9926 26.3298 28.0323 30.7692 28.3795 340030............................ 2.0869 0.9814 29.0122 29.6630 30.7705 29.8384 340032............................ 1.4485 0.9512 26.7475 26.5958 28.7619 27.4144 340035............................ 1.0891 0.8608 23.5476 23.9669 24.6257 24.0393 340036............................ 1.3731 0.9373 25.2077 27.2691 27.3834 26.6507 340037............................ 1.1089 0.8770 21.6411 25.6262 29.0640 25.6376 340038............................ 1.2278 0.8861 14.0713 22.4829 24.2103 19.1095 340039............................ 1.2800 0.9348 27.1275 27.4457 27.8213 27.4756 340040............................ 1.9806 0.9272 26.3325 27.6626 28.7422 27.6117 340041............................ 1.1961 0.8977 23.6600 24.3595 26.8306 25.0114 340042............................ 1.2712 0.8608 23.0236 25.0110 25.6323 24.5577 340045............................

***

* 23.1918

* 23.1918 340047............................ 1.8383 0.9083 25.0605 27.4022 28.4974 27.0298 340049............................ 1.8540 0.9814 30.4827 30.6791 29.6812 30.2355 340050............................ 1.1120 0.9600 24.2533 26.0365 27.5249 25.9399 340051............................ 1.2212 0.8819 23.4091 23.9612 24.4546 23.9484 340053............................ 1.4963 0.9512 27.7261 27.8577 28.9350 28.1745 340055............................ 1.2461 0.8977 24.1057 26.0647 26.5750 25.5722 340060............................ 1.1427 0.9111 22.8657 22.9097 25.1769 23.6611 340061............................ 1.8071 0.9814 27.5594 27.0089 29.8565 28.1789 340064............................ 1.0727 0.8608 22.9143 23.4233 23.9696 23.4392 340068............................ 1.2508 0.9172 21.8830 22.6814 23.6737 22.7405 340069............................ 1.8779 0.9603 27.4473 29.3439 29.2259 28.6869 340070............................ 1.2886 0.9111 24.9033 25.3226 26.6539 25.6456 340071............................ 1.0909 0.9373 25.4537 26.3921 27.9724 26.6149 340072............................ 1.2076 0.8608 23.1163 25.2493 24.1322 24.1635 340073............................ 1.6001 0.9603 30.2061 30.9849 32.2694 31.1640 340075............................ 1.2345 0.8977 26.0226 25.1551 25.1432 25.4400 340084............................ 1.1990 0.9512 21.2580 21.1363 23.1513 21.8365 340085............................ 1.1471 0.8858 23.9793 26.5164 27.9544 26.0796 340087............................ 1.2862 0.8608 22.0070 22.4287 25.4716 23.2830 340090............................ 1.3672 0.9373 23.4541 26.4031 26.7407 25.6220 340091............................ 1.5781 0.9083 25.8266 27.1285 28.8018 27.2994 340096............................ 1.2035 0.8858 25.2169 24.9036 26.5426 25.5725 340097............................ 1.2771 0.8608 24.2127 26.2228 29.7729 26.6118 340098............................ 1.4524 0.9512 27.3308 28.2493 29.6697 28.4313 340099............................ 1.3064 0.8608 20.3683 21.8564 23.9712 22.0909 340104............................ 0.9032 0.8770 15.7521 16.1204 17.6322 16.5484 340106............................ 1.1107 0.8608 22.4894 26.0892 26.1296 24.8414 340107............................ 1.2094 0.9017 22.9698 24.1762 26.6468 24.6193 340109............................ 1.2629 0.8785 23.4419 25.4464 26.6306 25.1776 340113............................ 1.9347 0.9512 28.2568 28.5587 30.3822 29.0843 340114............................ 1.5707 0.9603 26.6813 28.3222 28.1306 27.7302 340115............................ 1.6239 0.9603 25.0212 26.7592 27.2771 26.3716

[[Page 24894]]

340116............................ 1.7637 0.8977 25.3213 27.5881 29.3675 27.4184 340119............................ 1.3184 0.9512 24.2287 25.6226 29.4442 26.4327 340120............................ 1.0120 0.8608 23.0915 25.9134 25.5502 24.8610 340121............................ 1.1179 0.9338 21.7576 23.1343 23.8832 22.9461 340123............................ 1.3434 0.9111 26.1083 26.0637 28.5642 26.9157 340124............................ 1.0382 0.9373 20.8018 22.2988 23.5464 22.2123 340126............................ 1.2877 0.9373 25.0189 26.9866 28.2229 26.7660 340127............................ 1.1542 0.9603 25.7831 26.4746 28.2146 26.8344 340129............................ 1.2616 0.9348 25.4902 25.7976 26.7596 26.0411 340130............................ 1.3513 0.9512 25.2941 26.1717 28.1587 26.5937 340131............................ 1.5011 0.9272 27.9358 27.4750 28.8528 28.1009 340132............................ 1.1993 0.8608 21.3521 23.5856 24.3442 23.1134 340133............................ 1.0170 0.8850 22.5558 23.4678 24.8551 23.5976 340137............................

***

* 21.0642 22.1741 28.9661 23.0832 340138............................ 0.8420 0.9603 21.3670

* 21.3670 340141............................ 1.6591 0.9338 27.3355 29.3878 29.3158 28.6960 340142............................ 1.1639 0.8608 22.9907 26.6886 27.7501 25.8989 340143............................ 1.5072 0.8977 25.3633 28.0082 27.9782 27.1350 340144............................ 1.2446 0.9348 27.2686 26.1865 27.0139 26.8084 340145............................ 1.1838 0.9348 23.7131 25.8459 26.7457 25.4570 340147............................ 1.3000 0.9373 25.4534 26.9162 28.2605 26.9066 340148............................ 1.4008 0.9083 23.5880 25.3660 25.8316 24.9275 340151............................ 1.1664 0.8661 22.0052 22.7736 23.2142 22.6702 340153............................ 1.8779 0.9512 26.4896 27.6509 28.5972 27.6009 340155............................ 1.4283 0.9814 30.4940 30.3443 31.6013 30.8281 340156............................ 0.8549 1.4406

* 340158............................ 1.1124 0.9338 26.4849 27.7816 27.9252 27.3725 340159............................ 1.2301 0.9814 23.2991 24.2588 24.8366 24.1490 340160............................ 1.3374 0.8608 20.7525 21.7923 23.4619 22.0119 340166............................ 1.2904 0.9512 26.0558 27.1132 28.5388 27.2672 340168............................ 0.3793 0.9338 17.3249

* 17.3249 340171............................ 1.1735 0.9512 28.2734 27.8539 27.4705 27.8496 340173............................ 1.2951 0.9603 27.5072 28.3502 30.2808 28.7935 340177............................ 1.0970

* 24.7471 26.7155

* 25.7127 340178............................

***

* 28.7218

* 28.7218 340179............................

***

* 34.1895

* 34.1895 340182............................

***

* 27.8071

* 27.8071 340183............................ 1.0771 0.9512

* 350002............................ 1.8102 0.7329 22.0283 22.4307 23.7161 22.7683 350003............................ 1.1838 0.7329 21.8061 23.9639 24.9963 23.6034 350006............................ 1.5606 0.7329 19.4985 21.2726 22.4602 21.0489 350009............................ 1.1335 0.8189 23.0873 23.8681 24.5724 23.8525 350010............................ 0.9681 0.7313 19.1964 20.1290 20.4189 19.9339 350011............................ 1.9833 0.8189 23.1947 23.8400 24.1118 23.7255 350014............................ 0.9073 0.7313 17.7565 19.1684 17.5803 18.1595 350015............................ 1.6832 0.7329 20.1161 20.9046 21.3324 20.8688 350017............................ 1.2724 0.7313 21.0243 22.4359 21.6164 21.6690 350019............................ 1.6835 0.7729 22.1960 23.2018 23.9585 23.1800 350030............................ 0.9605 0.7313 18.9978 20.2722 22.5960 20.6212 350061............................ 1.4521

* 22.0515

* 22.0515 350063............................ 0.8930 1.4406

* 350070............................ 1.8146 0.8189 25.2836 25.2365 26.2446 25.5900 360001............................ 1.4375 0.9654 23.9101 25.8669 28.8621 26.1633 360002............................ 1.2626 0.8843 24.5789 24.5155 25.4859 24.8654 360003............................ 1.7692 0.9654 27.5029 28.9672 30.7793 29.0933 360006............................ 1.9028 1.0048 28.1698 30.1363 30.9800 29.7938 360008............................ 1.3248 0.8706 24.5714 26.2632 27.5658 26.1301 360009............................ 1.6042 0.9312 23.1012 25.0007 27.0599 25.0987 360010............................ 1.2239 0.8810 23.1178 23.7825 24.7338 23.9116 360011............................ 1.2624 0.9840 25.5340 27.6036 31.5555 28.1828 360012............................ 1.3983 1.0048 27.5470 30.1416 31.0504 29.6648

[[Page 24895]]

360013............................ 1.0938 0.9312 26.8130 27.0893 29.8398 27.9263 360014............................ 1.1288 0.9840 25.3861 27.1017 27.0725 26.5476 360016............................ 1.4363 0.9654 26.1283 27.8031 29.6279 27.8538 360017............................ 1.7059 1.0048 27.2910 29.8525 31.7064 29.6400 360019............................ 1.2999 0.9238 25.5926 26.9178 27.2984 26.6159 360020............................ 1.6208 0.9238 24.4343 23.6400 25.6319 24.5731 360024............................

***

* 23.5793

* 23.5793 360025............................ 1.4533 0.9276 25.5633 27.4533 27.1537 26.7665 360026............................ 1.3236 0.9283 23.5898 25.5379 25.2930 24.8033 360027............................ 1.6124 0.9238 25.4894 27.4454 28.2908 27.0616 360029............................ 1.0866 0.9276 22.7785 24.3216 26.4202 24.5304 360032............................ 1.2094 0.8701 23.2638 25.0034 25.9909 24.7561 360035............................ 1.7332 1.0048 27.5220 30.0172 31.3158 29.6736 360036............................ 1.2090 0.9238 27.6094 27.8343 29.3509 28.2916 360037............................ 1.4254 0.9365 24.3982 29.0046 30.0437 27.6733 360038............................ 1.5417 0.9654 22.8009 25.4274 31.0557 26.2991 360039............................ 1.4955 0.9840 24.0218 23.9783 24.7864 24.2787 360040............................ 1.1428 0.9093 24.0942 24.8569 25.5333 24.8327 360041............................ 1.4963 0.9365 24.1080 26.1522 26.6728 25.6861 360044............................ 1.1371 0.8824 21.8411 21.5619 24.3827 22.5765 360046............................ 1.2025 0.9654 25.0775 25.4673 26.2408 25.5991 360047............................ 1.0860

* 21.7248

* 21.7248 360048............................ 1.7551 0.9276 28.8107 29.3415 29.4798 29.2208 360049............................

***

* 25.8367 26.2222

* 26.0185 360051............................ 1.6982 0.9283 25.7556 26.8501 28.1154 26.9160 360052............................ 1.6085 0.9283 24.5405 26.2066 26.8786 25.8857 360054............................ 1.3922 0.8706 23.0376 22.9359 24.8241 23.5843 360055............................ 1.4135 0.8996 26.3112 27.3941 30.0124 27.8965 360056............................ 1.6196 0.9654 23.1024 26.5318 30.3674 26.6370 360058............................ 1.0570 0.8701 23.4429 23.8119 24.5004 23.9275 360059............................ 1.5019 0.9365 25.3516 29.3624 30.6157 28.4896 360062............................ 1.4828 1.0048 28.6518 31.7422 33.1325 31.3394 360064............................ 1.5894 0.8996 22.2393 25.2336 27.7775 24.9757 360065............................ 1.2185 0.9276 26.3036 28.0405 29.7142 28.0320 360066............................ 1.5174 0.9312 27.3362 27.1436 29.7605 28.0751 360068............................ 1.8821 0.9276 25.8414 26.2065 26.6926 26.2580 360069............................ 1.2464

* 24.2444

* 24.2444 360070............................ 1.6601 0.8921 24.8863 27.2389 27.8858 26.6566 360071............................ 1.1154 0.8736 22.0786 23.4619 26.4057 23.9592 360072............................ 1.5235 1.0048 24.4332 25.9589 27.2266 25.9252 360074............................ 1.3006 0.9276 24.9055 25.8959 27.5322 26.1110 360075............................ 1.1470 0.9365 26.8453 26.8925 26.1643 26.5899 360076............................ 1.4896 0.9654 25.9369 28.1013 29.0117 27.7066 360077............................ 1.5217 0.9365 25.6505 28.4449 28.2382 27.4520 360078............................ 1.2784 0.9238 26.1313 25.7885 27.4681 26.4451 360079............................ 1.7865 0.9654 26.0935 27.2437 30.1207 27.8332 360080............................ 1.1298 0.8701 20.8309 21.4526 22.7007 21.7293 360081............................ 1.3482 0.9276 27.5695 29.8366 29.5312 28.9628 360082............................ 1.3502 0.9365 27.1197 29.2561 28.7914 28.4294 360084............................ 1.6070 0.8854 25.8415 27.3917 28.5391 27.2562 360085............................ 2.0277 1.0048 29.0081 31.5800 33.1242 31.3481 360086............................ 1.6599 0.9283 22.1859 25.4218 27.1112 24.8912 360087............................ 1.3509 0.9365 25.4040 29.6579 28.4514 27.8631 360089............................ 1.1462 0.8701 22.7951 25.3465 25.5599 24.5871 360090............................ 1.5838 0.9276 26.7717 29.0199 30.7505 28.8607 360091............................ 1.3280 0.9365 27.5067 25.8657 27.6802 27.0162 360092............................ 1.2657 1.0048 25.6618 25.4954 25.4045 25.5161 360094............................

***

* 26.6348

* 26.6348 360095............................ 1.4017 0.9276 26.1275 26.4635 29.3772 27.2940 360096............................ 1.0892 0.8775 24.6317 25.9275 26.8627 25.8201 360098............................ 1.3635 0.9365 24.8447 25.5973 26.6025 25.7083

[[Page 24896]]

360100............................ 1.2005 0.8921 23.0561 25.4523 23.6159 24.0347 360101............................ 1.3623 0.9365 26.6209 27.6030 29.7806 28.0278 360106............................

***

* 24.1588

* 24.1588 360107............................ 1.1250 0.9276 25.9697 24.6095 26.0530 25.5447 360109............................ 1.0690 0.8701 25.4184 26.3131 30.1363 27.2357 360112............................ 1.9961 0.9276 28.6784 30.5715 31.1515 30.1229 360113............................ 1.3136 0.9654 25.6493 26.6556 30.2863 27.4972 360115............................ 1.2841 0.9365 24.0052 25.9841 26.1795 25.4590 360116............................ 1.1939 0.9654 18.0655 25.1717 26.4955 23.3907 360118............................ 1.5237 0.9214 27.7289 27.3884 28.5629 27.8928 360121............................ 1.3620 0.9276 24.5593 27.4442 28.3823 26.7820 360123............................ 1.4133 0.9365 22.6523 27.1920 28.0320 25.8332 360125............................ 1.1982 0.8701 22.1096 24.1388 25.9042 23.9896 360128............................

***

* 21.0067

* 21.0067 360130............................ 1.4718 0.9365 22.9762 25.6570 26.3962 25.2266 360131............................ 1.3051 0.8921 24.0496 25.3719 26.6628 25.3527 360132............................ 1.3639 0.9654 25.9453 27.7724 29.4046 27.6748 360133............................ 1.6035 0.9283 24.6208 29.8684 31.7499 28.7264 360134............................ 1.7956 0.9654 29.2974 27.7339 28.5138 28.4864 360137............................ 1.7463 0.9365 26.9522 26.1250 27.6882 26.9252 360141............................ 1.6594 0.8996 27.7085 29.7937 31.1769 29.5398 360142............................ 1.0704

* 22.1610

* 22.1610 360143............................ 1.2891 0.9365 24.6306 28.3057 27.3743 26.8209 360144............................ 1.3643 0.9365 25.7079 28.2473 28.9166 27.6777 360145............................ 1.6714 0.9365 25.8268 27.1908 28.1802 27.1029 360147............................ 1.2484 0.8701 24.1953 25.5854 27.5529 25.7869 360148............................ 1.0883 0.8701 26.1947 26.0837 26.3390 26.2100 360150............................ 1.2297 0.9238 24.7667 25.1217 31.2684 26.9639 360151............................ 1.6221 0.8921 24.8629 25.3780 26.5001 25.5913 360152............................ 1.5017 1.0048 27.9147 29.9425 31.5364 29.7871 360153............................ 0.9767 0.8701 19.0226 19.8499 20.2124 19.7383 360155............................ 1.4479 0.9365 25.3909 26.9127 28.9551 27.1136 360156............................ 1.1512 0.8796 24.0509 24.3281 25.0839 24.5014 360159............................ 1.2592 0.9840 33.1613 29.1529 28.6161 30.0443 360161............................ 1.3686 0.8996 24.3792 25.4433 27.0861 25.6054 360163............................ 1.9114 0.9654 26.9728 28.9742 30.0503 28.6581 360170............................ 1.3066 1.0048 24.3620 28.5474 30.2417 27.8461 360172............................ 1.3796 0.9365 26.3501 27.5669 28.8276 27.5898 360174............................ 1.2817 0.9283 24.9990 26.8586 28.3284 26.7426 360175............................ 1.2427 0.9840 26.5949 28.1531 28.3038 27.6954 360177............................ 1.1565

* 24.4712

* 24.4712 360179............................ 1.5926 0.9654 28.8645 30.0311 29.8291 29.5971 360180............................ 2.2538 0.9365 26.1514 29.6633 31.4318 29.1118 360185............................ 1.1979 0.8775 23.7173 25.6800 26.1053 25.1940 360187............................ 1.5392 0.9283 24.8173 24.9353 25.7593 25.1880 360189............................ 1.1090 1.0048 24.2136 26.3756 27.5194 26.0228 360192............................ 1.2914 0.9365 26.7577 26.4616 27.5979 26.9455 360195............................ 1.0872 0.9365 26.1281 25.0922 27.6148 26.2465 360197............................ 1.1400 0.9840 27.0896 28.7580 28.9190 28.2666 360203............................ 1.2433 0.8701 22.1414 24.4433 25.3724 24.0021 360210............................ 1.1676 1.0048 27.8415 28.2976 29.1231 28.4261 360211............................ 1.5603 0.8701 22.5449 25.7053 26.5443 24.7611 360212............................ 1.3255 0.9365 25.2756 25.6080 27.2263 26.0408 360218............................ 1.1995 1.0048 27.4288 29.8662 30.0072 29.0783 360230............................ 1.5565 0.9365 27.0223 28.8018 30.0644 28.6832 360234............................ 1.3350 0.9654 24.3625 25.9360 31.0655 27.0902 360236............................ 1.2597 0.9654 35.8143 25.6728 29.5312 29.3312 360239............................ 1.3159 0.9283 25.2474 27.2939 30.7698 27.7358 360241............................

***

* 24.7001 23.0662 25.7293 24.4913 360242............................ 1.8997

* 360245............................ 0.5512 0.9238 19.1884 20.6504 20.3411 20.0849

[[Page 24897]]

360247............................ 0.3793 1.0048 19.8891 19.3677

* 19.6148 360253............................ 2.4484 0.9654 30.4276 33.2371 34.3298 32.7134 360259............................ 1.3020 0.9276 25.1338 25.9878 27.2896 26.1978 360260............................

***

* 27.3903

* 27.3903 360261............................ 1.3730 0.8845 22.5431 22.3614 25.6328 23.5171 360262............................ 1.3188 0.9276 27.1680 28.6995 30.1562 28.7641 360263............................ 1.8192 0.9312 20.8884 25.1652 25.4813 23.9900 360264............................

***

* 36.0754

* 36.0754 360265............................

***

* 36.6265

* 36.6265 360266............................ 2.1280 1.0048

* 31.7532 31.7532 360267............................

***

* 34.0914 34.0914 360268............................

***

* 34.0503 34.0503 360269............................ 1.7180 0.9654

* 24.8569 24.8569 360270............................ 1.1022 0.8701

* 360271............................ 1.4810 0.9654

* 360273............................ 1.6114 0.8701

* 370001............................ 1.6364 0.8504 27.7245 26.0194 26.9066 26.8618 370002............................ 1.2199 0.7702 20.1479 22.0476 23.6850 21.9862 370004............................ 1.1269 0.9040 25.3919 26.7434 26.8511 26.3097 370006............................ 1.2605 0.8504 20.1063 22.4802 23.9928 22.1048 370007............................ 1.0754 0.7702 17.6547 19.4036 20.3673 19.1460 370008............................ 1.4647 0.8764 24.2978 25.3352 26.6546 25.4718 370011............................ 0.9837 0.8764 19.7821 21.9649 22.3379 21.3301 370013............................ 1.5640 0.8764 24.9294 26.5364 27.2662 26.2290 370014............................ 1.0060 0.8535 25.3576 25.9393 26.4459 25.9300 370015............................ 1.0124 0.8504 23.6694 24.7547 25.5786 24.6931 370016............................ 1.6367 0.8764 25.4062 26.7938 29.8253 27.2541 370018............................ 1.5049 0.8504 23.5336 25.3573 24.6848 24.5166 370019............................ 1.2516 0.7702 21.4474 22.0221 25.2799 22.9578 370020............................ 1.3456 0.7702 18.5046 20.8723 22.7512 20.7432 370022............................ 1.2128 0.8071 19.6495 24.6099 22.2254 22.0686 370023............................ 1.3507 0.7792 21.5762 23.5170 23.9997 23.0468 370025............................ 1.2923 0.8504 23.5659 23.9873 24.5531 24.0379 370026............................ 1.4292 0.8764 23.0848 25.8428 25.3460 24.7668 370028............................ 1.8835 0.8764 26.6153 27.8621 28.5594 27.6903 370029............................ 1.1365 0.7702 23.9956 26.8508 28.5284 26.4589 370030............................ 1.0204 0.7702 23.3037 24.1483 25.8183 24.4349 370032............................ 1.4524 0.8764 23.4843 24.8626 26.3171 24.8715 370034............................ 1.2252 0.7702 18.2341 19.5099 20.4074 19.4048 370036............................ 1.1122 0.7702 17.7575 19.2318 19.8132 18.9467 370037............................ 1.6252 0.8764 23.9685 24.9553 25.5152 24.8480 370039............................ 1.0449 0.8504 21.8220 23.0254 23.5733 22.8098 370040............................ 0.9665 0.8056 22.4048 22.8356 26.7367 23.9154 370041............................ 0.8802 0.8504 22.3496 22.6731 22.9777 22.6684 370047............................ 1.3864 0.8764 20.4657 24.1991 24.4738 23.0657 370048............................ 1.0417 0.7702 19.2464 21.4543 22.0594 20.9179 370049............................ 1.3124 0.8764 23.2171 23.8844 22.8742 23.3160 370051............................ 1.0579 0.7702 17.2618 19.8329 19.3164 18.8224 370054............................ 1.2325 0.7702 21.5044 22.4652 25.2122 22.9823 370056............................ 1.8614 0.8406 22.0312 24.3986 25.5420 23.9740 370057............................ 0.9753 0.8504 19.7284 19.8683 22.1308 20.5333 370060............................ 0.9969 0.8504 18.7592 19.9025 23.3793 20.5008 370064............................ 0.8912

* 14.2053

* 14.2053 370065............................ 1.0064 0.7799 20.0227 21.2343 23.5785 21.6442 370072............................ 0.8029 0.7962 9.9615 11.7942 13.0903 11.6655 370078............................ 1.5669 0.8504 25.4068 27.8611 26.6945 26.6513 370080............................ 0.8703 0.7702 18.0665 19.9595 22.3662 20.0726 370083............................ 0.8972 0.7753 16.8836 19.2568 20.9831 18.9413 370084............................ 0.9999 0.7702 16.6513 19.6230 20.7278 19.1519 370089............................ 1.3096 0.7702 20.4699 20.6153 22.1503 21.0632 370091............................ 1.5724 0.8504 23.3357 24.1438 25.8676 24.4372

[[Page 24898]]

370093............................ 1.6188 0.8764 26.9774 26.0459 27.4328 26.8140 370094............................ 1.4242 0.8764 23.1191 24.5555 26.5223 24.7218 370097............................ 1.3209 0.8406 22.3267 26.3168 26.7940 25.2222 370099............................ 1.0704 0.7702 20.5075 24.9971 26.7160 23.9172 370100............................ 0.9275 0.7803 14.7711 17.9732 19.3931 17.4549 370103............................ 1.0056 0.7702 17.8018 18.8933 19.4227 18.7231 370105............................ 1.9411 0.8764 23.8978 26.7973 26.6370 25.8992 370106............................ 1.4000 0.8764 26.5867 27.8979 28.5947 27.7396 370112............................ 0.9491 0.8056 15.4471 16.0592 16.7860 16.1368 370113............................ 1.1449 0.8719 25.3565 26.9720 26.4599 26.2279 370114............................ 1.5828 0.8504 21.7880 23.0006 25.9816 23.5714 370123............................

***

* 25.4733

* 25.4733 370125............................

***

* 17.1361

* 17.1361 370138............................ 1.0409 0.7702 18.3113 20.2528 22.1656 20.1240 370139............................ 0.9462 0.7702 18.5226 19.4287 20.5120 19.5050 370148............................ 1.5477 0.8764 25.2348 27.0904 28.1920 26.9001 370149............................ 1.2424 0.8764 22.3537 23.3493 23.3403 23.0323 370153............................ 1.1462 0.7702 19.8349 23.2778 24.1577 22.4430 370156............................ 0.9979 0.7824 19.4743 25.2562 23.0030 22.5278 370158............................ 0.9453 0.8764 18.5578 20.7641 21.5187 20.2564 370166............................ 0.8427 0.8504 23.1682 25.1107 24.7202 24.3416 370169............................ 0.8651 0.7866 15.8002 16.8252 16.6722 16.4248 370170............................ 0.9077 1.4406

* 370171............................ 0.8795 1.4406

* 370172............................ 0.8593 1.4666

* 370173............................ 0.9221 1.4406

* 370174............................ 0.7942 1.4406

* 370176............................ 1.2142 0.8504 25.0509 24.7655 24.9681 24.9283 370177............................

***

* 14.7193

* 14.7193 370178............................ 0.8842 0.7702 14.6070 16.0179 16.0702 15.5699 370179............................ 0.8038

* 23.5794

* 23.5794 370180............................ 1.0055 1.4406

* 370183............................ 0.9349 0.8504 21.8147 24.7103 23.8398 23.4249 370190............................ 1.4248 0.8504 33.1137 29.1568 34.8952 32.5860 370192............................ 1.9859 0.8764 31.4930 27.6367 19.0636 24.5970 370196............................

***

* 22.6824 22.3498 20.8286 21.9381 370199............................ 0.7713 0.8764 26.0450 23.3989 23.7422 24.3360 370200............................ 1.0426 0.7702 17.6317 20.5175 21.7857 19.8245 370201............................ 1.6779 0.8764 23.3550 23.8090 24.2461 23.8017 370202............................ 1.4321 0.8504 25.1181 26.1132 25.7745 25.6728 370203............................ 2.0656 0.8764 23.5190 22.8869 25.7761 24.0066 370206............................ 1.5795 0.8764 26.0912 26.0353 27.5742 26.5857 370210............................ 2.1553 0.8504 21.2682 23.3786 27.2693 23.9762 370211............................ 1.0823 0.8764 26.5345 27.8737 28.6515 27.7373 370212............................ 1.7647 0.8764 21.0758 19.1720 20.3497 20.1566 370213............................

***

* 29.3777

* 29.3777 370214............................ 0.9301 0.7824

* 20.6217 21.0658 20.8579 370215............................ 2.4404 0.8764 32.3589 31.5652 32.4081 32.1113 370216............................ 2.0143 0.8504

* 27.2429 25.8238 26.4842 370217............................

***

* 26.8677

* 26.8677 370218............................ 2.3290 0.8504

* 30.3422 30.3422 370220............................ 2.0085 0.8764

* 370222............................ 1.8273 0.8764

* 370223............................ 0.8874 0.8764

* 370224............................ 1.0183 0.8764

* 380001............................ 1.3085 1.1233 30.0103 29.5842 32.0772 30.5857 380002............................ 1.2471 0.9950 27.1861 30.3385 31.5214 29.7041 380004............................ 1.7236 1.1233 30.5172 32.6901 34.5430 32.6119 380005............................ 1.4094 1.0304 30.2210 30.9087 33.2838 31.5051 380007............................ 2.0573 1.1233 33.9969 33.9601 35.1698 34.3879 380008............................

***

* 25.8356

[[Page 24899]]

380009............................ 2.0468 1.1233 31.7042 32.4016 34.5626 32.8910 380010............................

***

* 30.2957 34.4208

* 32.1520 380014............................ 1.9254 1.0708 29.9648 33.6078 33.1920 32.2199 380017............................ 1.8307 1.1233 32.2447 34.2605 35.3727 33.9499 380018............................ 1.9127 1.0304 28.0701 30.9923 31.8162 30.3574 380020............................ 1.4175 1.1008 28.3563 29.6053 34.6178 30.5328 380021............................ 1.4799 1.1233 29.3295 29.2164 32.6143 30.3295 380022............................ 1.3427 1.0322 29.2642 30.1742 29.6225 29.6961 380023............................ 1.1613

* 26.5439

* 26.5439 380025............................ 1.2130 1.1233 33.2105 35.5084 36.4904 35.1203 380027............................ 1.2891 1.0713 25.5161 26.4982 28.0232 26.6747 380029............................ 1.2598 1.0404 26.9967 28.7994 29.4458 28.4963 380033............................ 1.7477 1.1008 30.8767 33.4828 34.0066 32.8324 380037............................ 1.3213 1.1233 30.5818 32.4033 32.7927 31.9695 380038............................ 1.3172 1.1233 34.2303 34.5971 35.1114 34.6434 380039............................

***

* 32.3959 38.0989

* 34.9720 380040............................ 1.4149 0.9950 32.0103 31.2286 32.9082 32.0782 380047............................ 1.8758 1.0592 29.8627 31.0584 32.8186 31.2890 380050............................ 1.4603 1.0151 25.6190 27.1814 29.7312 27.5470 380051............................ 1.6397 1.0404 29.7219 30.8891 32.8537 31.1839 380052............................ 1.2960 0.9950 24.9476 25.6085 28.6112 26.2863 380056............................ 1.1337 1.0404 25.1475 27.7253 29.1649 27.4834 380060............................ 1.4638 1.1233 30.7041 32.0101 33.8855 32.2257 380061............................ 1.6749 1.1233 29.8217 32.3699 34.5222 32.2741 380071............................ 1.3167 1.1233 30.2304 31.7761 31.0905 31.0383 380075............................ 1.3427 1.0304 29.0368 33.8962 31.6899 31.4887 380081............................ 0.6765 0.9950 21.8850 26.8149 28.9626 25.5794 380082............................ 1.2728 1.1233 32.3002 35.6708 35.7815 34.6173 380089............................ 1.3127 1.1233 33.4214 34.6015 35.4845 34.5150 380090............................ 1.3031 1.0713 34.4536 33.0990 35.5491 34.3699 380091............................ 1.3581 1.1233 33.8950 39.9703 40.5058 38.1381 380100............................ 1.6492 1.1233

* 390001............................ 1.5910 0.8366 22.5309 23.6075 24.3387 23.5011 390002............................ 1.2796 0.8388 22.4388 24.7867 25.0846 24.1306 390003............................ 1.1972 0.8366 21.6477 23.3672 24.6385 23.2157 390004............................ 1.5727 0.9240 24.3249 24.4068 25.3218 24.7131 390006............................ 1.9184 0.9130 25.1216 26.8581 28.7849 27.0024 390008............................ 1.1369 0.8421 22.2680 22.8042 22.6293 22.5687 390009............................ 1.8139 0.8507 25.5482 26.7462 26.7227 26.3592 390010............................ 1.1864 0.8388 23.5390 24.5785 24.8175 24.2866 390011............................

***

* 21.9279 21.4856 20.2276 21.2239 390012............................ 1.2254 1.0906 28.5076 30.7542 32.3118 30.5163 390013............................ 1.3340 0.9130 24.0044 25.0037 26.2309 25.0972 390016............................ 1.2391 0.8701 21.9549 23.2095 24.3473 23.2182 390019............................ 1.1019 1.0024 23.4636 24.0538 25.7506 24.3568 390022............................

***

* 29.0710 30.3565 29.6304 29.6954 390023............................ 1.2530 1.0906 31.7149 35.4452 34.7747 34.0474 390024............................ 1.0208 1.0906 35.3960 33.5186 39.7191 35.9814 390025............................ 0.4785 1.0906 17.2977 19.1362 20.3840 18.9796 390026............................ 1.2151 1.0906 29.5157 31.8512 31.8294 31.0655 390027............................ 1.7286 1.0906 35.8381 35.5692 39.2148 36.9324 390028............................ 1.6335 0.8388 25.7246 27.1869 27.1447 26.6793 390030............................ 1.1566 1.0024 22.1581 23.6063 24.6318 23.4864 390031............................ 1.2252 0.9419 22.6828 26.2654 27.2007 25.3401 390032............................ 1.2843 0.8388 22.7205 23.9466 24.5233 23.7226 390035............................ 1.1523 1.0906 26.2647 28.4564 29.5405 28.1286 390036............................ 1.4372 0.8388 24.6032 21.6358 24.4924 23.5132 390037............................ 1.4045 0.8388 24.7820 25.4290 25.2295 25.1463 390039............................ 1.1412 0.8366 20.3787 22.0208 23.2288 21.8618 390041............................ 1.2811 0.8388 21.5925 22.9814 24.2252 22.9571 390042............................ 1.3531 0.8388 25.6328 28.3633 28.0982 27.3600

[[Page 24900]]

390043............................ 1.2012 0.8366 22.2549 23.2378 24.2078 23.2254 390044............................ 1.6708 1.0778 27.1505 28.7758 29.4037 28.4744 390045............................ 1.5821 0.8366 23.0712 23.9343 24.6486 23.8977 390046............................ 1.6479 0.9589 27.2630 29.6574 29.9620 28.9961 390048............................ 1.0778 0.9130 24.9759 28.5342 28.3118 27.3366 390049............................ 1.5920 1.0024 27.1366 29.6121 30.7411 29.2421 390050............................ 2.0718 0.8388 26.6931 27.2599 27.3478 27.1027 390052............................ 1.1793 0.8410 23.3474 24.9510 25.1446 24.4778 390054............................

***

* 22.8087 24.4435 27.4795 24.7386 390055............................

***

* 25.6945

* 25.6945 390056............................ 1.0633 0.8366 19.5537 23.5077 23.5637 22.1096 390057............................ 1.3240 1.0906 27.9583 29.7982 30.8283 29.5698 390058............................ 1.3199 0.9240 27.4799 26.9546 27.7268 27.3837 390061............................ 1.4182 0.9589 28.4538 29.1318 30.0565 29.1849 390062............................ 1.1297 0.8366 21.4051 21.2999 21.0708 21.2582 390063............................ 1.8004 0.8507 24.7614 26.4998 26.8353 26.0645 390065............................ 1.2577 1.0108 25.2188 27.6249 29.5649 27.4343 390066............................ 1.4268 0.9130 24.2087 25.9645 25.4393 25.2120 390067............................ 1.8076 0.9240 26.3287 29.7234 30.6094 28.8535 390068............................ 1.3351 0.9589 25.8291 26.7358 29.0944 27.1392 390070............................ 1.4180 1.0906 30.9500 33.3185 34.4930 32.9334 390071............................ 1.0299 0.8366 21.8367 24.6462 24.8460 23.7235 390072............................ 1.0763 0.8366 24.9389 25.3029 26.2548 25.5020 390073............................ 1.7429 0.8366 26.3698 25.7822 26.4077 26.2014 390074............................

***

* 22.8545 23.6500 25.4092 23.9492 390075............................

***

* 24.6359

* 24.6359 390076............................ 1.4123 1.0906 27.9004 31.8500 32.7649 30.8669 390079............................ 1.8385 0.8779 23.3053 22.5607 24.4435 23.4342 390080............................ 1.3296 1.0906 27.2616 28.7063 29.2639 28.4487 390081............................ 1.2598 1.0752 30.3840 31.7569 33.6236 31.9438 390084............................ 1.0968 0.8366 19.8606 23.2039 24.3329 22.4562 390086............................ 1.6536 0.8366 22.5317 23.5141 25.0983 23.7475 390090............................ 1.9853 0.8388 25.2014 27.3528 27.0118 26.5228 390091............................ 1.1455 0.8775 21.5586 21.7010 23.3559 22.1984 390093............................ 1.1582 0.8388 21.4401 22.6082 22.6016 22.2273 390095............................ 1.1970 0.8366 23.6240 22.6150 24.6271 23.6286 390096............................ 1.5973 1.0778 27.0763 28.8258 28.6039 28.1713 390097............................ 1.2470 1.0906 25.6660 26.1741 27.9853 26.5901 390100............................ 1.7090 0.9589 27.7208 30.0132 30.0428 29.3272 390101............................ 1.2975 0.9307 21.9418 23.1497 24.8352 23.3524 390102............................ 1.4439 0.8388 24.8898 24.8369 24.4585 24.7139 390103............................ 0.8439 0.8388 20.6775 20.5741 20.4440 20.5654 390104............................ 1.0870 0.8366 19.6428 19.2326 19.6622 19.5081 390107............................ 1.5261 0.8388 24.1386 24.1159 24.6567 24.3173 390108............................ 1.2329 1.0906 27.2661 27.8171 28.5901 27.9019 390109............................ 1.1589

* 19.9156

* 19.9156 390110............................ 1.6020 0.8388 23.9808 27.7311 25.3386 25.6176 390111............................ 2.1643 1.0906 32.6510 34.2990 34.8737 33.9658 390112............................ 1.2290 0.8366 19.2126 20.2380 21.5428 20.3235 390113............................ 1.2888 0.8775 22.2591 23.3686 24.2583 23.3082 390114............................ 1.5631 0.8388 24.0473 26.9620 27.9174 26.3014 390115............................ 1.4526 1.0906 27.7333 29.6905 30.8033 29.4301 390116............................ 1.2416 1.0906 30.2722 32.2513 33.2549 31.9771 390117............................ 1.1678 0.8366 20.3946 20.7821 21.5035 20.9015 390118............................ 1.1725 0.8366 21.5001 20.5614 21.8906 21.3374 390119............................ 1.3029 0.8366 22.2746 23.0928 24.3227 23.2316 390121............................

***

* 23.1408 25.4826

* 24.2748 390122............................ 1.0760 0.8415 22.5786 23.1866 23.3220 23.0325 390123............................ 1.1933 1.0906 28.6269 32.4528 34.0037 31.6497 390125............................ 1.2622 0.8366 20.9456 22.4033 22.8792 22.0898 390127............................ 1.3278 1.0906 30.9374 31.9091 33.6955 32.1928

[[Page 24901]]

390128............................ 1.2537 0.8388 23.1539 24.1628 24.1382 23.8227 390130............................ 1.2868 0.8366 24.0685 23.0592 23.2426 23.4688 390131............................ 1.3320 0.8388 22.6306 23.0577 23.5768 23.1072 390132............................ 1.4492 1.0906 27.7250 29.6396 31.1131 29.5021 390133............................ 1.7198 1.0778 28.7162 31.1083 32.9942 31.0177 390135............................

***

* 24.4738

* 24.4738 390136............................

***

* 22.1415 23.9813

* 23.0891 390137............................ 1.4877 0.8366 23.4877 24.2878 26.1444 24.6484 390138............................ 1.1925 0.9130 24.2769 25.3410 27.4226 25.7127 390139............................ 1.3707 1.0906 30.4246 34.1447 34.0800 32.9175 390142............................ 1.5236 1.0906 32.5786 33.8224 34.5755 33.7216 390145............................ 1.5372 0.8388 23.8041 24.6672 25.6972 24.7296 390146............................ 1.2178 0.8385 25.2460 22.6752 25.1795 24.3869 390147............................ 1.3587 0.8388 25.0971 26.8522 28.6585 26.8141 390150............................ 1.1283 0.8388 24.1855 22.8228 22.7669 23.2856 390151............................ 1.3568 1.0990 27.1539 29.9254 31.4053 29.5922 390153............................ 1.3449 1.0906 30.0585 32.8234 33.2401 32.1631 390154............................ 1.2257 0.8366 20.6982 22.8391 23.3554 22.2878 390156............................ 1.3797 1.0752 31.2571 32.2688 32.8981 32.1217 390157............................ 1.2706 0.8388 22.7493 21.5923 22.1101 22.1488 390160............................ 1.2523 0.8388 21.4877 24.0208 22.9688 22.8164 390162............................ 1.4945 1.1578 30.0900 35.5057 34.5792 33.2581 390163............................ 1.2309 0.8388 22.1741 23.2055 22.8331 22.7280 390164............................ 2.1785 0.8388 26.4971 26.3087 27.1941 26.6933 390166............................ 1.1701 0.8388 24.9810 20.9272 23.3249 23.1376 390168............................ 1.5196 0.8388 24.5820 26.1365 26.9801 25.9244 390169............................ 1.4291 0.8366 27.2242 26.5514 26.2631 26.6871 390173............................ 1.1808 0.8366 22.8220 23.9927 25.6446 24.1667 390174............................ 1.7023 1.0906 32.6265 34.2069 35.2897 34.0693 390176............................ 1.0556 0.8388

* 23.9779 24.1240 24.0542 390178............................ 1.3607 0.8996 20.7270 22.6006 23.1440 22.1434 390179............................ 1.4433 1.0906 27.2222 28.0688 30.1208 28.5190 390180............................ 1.4073 1.0752 32.4375 34.9832 35.5103 34.3001 390181............................ 1.1003 0.8366 24.4573 25.9871 26.6009 25.6297 390183............................ 1.1425 0.8366 25.6554 27.0122 27.8354 26.8138 390184............................ 1.1043 0.8388 22.5519 22.7451 23.9729 23.0650 390185............................ 1.2679 0.8366 23.0202 25.4256 27.1111 25.2264 390189............................ 1.1536 0.8366 22.3722 22.6796 23.6210 22.9386 390191............................ 1.1480

* 20.8761

* 20.8761 390192............................ 0.9891 0.8366 21.2619 20.5459 23.6172 21.8230 390193............................

***

* 20.1024

* 20.1024 390194............................ 1.1200 1.0024 25.4235 27.5890 26.3138 26.4431 390195............................ 1.6265 1.0906 31.0019 34.2980 34.5552 33.3460 390196............................ 1.6615

* 390197............................ 1.3824 1.0024 25.7739 26.8270 27.2431 26.6095 390198............................ 1.0937 0.8507 18.7222 20.5979 20.4340 19.9083 390199............................ 1.1706 0.8366 21.3157 22.3224 23.0031 22.2033 390200............................

***

* 23.7471

* 23.7471 390201............................ 1.3000 0.8366 26.3658 27.0054 27.3536 26.9243 390203............................ 1.6186 1.0906 28.9054 29.4930 29.1367 29.1780 390204............................ 1.2999 1.0906 28.6829 29.5251 30.3378 29.5558 390211............................ 1.2565 0.8996 23.1450 25.1689 26.5027 24.9525 390215............................

***

* 28.0403

* 28.0403 390217............................ 1.2441 0.8388 24.3610 23.5879 24.1877 24.0510 390219............................ 1.3184 0.8388 25.1705 25.4886 26.1182 25.5759 390220............................ 1.1219 1.0906 41.6138 28.9128 30.7413 32.7167 390222............................ 1.2934 1.0752 28.7488 30.9464 31.7312 30.5055 390223............................ 2.0315 1.0906 27.6407 30.2523 34.3250 30.7316 390224............................

***

* 18.7624

* 18.7624 390225............................ 1.2235 0.9589 24.9391 27.5803 27.2537 26.6140 390226............................ 1.7791 1.0906 28.5890 32.6658 32.6482 31.2951

[[Page 24902]]

390228............................ 1.3964 0.8388 23.3078 23.9845 24.2239 23.8473 390231............................ 1.4024 1.0906 29.2653 30.9339 32.8332 30.9979 390233............................ 1.3811 0.9307 24.8690 25.6904 27.2575 25.9600 390236............................ 0.9656 0.8366 21.9169 22.1144 23.1290 22.3772 390237............................ 1.6150 0.8366 26.9533 27.4944 28.4317 27.5813 390246............................ 1.1274 0.8366 20.1581 25.1956 26.0175 23.4881 390256............................ 1.9049 0.9240 26.3619 28.0617 28.8967 27.8208 390258............................ 1.5061 1.0906 29.4626 30.4142 31.7149 30.6070 390263............................ 1.5329 1.0024 26.0170 28.5864 29.9800 28.2983 390265............................ 1.5078 0.8388 23.4836 24.0675 24.5237 24.0290 390266............................ 1.1594 0.8996 20.3918 20.8789 22.2224 21.1790 390267............................ 1.2788 0.8388 23.1051 24.2428 24.8302 24.0574 390268............................ 1.3895 0.8625 25.0021 25.6643 26.7336 25.8427 390270............................ 1.6237 0.8366 24.1496 24.9510 26.5010 25.2638 390272............................ 0.5351 1.0906

* 390278............................ 0.5328 1.0906 23.6843 26.6664 28.6253 26.2989 390279............................

***

* 17.0012

* 17.0012 390285............................ 1.4982 1.0906 35.0426 36.7163 37.6664 36.3989 390286............................ 1.1892 1.0906 28.1761 29.5281 31.3380 29.6274 390287............................

***

* 37.6569 39.3176 42.2395 39.3145 390288............................

***

* 29.7287 30.9701

* 30.3388 390289............................

***

* 28.8826 30.7583

* 29.8023 390290............................ 1.8483 1.0906 37.9040 38.3776 41.1403 39.1280 390301............................

***

* 30.9836

* 30.9836 390302............................ 2.0384 1.0906

* 390303............................

***

* 27.5580

* 27.5580 390304............................ 1.2294 1.0906

* 30.4832 32.1625 31.3744 390305............................

***

* 29.3209 29.3209 390306............................

***

* 40.3778 40.3778 390307............................ 1.9734 0.8996

* 24.5413 24.5413 390308............................

***

* 36.1732 36.1732 390309............................

***

* 37.8919 37.8919 390310............................

***

* 44.3970 44.3970 390311............................ 2.0736 1.0906

* 390312............................ 1.1713 1.0906

* 390313............................ 1.1482 0.9419

* 400001............................ 1.2869 0.4517 13.1847 13.9386 14.9133 14.0366 400002............................ 1.8475 0.4161 16.7582 15.3833 12.9440 14.8789 400003............................ 1.3852 0.4161 12.8329 13.9258 15.6771 14.1320 400004............................ 1.2261 0.4517 14.3108 12.0923 12.5936 12.8944 400005............................ 1.1254 0.4517 10.7207 10.3505 11.1153 10.7266 400006............................ 1.1848 0.4517 9.2265 8.1841 8.4089 8.6005 400007............................ 1.2016 0.4517 9.2463 11.8203 12.0726 11.0856 400009............................ 1.0096 0.2946 9.3116 9.3834 9.5111 9.4052 400010............................ 0.9284 0.3298 10.0962 9.8132 10.7991 10.2159 400011............................ 1.0610 0.4517 8.5534 9.6641 8.5501 8.9390 400012............................ 1.4671 0.4517 8.3802 12.3362 10.1144 10.1137 400013............................ 1.2470 0.4517 10.3347 11.1414 11.4213 10.9909 400014............................ 1.3721 0.3659 12.2169 10.5286 9.9385 10.8298 400015............................ 1.3247 0.4517 15.6349 13.7043 22.1997 17.0460 400016............................ 1.3936 0.4517 14.7607 16.6472 16.1412 15.8512 400017............................ 0.9861 0.4517 10.2734 10.3123 9.9191 10.1746 400018............................ 1.1698 0.4517 11.6165 11.9184 12.3935 11.9802 400019............................ 1.4381 0.4517 12.8029 12.8380 14.7123 13.3471 400021............................ 1.4346 0.4605 14.1534 14.4549 13.9215 14.1634 400022............................ 1.4165 0.4161 15.9246 14.9089 15.2620 15.3447 400024............................ 0.8885 0.3659 12.4648 10.8439 12.6216 11.9950 400026............................ 1.0798 0.2946 5.8200 9.9262 7.1176 7.2041 400028............................ 1.0991 0.4161 10.9808 11.3260 10.6709 10.9928 400032............................ 1.1384 0.4517 10.2652 10.3736 10.7136 10.4544 400044............................ 1.2888 0.4161 13.7509 14.6420 10.5388 12.6107

[[Page 24903]]

400048............................ 1.1731 0.4517 10.4266 9.6416 9.6856 9.9021 400061............................ 2.0008 0.4517 18.9123 18.1303 18.0103 18.3237 400079............................ 1.2350 0.3298 12.7825 9.5296 10.2856 10.6551 400087............................ 1.1993 0.4517 10.6849 11.0377 11.4156 11.0321 400098............................ 1.3670 0.4517 12.8230 13.8034 13.7875 13.3736 400102............................ 1.3166 0.4517 10.2677 10.5879 12.1755 10.9323 400103............................ 1.7536 0.3659 9.3859 10.6971 11.7480 10.5154 400104............................ 1.1995 0.4517 9.3854 11.4322 12.8402 11.2160 400105............................ 1.1555 0.4517 14.0219 15.6626 16.9039 15.5355 400106............................ 1.1079 0.4517 11.4507 13.4097 12.9264 12.5584 400109............................ 1.4454 0.4517 14.2111 14.4386 14.8196 14.4933 400110............................ 1.2255 0.3203 12.3449 11.1812 9.9275 11.1279 400111............................ 1.1570 0.3298 14.5029 14.1718 10.0679 12.5939 400112............................ 1.2217 0.4517 19.3945 10.1512 13.4904 13.2997 400113............................ 1.2935 0.4161 9.6778 10.5305 10.9503 10.3752 400114............................ 1.1422 0.4517 11.5478 10.1379 10.8905 10.8232 400115............................ 1.0297 0.4517 13.7392 12.0713 9.6200 11.5296 400117............................ 1.1097 0.4517 12.7600 9.5929 11.2873 10.9990 400118............................ 1.2474 0.4517 12.5743 12.8692 12.2614 12.5587 400120............................ 1.3545 0.4517 12.7955 13.4069 14.0810 13.4541 400121............................ 1.0490 0.4517 8.2197 9.7427 9.1824 9.0004 400122............................ 1.9135 0.4517 11.2324 8.9478 9.5819 10.3492 400123............................ 1.2192 0.3659 12.3041 12.8317 12.5605 12.5624 400124............................ 2.7654 0.4517 16.1812 17.2139 17.9135 17.1102 400125............................ 1.2125 0.4121 11.6386 11.9787 12.7755 12.1173 400126............................ 1.2050 0.4605 9.8008 14.1062 16.5721 12.5521 400127............................ 1.7568 0.4517

* 17.8303 20.7788 19.5311 400128............................ 1.0765 0.4517

* 12.3508 12.3508 410001............................ 1.3006 1.1256 28.0816 29.0877 30.0107 29.0623 410004............................ 1.2498 1.1256 27.4209 29.4953 33.5477 30.0869 410005............................ 1.2488 1.1256 30.1606 28.1141 31.7260 29.9813 410006............................ 1.3443 1.0654 29.4395 30.1855 32.8447 30.8317 410007............................ 1.6516 1.1256 31.8548 33.2896 32.0716 32.4071 410008............................ 1.2351 1.0654 29.6092 30.9505 32.5870 31.0405 410009............................ 1.2438 1.0654 29.4094 31.7300 32.8406 31.3626 410010............................ 1.1857 1.1256 32.8599 32.0704 32.7383 32.5468 410011............................ 1.3917 1.1256 30.3787 33.8781 30.2382 31.4189 410012............................ 1.6858 1.1256 32.6009 33.6072 37.0294 34.4552 410013............................ 1.2112 1.1794 35.4624 35.8075 41.0799 37.4473 420002............................ 1.5894 0.9512 28.2848 29.5592 30.5925 29.4848 420004............................ 1.9971 0.9144 27.2620 28.1455 28.9237 28.1331 420005............................ 1.1309 0.8791 23.1943 25.0420 26.3939 24.9179 420006............................

***

* 24.0811 26.3293 27.7699 26.0549 420007............................ 1.6214 0.9386 25.2650 26.8165 28.8268 26.9868 420009............................ 1.3837 0.9386 25.5079 27.0147 29.9490 27.4958 420010............................ 1.1456 0.8791 23.4562 25.1452 25.5677 24.7554 420011............................ 1.1700 0.9664 21.4029 22.1787 24.5883 22.7258 420015............................ 1.3589 0.9664 26.2154 24.1685 26.3714 25.5781 420016............................ 0.9742 0.8791 17.1229 21.6266 22.2776 20.2191 420018............................ 1.8381 0.8791 24.8024 25.6687 27.5522 26.0434 420019............................ 1.0975 0.8933 22.5312 22.5489 25.4922 23.3958 420020............................ 1.2772 0.9144 25.8883 28.4344 29.5695 27.8470 420023............................ 1.6934 0.9664 26.7263 27.4589 29.9819 28.0277 420026............................ 1.8820 0.8791 27.4814 27.8986 27.2418 27.5412 420027............................ 1.5860 0.9386 25.1692 26.4472 28.1687 26.6066 420030............................ 1.2464 0.9144 26.0079 27.8435 28.4401 27.4508 420033............................ 1.1208 0.9664 31.8759 30.4162 31.6349 31.2973 420036............................ 1.2394 0.9348 22.8294 23.8742 24.6494 23.7914 420037............................ 1.3000 0.9664 29.4156 29.8321 30.8503 30.0400 420038............................ 1.2507 0.9664 24.2259 24.6642 26.6292 25.1611 420039............................ 1.1499 0.9334 25.1148 28.2220 28.9841 27.4319

[[Page 24904]]

420043............................ 1.1016 0.8923 23.0555 24.0971 25.7926 24.3478 420048............................ 1.2711 0.8791 24.1923 25.9610 26.8917 25.7298 420049............................ 1.2515 0.8791 23.9722 26.0953 25.6953 25.2614 420051............................ 1.6594 0.8791 24.8026 25.9056 26.6341 25.7969 420053............................ 1.1285 0.8791 22.2825 23.2246 24.4642 23.3619 420054............................ 1.1334 0.8791 24.8931 25.6779 25.6413 25.3982 420055............................ 1.0786 0.8791 21.9764 24.0965 25.1550 23.7646 420056............................ 1.3295 0.8791 21.6963 27.7250 25.5489 24.9908 420057............................ 1.1850 0.8791 23.4312 24.9313 25.4571 24.6270 420062............................ 1.0478 0.9348 25.9526 26.7467 25.9555 26.2258 420064............................ 1.1882 0.8791 23.3610 24.3540 24.5219 24.0703 420065............................ 1.4437 0.9144 24.5715 25.5483 26.8333 25.6653 420066............................ 1.0105 0.8791 23.9049 25.1062 26.7458 25.3096 420067............................ 1.3630 0.8987 25.0345 25.8561 26.5058 25.8193 420068............................ 1.3719 0.9144 23.4248 25.6857 27.5799 25.6023 420069............................ 1.1737 0.8791 20.5546 22.3445 23.7228 22.2320 420070............................ 1.2994 0.8875 23.4355 24.7899 27.5115 25.3139 420071............................ 1.4292 0.9386 24.9418 25.2862 27.6368 25.9945 420072............................ 1.0662 0.8791 18.6742 17.8019 21.6507 19.2795 420073............................ 1.3854 0.8791 24.5813 25.5204 26.1111 25.4567 420078............................ 1.9217 0.9664 28.9112 29.5135 30.6777 29.7053 420079............................ 1.4849 0.9144 25.4935 27.5439 28.6353 27.2411 420080............................ 1.4418 0.8987 28.4735 28.6060 31.5679 29.4702 420082............................ 1.5165 0.9600 29.8528 31.2671 33.6740 31.5607 420083............................ 1.4762 0.9386 27.1322 26.4932 28.9023 27.5471 420085............................ 1.5565 0.9172 26.8692 27.8386 29.2277 27.9683 420086............................ 1.4540 0.8791 25.8869 28.0485 27.9384 27.3327 420087............................ 1.8324 0.9144 24.3609 25.4697 27.3264 25.7075 420089............................ 1.3997 0.9144 26.0074 28.1855 29.5860 27.9479 420091............................ 1.4226 0.8791 26.9214 26.0592 26.8712 26.6184 420093............................

***

* 27.4767 28.0765 32.8212 29.1829 420098............................ 1.1883 0.8791

* 30.7532 29.4620 30.0328 420099............................

***

* 30.2160 30.2160 420101............................ 1.1332 0.8791

* 430005............................ 1.3007 0.8343 22.3272 22.4111 23.8690 22.8727 430008............................ 1.1443 0.8880 23.3790 24.4277 26.0865 24.5248 430012............................ 1.3092 0.9395 24.0850 24.0326 25.2032 24.4263 430013............................ 1.1862 0.9395 25.1378 25.9828 27.6885 26.2696 430014............................ 1.4176 0.8343 26.4964 26.8752 27.9285 27.1026 430015............................ 1.2647 0.8343 22.7947 23.6296 26.5781 24.3440 430016............................ 1.6466 0.9558 27.8453 28.9376 32.8752 29.8586 430027............................ 1.7919 0.9558 26.2139 26.6044 27.5745 26.8174 430031............................

***

* 16.0346

* 16.0346 430047............................ 1.0090

* 18.8982

* 18.8982 430048............................ 1.2827 0.8343 23.0782 24.1969 25.1698 24.1626 430060............................ 0.8255 0.8343

* 13.2618 13.5646 13.4165 430064............................ 1.0259 0.8343 17.5376 18.3125 16.4884 17.3474 430077............................ 1.8114 0.8690 25.1763 25.8572 27.2106 26.0775 430081............................ 0.8795 1.4406

* 430082............................ 0.8113 1.4406

* 430083............................ 0.8773 1.4406

* 430084............................ 0.9092 1.4406

* 430085............................ 0.8887 1.4406

* 430089............................ 1.8601 0.9220 22.5625 22.3335 23.2471 22.7179 430090............................ 1.4726 0.9558 25.8460 26.4862 29.0203 27.2004 430091............................ 2.1556 0.8690 24.3021 25.1105 24.7273 24.7229 430092............................ 1.8602 0.8343 20.9486 21.6478 21.9206 21.5139 430093............................ 0.8372 0.8690 29.5244 27.5326 26.0248 27.6517 430094............................ 1.6473 0.8398 18.9099 22.9091 23.2862 21.6352 430095............................ 2.4550 0.9558 28.1749 31.3409 32.2291 30.5974 430096............................ 1.8925 0.8343 21.6997 21.6713 24.6038 22.6697

[[Page 24905]]

440001............................ 1.1421 0.7916 19.3100 21.2398 21.5725 20.7286 440002............................ 1.7517 0.8951 24.6664 25.7434 26.3607 25.6113 440003............................ 1.3294 0.9675 25.9209 28.4862 28.3551 27.6394 440006............................ 1.5106 0.9675 28.5951 29.7146 31.5513 29.9422 440007............................ 1.0215 0.8142 25.8236 19.9754 18.8253 20.7863 440008............................ 1.0651 0.8432 23.4301 23.2126 27.3717 24.8406 440009............................ 1.2224 0.7916 21.5970 23.9279 23.8117 23.1545 440010............................ 0.9454 0.7916 17.1803 19.3669 19.6194 18.7378 440011............................ 1.3473 0.8043 22.5068 23.6154 23.6692 23.2732 440012............................ 1.5819 0.7916 22.3029 24.0169 23.7854 23.3703 440015............................ 1.8656 0.8043 23.7422 25.0430 26.0583 24.9717 440016............................ 1.0064 0.8060 22.1645 23.0350 24.5792 23.2189 440017............................ 1.8252 0.7916 22.9364 25.0588 24.6678 24.2288 440018............................ 1.1288 0.7916 23.3445 23.2107 25.0764 23.9420 440019............................ 1.7505 0.8043 25.2553 25.3592 26.0762 25.5315 440020............................ 1.0946 0.8760 23.9475 24.0995 24.7759 24.2798 440024............................ 1.2187 0.8967 23.2717 23.9745 24.7683 24.0292 440025............................ 1.1305 0.8608 20.6798 22.5407 22.4856 21.9261 440026............................ 0.6838 0.9675 26.8986 28.0349 26.8138 27.2465 440029............................ 1.3902 0.9675 28.0779 30.1204 31.2276 29.8852 440030............................ 1.3259 0.7931 22.1217 23.7670 22.1894 22.7002 440031............................ 1.1820 0.7941 19.6684 20.8964 22.3877 20.9813 440032............................ 1.2192 0.7916 18.5277 19.7150 21.0368 19.7420 440033............................ 1.0331 0.7952 20.7917 21.1087 22.7949 21.5084 440034............................ 1.6264 0.8043 23.5403 24.6994 25.5041 24.6078 440035............................ 1.4158 0.9408 24.3752 25.9613 26.2444 25.5503 440039............................ 2.1833 0.9675 28.4678 29.8611 30.1798 29.5492 440040............................ 0.9032 0.7916 17.8509 20.8637 20.8737 19.8795 440041............................ 0.9123

* 17.9409

* 17.9409 440046............................ 1.2556 0.9675 26.1341 27.9539 29.7354 27.9631 440047............................ 0.9027 0.8254 21.4280 21.7892 22.9125 22.0779 440048............................ 1.8381 0.9291 27.7560 29.4789 29.3276 28.8736 440049............................ 1.6379 0.9291 25.3043 26.4772 28.8751 26.9261 440050............................ 1.3564 0.7916 23.1363 24.4616 24.9749 24.2258 440051............................ 0.9547 0.7987 21.9108 23.9253 23.4849 23.1289 440052............................ 0.9974 0.7916 21.1133 22.8016 22.6093 22.1794 440053............................ 1.2683 0.9675 25.4345 27.1197 27.8161 26.7570 440054............................ 1.1306 0.7916 21.4400 23.5137 23.7916 22.9255 440056............................ 1.1615 0.8043 22.1067 22.7820 23.2296 22.7142 440057............................ 1.0901 0.7944 16.4451 16.6346 17.2159 16.7756 440058............................ 1.1778 0.7916 22.9263 24.3522 26.0692 24.4594 440059............................ 1.4611 0.7916 26.3551 28.3565 27.9440 27.5537 440060............................ 1.1303 0.8432 23.3014 24.1024 25.0943 24.2363 440061............................ 1.1231 0.7916 21.8274 23.9678 23.7344 23.1104 440063............................ 1.5848 0.7916 22.3256 24.2566 23.9625 23.5403 440064............................ 1.0103 0.8967 22.0955 23.7176 26.1228 23.9663 440065............................ 1.2648 0.9675 22.3247 24.6169 25.8517 24.2948 440067............................ 1.1058 0.7916 23.1089 24.4772 24.6523 24.0976 440068............................ 1.1547 0.8967 24.5972 24.8146 26.1066 25.1512 440070............................ 0.9790 0.8025 19.4372 20.0938 21.9133 20.5428 440072............................ 1.1053 0.8951 27.1442 23.9563 25.6126 25.4529 440073............................ 1.4655 0.9408 23.9198 26.3570 27.6130 25.9554 440081............................ 1.1997 0.7985 19.7878 20.7125 20.7679 20.4353 440082............................ 2.1152 0.9675 27.9724 30.6115 32.5266 30.3207 440083............................ 0.9664 0.7916 17.3329 25.6099 23.6295 22.2394 440084............................ 1.1855 0.7950 16.3738 18.6043 18.8661 17.9487 440091............................ 1.7522 0.8967 25.6797 26.5687 28.1980 26.8419 440102............................ 1.1442 0.7916 17.5261 20.7363 21.6734 19.9750 440104............................ 1.7686 0.8967 25.3739 26.5741 27.9739 26.6317 440105............................ 0.8903 0.7916 22.3438 22.9372 27.5434 24.0199 440109............................ 0.9695 0.7986 18.6720 20.8924 21.4586 20.4120

[[Page 24906]]

440110............................ 1.1525 0.8043 21.3287 20.9179 22.5922 21.8673 440111............................ 1.2969 0.9675 28.5705 29.0975 28.8328 28.8339 440114............................

***

* 24.0146

* 24.0146 440115............................ 1.0086 0.8254 21.7830 23.1409 23.7906 22.9173 440120............................ 1.5948 0.8043 25.5961 25.7161 24.7561 25.3527 440125............................ 1.6036 0.8043 22.4196 22.8097 23.6317 22.9327 440130............................ 1.1054 0.7916 23.4517 23.9955 25.1259 24.1967 440131............................ 1.2045 0.9291 24.9599 25.6666 26.9643 25.8558 440132............................ 1.2396 0.7916 21.5085 23.9410 24.0684 23.2162 440133............................ 1.7133 0.9675 26.2422 29.2829 30.7751 28.6805 440135............................ 0.9959 0.7916 26.6615 28.1925 27.7163 27.5263 440137............................ 1.0781 0.8679 20.6663 22.2538 22.9527 21.8983 440141............................ 0.9681 0.7916 21.3314 24.2406 24.9849 23.5732 440144............................ 1.3047 0.9408 23.3828 23.9241 25.2267 24.2122 440145............................ 1.0761

* 20.7875

* 20.7875 440147............................

***

* 31.4012 33.1756 35.3815 33.3203 440148............................ 1.1126 0.9408 24.6412 23.9810 22.6179 23.6901 440149............................

***

* 20.4563

* 20.4563 440150............................ 1.3903 0.9675 26.8308 28.1012 29.4367 28.1239 440151............................ 1.1741 0.9408 23.9808 27.1729 28.2182 26.4231 440152............................ 1.9279 0.9291 26.5513 27.1877 27.6451 27.1413 440153............................ 1.0815 0.7916 22.2846 23.6473 24.7378 23.4975 440156............................ 1.6521 0.8967 26.9689 27.7309 28.5630 27.7803 440159............................ 1.5137 0.9291 22.8645 26.9098 25.8246 25.2919 440161............................ 1.8708 0.9675 28.6971 28.7074 29.9892 29.1536 440162............................

***

* 21.1418 27.6837 24.8692 24.4630 440166............................

***

* 31.0779 35.3064

* 32.7296 440168............................ 0.9651 0.9291 22.8768 28.1215 29.4005 26.9610 440173............................ 1.4388 0.8043 22.8846 23.1167 24.0604 23.3811 440174............................ 0.8951 0.8226 22.0974 25.4829 26.2049 24.7272 440175............................ 1.0345 0.9408 22.7299 24.4848 24.7857 23.9708 440176............................ 1.2746 0.7916 23.6659 22.9631 24.1236 23.6112 440180............................ 1.2911 0.7952 23.3808 24.9841 22.3062 23.4471 440181............................ 0.9192 0.8277 22.7151 24.8857 26.0287 24.6007 440182............................ 0.9950 0.8060 22.3612 24.3302 25.0070 23.9818 440183............................ 1.5965 0.9291 27.1515 29.1982 30.6570 28.9837 440184............................ 0.9643 0.7916 22.3475 24.5786 23.3803 23.4120 440185............................ 1.1499 0.8967 23.9052 25.3817 26.7453 25.4013 440186............................ 0.9668 0.9675 25.7445 27.3733 28.9113 27.3826 440187............................ 1.0856 0.7916 21.3252 24.0723 25.8192 23.7538 440189............................ 1.3576 0.8590 27.5435 28.2621 28.8947 28.1761 440192............................ 1.0840 0.9408 25.7495 27.3917 29.6238 27.6362 440193............................ 1.3501 0.9675 24.4299 24.3622 25.2113 24.6709 440194............................ 1.3057 0.9675 26.6527 29.4706 30.8500 29.0988 440197............................ 1.3661 0.9675 27.1534 29.4275 30.3318 28.9141 440200............................ 0.9726 0.9675 17.7491 21.1860 23.8598 20.9517 440203............................

***

* 19.3864 23.7451 17.9024 20.1678 440217............................ 1.3238 0.9291 28.5968 28.8641 29.9206 29.1168 440218............................ 2.1944 0.9675 24.6465 23.7257 18.7271 22.2602 440222............................ 1.0509 0.9291 29.7292 28.4664 29.0064 29.0426 440224............................ 0.8974 0.9675

* 440225............................ 0.7984 0.8043

* 24.8328 27.8866 26.2413 440226............................ 1.5497 0.8043

* 26.5831 28.3236 27.4254 440227............................ 1.3258 0.9675

* 30.7783 30.7783 440228............................ 1.4433 0.9291

* 28.3673 28.3673 450002............................ 1.4197 0.9144 25.7171 28.0936 28.8502 27.4825 450005............................ 1.0714 0.8587 23.5576 24.4933 24.5392 24.1596 450007............................ 1.3062 0.8916 20.7321 23.0026 23.9736 22.5788 450008............................ 1.2938 0.8308 22.9669 24.4701 24.5969 24.0254 450010............................ 1.6531 0.8488 23.7529 25.5503 26.5222 25.2850 450011............................ 1.6897 0.9177 24.8831 26.7418 28.5316 26.6971

[[Page 24907]]

450015............................ 1.5327 0.9795 27.4012 29.9193 29.4897 28.9233 450018............................ 1.5156 1.0048 26.7999 30.2383 30.7798 29.2592 450020............................ 0.9414

* 18.3047

* 18.3047 450021............................ 1.8775 0.9795 29.1350 29.5658 31.2631 29.9537 450023............................ 1.4776 0.8204 22.0558 25.4450 25.5456 24.3102 450024............................ 1.6726 0.9144 24.4195 26.9113 28.1995 26.5982 450028............................ 1.6122 0.9577 26.8250 29.1438 30.7386 28.7980 450029............................ 1.6195 0.8484 23.2995 25.0602 26.9317 25.0099 450031............................ 1.4016 0.9795 27.9626 29.0824 30.3520 29.1122 450032............................ 1.2877 0.8615 27.0748 21.5084 25.5763 24.5156 450033............................ 1.6325 0.9577 28.4781 29.2468 29.9792 29.1869 450034............................ 1.5788 0.8587 24.1589 26.5313 27.6906 26.1014 450035............................ 1.4933 1.0048 26.2838 28.0668 28.8961 27.7041 450037............................ 1.6443 0.8875 24.2684 26.6207 28.3379 26.4148 450039............................ 1.4633 0.9681 24.7347 26.7503 28.2052 26.5789 450040............................ 1.8073 0.8678 24.9590 25.4734 26.8399 25.7395 450042............................ 1.7896 0.8598 24.1181 26.6382 26.5414 25.7894 450044............................ 1.7520 0.9795 29.4308 31.0381 29.4295 29.9719 450046............................ 1.6190 0.8460 23.4907 24.8947 25.5895 24.6756 450047............................ 0.8462 0.9577 19.8221 21.8824 23.8397 21.9016 450050............................ 0.8661

* 23.3044

* 23.3044 450051............................ 1.9226 0.9795 28.0411 28.8829 29.9034 28.9706 450052............................ 0.9462 0.8204 19.7774 22.6448 22.9956 21.3913 450053............................ 0.9303

* 21.9082

* 21.9082 450054............................ 1.7987 0.8308 24.2782 27.5399 26.5580 26.0520 450055............................ 1.0496 0.8204 22.1979 22.9245 23.6359 22.9294 450056............................ 1.7616 0.9518 27.0530 28.3092 31.5925 28.7714 450058............................ 1.5924 0.8916 25.9653 26.6926 26.9903 26.5543 450059............................ 1.3101 0.9518 26.6535 26.8325 27.3949 26.9660 450064............................ 1.4743 0.9681 23.8748 26.8355 28.2780 26.2937 450068............................ 2.1568 1.0048 27.9633 29.5876 30.5075 29.3731 450072............................ 1.2060 1.0048 24.0166 25.8619 27.0747 25.6777 450073............................ 0.8869 0.8204 21.7337 26.9446 26.0900 24.8080 450076............................ 1.6718

* 450078............................ 0.9157 0.8204 15.8968 21.4716 20.0665 18.9487 450079............................ 1.6354 0.9795 28.1096 30.2420 30.8882 29.6870 450080............................ 1.2459 0.8875 22.9836 27.9191 26.2251 25.5990 450082............................ 1.1501 0.8204 22.0442 23.9025 24.1995 23.3896 450083............................ 1.8302 0.9190 25.8214 27.4955 32.6432 28.5954 450085............................ 1.0618 0.8204 22.0840 24.3637 25.6398 24.0602 450087............................ 1.4149 0.9681 29.1587 30.0095 31.2651 30.1449 450090............................ 1.2358 0.8855 19.4245 21.3837 21.8819 20.8844 450092............................ 1.1888 0.8204 23.2071 24.9917 26.0863 24.7978 450094............................

***

* 25.2434

* 25.2434 450096............................

***

* 24.1618 26.5103 28.1877 26.1057 450097............................ 1.4833 1.0048 26.4965 29.0142 29.8695 28.4563 450098............................ 0.9764

* 22.6626

* 22.6626 450099............................ 1.2850 0.9141 26.6796 31.3495 31.8214 29.8896 450101............................ 1.6845 0.8598 23.6905 25.4409 26.7429 25.2714 450102............................ 1.7567 0.9190 24.5503 25.6318 26.4138 25.5264 450104............................ 1.1914 0.8916 23.8469 24.6169 28.8008 25.7423 450107............................ 1.5656 0.9144 25.9326 27.6064 27.8167 27.1281 450108............................ 1.2022 0.8916 19.4935 21.6557 19.3203 20.1279 450113............................

***

* 54.6663

* 54.6663 450119............................ 1.3063 0.9140 25.7008 27.8027 31.0620 28.0085 450121............................

***

* 25.7051 29.1296 27.7456 27.5362 450123............................ 1.2264 0.8587 21.2154 24.9674 26.2404 24.0842 450124............................ 1.8765 0.9518 27.4198 28.2571 30.9581 28.8840 450126............................ 1.3815 1.0048 28.3032 29.3768 29.6165 29.1427 450128............................ 1.2607 0.9140 23.3633 25.1122 26.3380 24.9423 450130............................ 1.1616 0.8916 21.5226 24.3295 24.3816 23.4123

[[Page 24908]]

450131............................

***

* 23.7098 25.9494

* 24.6979 450132............................ 1.5741 0.9959 28.6954 30.1620 31.9964 30.2610 450133............................ 1.5650 1.0016 26.8344 28.4647 31.0158 28.7726 450135............................ 1.7036 0.9681 26.0755 27.8983 30.1366 28.0785 450137............................ 1.7292 0.9681 30.4254 31.4950 31.9628 31.3189 450143............................ 0.9894 0.9518 21.8705 23.4592 23.6800 23.0239 450144............................ 1.0806 0.8762 21.3289 26.2881 29.4336 25.2664 450147............................ 1.5058 0.8204 23.9771 24.3562 24.7217 24.3816 450148............................ 1.2596 0.9681 25.3498 27.0894 29.6769 27.2881 450151............................

***

* 22.2915 23.9558 26.1922 24.2420 450152............................ 1.2210 0.8308 22.7463 23.3428 23.1056 23.0676 450154............................ 1.3960 0.8204 21.2021 21.7237 22.9324 21.9516 450155............................ 1.1128 0.8204 18.0588 21.7604 24.8023 21.2754 450162............................ 1.3172 0.8678 30.9903 33.3285 32.9269 32.4564 450163............................ 1.0672 0.8257 23.1400 24.1267 24.7829 24.0364 450165............................ 1.1659 0.8916 24.3242 28.6490 29.1799 27.3444 450176............................ 1.3543 0.9140 20.9297 23.1284 24.4427 22.7685 450177............................ 1.1710 0.8204 21.3322 23.7624 24.4026 23.1595 450178............................ 0.9841 0.9527 24.7301 27.8405 27.1083 26.5644 450184............................ 1.5603 1.0048 26.7821 28.5399 29.7402 28.3456 450187............................ 1.1820 1.0048 25.6787 28.3243 27.7355 27.2563 450188............................ 0.9378 0.8204 20.4070 23.0595 23.2229 22.2784 450191............................ 1.1685 0.9518 26.0298 26.5863 28.3929 27.0034 450192............................ 1.1362 0.8475 22.5880 24.1186 26.5577 24.4507 450193............................ 2.0914 1.0048 32.2964 34.4545 36.4769 34.4405 450194............................ 1.3698 0.8417 24.8972 22.9605 24.3528 24.0549 450196............................ 1.4362 0.9681 24.7557 24.0161 23.4570 24.1008 450200............................ 1.5832 0.8204 23.5344 23.5012 25.6410 24.1113 450201............................ 0.9691 0.8204 20.9810 23.2510 23.2742 22.5445 450203............................ 1.1773 0.9646 24.1675 26.5237 27.8762 26.2137 450209............................ 1.9557 0.9141 26.0958 27.5668 30.4681 27.9965 450210............................ 0.9541 0.8354 19.9832 21.8722 22.5708 21.5253 450211............................ 1.3229 0.8875 23.8230 28.4581 28.3715 26.9028 450213............................ 1.9199 0.8916 23.9676 25.9169 26.8539 25.6070 450214............................ 1.2475 1.0048 25.9598 27.4357 28.1262 27.1815 450219............................ 0.9710 0.8204 21.7934 21.9207 23.9627 22.5466 450221............................ 1.1296 0.8204 20.3186 19.3793 21.3691 20.3727 450222............................ 1.6669 1.0048 27.4426 30.0314 30.3786 29.2826 450224............................ 1.3681 0.9190 24.1956 26.8302 28.4367 26.4253 450229............................ 1.6513 0.8244 21.4459 24.4450 25.1327 23.6486 450231............................ 1.6695 0.9141 25.2852 27.1674 26.9773 26.4819 450234............................ 1.0260 0.8204 18.4451 20.6889 20.4622 19.9270 450235............................ 1.0130 0.8204 21.5138 23.5212 21.8936 22.3093 450236............................ 1.0590 0.8593 22.0788 23.5426 22.9579 22.8801 450237............................ 1.6297 0.8916 24.8901 25.7939 30.5876 26.8886 450239............................ 0.9810 0.8308 21.1945 21.2586 19.1354 20.4357 450241............................ 1.0075 0.8204 18.7958 20.8732 21.3480 20.3076 450243............................ 0.9797 0.8204 15.4636 15.4510 17.2294 16.0640 450253............................ 0.9225 1.0048 20.6124 24.2435 24.1019 23.0154 450270............................ 1.1797 0.8475 14.4325 15.2190 19.8112 16.4138 450271............................ 1.2059 0.9646 21.7719 22.7035 24.1257 22.9106 450272............................ 1.2098 0.9518 25.7392 26.2576 27.0499 26.3724 450276............................

***

* 16.6319

* 16.6319 450280............................ 1.4750 0.9795 28.7233 29.9730 31.6561 30.1306 450283............................ 1.0410 0.9681 20.9679 22.7938 24.1724 22.6240 450289............................ 1.4241 1.0048 28.5665 32.2645 33.6901 31.5939 450292............................ 1.2711 0.9795 25.0411 26.3242 26.8105 26.0606 450293............................ 0.8636 0.8204 21.3135 23.6413 24.0753 22.9676 450296............................ 1.1007 1.0048 27.9690 30.4324 31.5551 30.0325 450299............................ 1.6637 0.9177 26.4933 27.5797 28.4163 27.4987 450306............................ 0.9556 0.8244 15.9855 21.4558 22.9398 19.7033

[[Page 24909]]

450315............................ 1.8055 0.9795

* 37.1721

* 37.1721 450324............................ 1.5715 0.9681 24.9128 25.1633 26.6082 25.5438 450330............................ 1.2148 1.0048 25.5820 26.0771 27.1088 26.2637 450340............................ 1.3764 0.8663 24.0637 25.0344 25.6777 24.9272 450346............................ 1.4306 0.8587 22.2468 23.6072 23.8975 23.2898 450347............................ 1.1980 1.0048 27.2203 28.7667 30.6500 28.8612 450348............................ 1.0409 0.8204 18.7675 21.6787 21.0437 20.5420 450351............................ 1.2643 0.9646 25.6859 26.5388 29.2557 27.1709 450352............................ 1.1040 0.9795 24.8012 26.2281 27.2978 26.1097 450353............................

***

* 24.4454 27.0248 28.2683 26.5977 450358............................ 1.9691 1.0048 30.4280 31.4926 32.5905 31.5502 450362............................

***

* 25.4372

* 25.4372 450369............................ 1.0332 0.8204 18.4848 19.9148 22.9249 20.4404 450370............................ 1.1948 0.8445 20.0832 25.5834 26.3438 23.8025 450372............................ 1.3682 0.9795 28.3359 30.8886 30.9228 30.0232 450373............................ 0.8647 0.8204 22.2213 24.8286 27.0704 24.8199 450374............................ 0.9938

* 23.2283

* 23.2283 450378............................ 1.4683 1.0048 30.7684 30.3883 32.2274 31.1285 450379............................ 1.3342 0.9795 30.6071 33.7521 35.3777 33.1813 450381............................ 0.9328

* 22.0482

* 22.0482 450388............................ 1.6608 0.8916 25.8674 27.4328 27.9807 27.1010 450389............................ 1.1532 0.9681 23.8764 25.6732 26.9621 25.5400 450393............................ 0.5363 0.9681 18.4551 21.9347

* 19.7864 450395............................ 1.0563 1.0048 24.8656 27.5189 26.7686 26.4980 450399............................ 0.8955 0.8204 18.2074 20.3528 22.1687 20.1538 450400............................ 1.0787 0.8204 23.1739 23.6358 26.2840 24.2918 450403............................ 1.3144 0.9795 29.3063 29.0359 29.8626 29.4101 450411............................ 1.0097 0.8204 19.6086 20.9372 21.5711 20.7282 450417............................ 0.8612

* 20.0351

* 20.0351 450418............................

***

* 26.8434 28.4362

* 27.5264 450419............................ 1.2715 0.9681 31.0405 31.9966 34.2413 32.4898 450422............................ 1.2225 0.9795 30.6659 34.4331 31.3421 32.1009 450424............................ 1.3427 1.0048 28.3149 28.2463 30.7204 29.0895 450431............................ 1.5890 0.9518 25.2477 26.3263 27.3917 26.3384 450438............................ 1.1315 1.0048 21.9350 27.8659 26.5110 25.2161 450446............................ 0.6348 1.0048 14.3132 17.0691 17.2849 16.0873 450447............................ 1.2629 0.9681 23.5047 25.4200 26.5230 25.1012 450451............................ 1.1286 0.8741 23.3043 24.6201 27.7093 25.1820 450460............................ 0.9637 0.8252 20.5811 22.4227 24.9806 22.7331 450462............................ 1.7172 0.9795 27.8923 29.6069 30.1441 29.2303 450465............................ 1.1120 1.0048 22.4183 26.2759 27.0808 25.3172 450469............................ 1.4925 0.9681 28.7890 26.3262 26.3408 27.1795 450475............................ 1.0926 0.8875 23.5596 23.0942 24.4820 23.6936 450484............................ 1.3680 0.8875 25.3527 26.7242 28.3900 26.8376 450488............................ 1.1517 0.8875 23.9144 22.3981 23.7940 23.3805 450489............................ 0.9935 0.8204 21.4771 23.4806 25.2611 23.4854 450497............................ 1.0139 0.8599 18.8344 22.0918 23.1798 21.3680 450498............................ 0.9453 0.8204 17.7822 18.6563 20.2424 18.8921 450508............................ 1.5948 0.8875 23.9572 28.4471 27.2884 26.5810 450514............................

***

* 22.6552 26.3704 26.9571 25.3918 450518............................ 1.4362 0.8587 24.1194 28.1755 28.0142 26.7922 450530............................ 1.2781 1.0048 28.7451 29.1349 29.9698 29.2956 450537............................ 1.4003 0.9795 27.5856 27.7757 28.7442 28.0479 450539............................ 1.1997 0.8275 21.0442 23.1829 24.2118 22.7454 450547............................ 0.9677 0.8399 21.6542 23.7820 34.3322 25.8915 450558............................ 1.8248 0.8244 26.1551 26.9407 28.0643 27.0629 450563............................ 1.5242 0.9681 28.7289 30.8332 32.0505 30.6110 450565............................ 1.2509 0.8685 23.8846 26.7942 28.1669 26.2638 450571............................ 1.6017 0.8663 22.7703 25.2108 27.4577 25.0804 450573............................ 1.1244 0.8319 20.1479 22.0797 22.1565 21.5134 450578............................ 0.9614 0.8204 20.2696 22.5167 25.0487 22.6269

[[Page 24910]]

450580............................ 1.0846 0.8204 21.1574 22.3886 23.8964 22.4730 450584............................ 1.1129 0.8204 21.0808 20.5257 22.5149 21.3615 450586............................ 0.9359 0.8204 16.1003 18.9107 20.6563 18.6521 450587............................ 1.2013 0.8204 20.4512 23.1202 25.0153 22.8383 450591............................ 1.2535 1.0048 23.9992 25.7031 27.0806 25.5834 450596............................ 1.2190 0.9646 25.3317 27.4011 29.8448 27.4270 450597............................ 0.9772 0.8204 23.1711 24.7853 24.2555 24.0721 450604............................ 1.3487 0.8204 20.9514 24.4743 25.9097 23.8485 450605............................ 0.9394 0.8460 22.2205 20.9276 23.9323 22.2907 450610............................ 1.5913 1.0048 26.8710 27.7317 28.3923 27.6892 450615............................ 0.9880 0.8204 20.3028 21.8442 24.1786 22.0818 450617............................ 1.5099 1.0048 26.5026 28.0225 28.8304 27.8233 450620............................ 1.0016 0.8204 17.7138 18.6183 20.3650 18.9167 450623............................ 1.1755

* 28.3552

* 28.3552 450626............................

***

* 26.8374

* 26.8374 450630............................ 1.5447 1.0048 29.6796 29.1462 29.8420 29.5559 450634............................ 1.7057 0.9795 28.1705 28.7312 30.3207 29.0783 450638............................ 1.6763 1.0048 29.6184 30.6572 32.4988 30.8669 450639............................ 1.4439 0.9681 29.2669 30.4019 32.6237 30.7769 450641............................ 1.0317 0.8599 17.5845 19.4389 20.2439 19.0709 450643............................ 1.3269 0.8484 21.1205 22.7355 24.3088 22.7006 450644............................ 1.5884 1.0048 29.0186 29.7918 30.8220 29.9124 450646............................ 1.4235 0.9144 23.8908 25.6313 26.8036 25.4367 450647............................ 1.8302 0.9795 30.7334 30.6924 32.4230 31.2795 450651............................ 1.4808 0.9795 32.4822 30.4484 31.9155 31.5983 450653............................ 1.1658 0.8204 23.2603 25.2144 26.1733 24.8551 450654............................ 0.9021 0.8204 19.9992 21.5002 22.5409 21.4221 450656............................ 1.4166 0.8875 23.8280 25.5050 28.1462 25.7173 450658............................ 0.9853 0.8204 20.5398 22.2293 24.7846 22.5182 450659............................ 1.4617 1.0048 30.1727 31.5024 34.2303 31.8885 450661............................ 1.1887 0.9959 23.2989 30.2610 30.0728 27.8676 450662............................ 1.5737 0.9577 28.0913 29.0535 29.0508 28.7285 450665............................

***

* 18.6054

* 18.6054 450668............................ 1.5281 0.9144 26.2375 28.8635 30.6109 28.5359 450669............................ 1.2115 0.9795 27.4507 27.9796 30.2655 28.6146 450670............................ 1.4063 1.0048 25.1575 25.9638 26.4296 25.8782 450672............................ 1.8206 0.9681 27.6359 30.1191 31.7990 29.9252 450674............................ 1.0675 1.0048 28.4416 28.7101 29.8969 29.0121 450675............................ 1.3872 0.9681 28.7765 28.9005 30.9547 29.5677 450677............................ 1.2672 0.9681 27.3728 25.9555 27.5747 26.9441 450678............................ 1.5041 0.9795 30.1500 31.1563 33.3407 31.5042 450683............................ 1.1582 0.9795 24.6609 27.4925 21.1727 24.2963 450684............................ 1.2927 1.0048 27.6789 29.3025 30.2122 29.1272 450686............................ 1.5920 0.8678 23.2367 24.2331 26.1607 24.5665 450688............................ 1.1942 0.9795 27.9057 26.8599 26.9879 27.2206 450690............................ 1.3072 0.9190 28.2531 26.5528 26.1729 27.0373 450694............................ 1.1612 0.8204 23.5789 23.9961 24.0008 23.8662 450697............................ 1.4207 0.8916 23.7155 24.8667 26.4094 25.0094 450698............................ 0.8996 0.8339 18.6494 20.0955 21.5692 20.0851 450702............................ 1.7092 0.8875 25.6147 26.8384 26.3694 26.2786 450709............................ 1.3571 1.0048 25.4855 26.8146 28.4214 26.8732 450711............................ 1.4822 0.9140 28.0104 26.7472 27.5782 27.4494 450713............................ 1.5798 0.9518 27.2801 28.8285 29.4951 28.5529 450715............................ 1.2415 0.9795 28.0365 17.3991 17.0201 19.5798 450716............................ 1.3493 1.0048 30.8440 32.3960 33.7175 32.3165 450718............................ 1.3798 0.9518 27.3408 27.3215 28.1558 27.6252 450723............................ 1.4651 0.9795 28.0812 28.5103 30.1696 28.9691 450730............................ 1.3611 0.9795 29.9430 31.3324 32.7866 31.3503 450733............................

***

* 26.4977

* 26.4977 450742............................ 1.1915 0.9795 26.1189 27.2023 30.0561 27.8905 450743............................ 1.4606 0.9795 27.3213 28.3362 28.4726 28.0740

[[Page 24911]]

450746............................ 0.9236 0.8204 12.4748 20.6343 22.7521 18.2376 450747............................ 1.2814 0.9190 22.2870 23.8314 25.8165 23.8624 450749............................ 0.9915 0.8204 17.8227 20.0487 22.1526 19.9050 450751............................

***

* 19.3267 18.7456 21.4208 19.9009 450754............................ 0.9278 0.8204 20.8968 22.1819 24.7752 22.6387 450755............................ 0.9399 0.8499 18.0092 19.8988 22.1950 20.0118 450758............................

***

* 25.6547 28.7342 28.2792 27.5628 450760............................ 1.0571 0.9144 24.6349 24.7489 25.1612 24.8383 450761............................ 0.8818

* 15.7483

* 15.7483 450763............................ 1.0706

* 22.4905

* 22.4905 450766............................ 1.9343 0.9795 30.0441 30.8004 30.2340 30.3516 450770............................ 1.2426 0.9518 20.3656 24.1647 23.7634 22.8145 450771............................ 1.6724 0.9795 31.3924 30.7105 32.0501 31.3870 450774............................ 1.6316 1.0048 24.9683 27.2080 25.7438 25.9776 450775............................ 1.2937 1.0048 24.4006 28.1428 29.7897 27.3080 450779............................ 1.2690 0.9681 26.9908 29.9674 31.8378 29.6435 450780............................ 2.0333 0.8916 23.9516 26.7611 27.0062 25.8978 450788............................ 1.5557 0.8460 25.4172 26.2840 28.3742 26.7014 450795............................ 1.1878 1.0048 23.7510 25.2007 32.9739 27.3766 450796............................ 1.7361 0.9141 27.9734 36.4073 37.8715 34.0484 450797............................ 1.9643 1.0048 20.5379 24.8950 24.8592 23.1190 450801............................ 1.4991 0.8204 23.0373 24.6328 25.3647 24.3609 450803............................ 1.1833 1.0048 30.6093 28.9235 30.3031 29.9076 450804............................ 1.9178 1.0048 26.0981 27.8775 29.1013 27.7076 450808............................ 1.3363 0.9518 23.8067 21.9793 23.0296 22.9175 450809............................ 1.5657 0.9518 26.3659 26.4223 27.3070 26.7163 450811............................ 1.8168 0.9140 25.8491 27.2584 31.1988 27.9792 450813............................ 1.1710 0.8916 25.5949 20.1710 22.9211 22.7699 450820............................ 1.3272 1.0048 30.5288 31.4666 33.9016 32.1404 450822............................ 1.2882 0.9795 31.1430 32.2968 32.2138 31.9065 450824............................ 2.4916 0.9518 26.7803 31.2375 33.3605 30.5401 450825............................ 1.3904 0.9140 20.2959 20.6457 25.1439 21.9852 450827............................ 1.3898 0.8488 20.9704 23.7554 24.1907 23.0383 450828............................ 1.3232 0.8204 22.3667 24.4740 24.8207 24.1285 450829............................

***

* 19.5014 20.6016 19.5826 19.9024 450830............................ 1.0196 0.9527 28.1617 28.5902 27.7967 28.1873 450831............................ 1.4011 1.0048 22.7885 23.3880 23.9437 23.3300 450832............................ 1.2713 1.0048 26.6628 26.5229 27.3292 26.8495 450833............................ 1.3228 0.9795 26.0044 27.0133 27.9622 27.0354 450834............................ 1.5862 0.9177 21.2204 20.9607 27.4845 22.7773 450838............................ 1.1487 0.8319 15.8026 19.5754 18.9504 18.1883 450839............................ 0.9901 0.8615 22.9711 25.8222 27.2151 25.2472 450840............................ 1.2907 0.9795 31.1914 30.1743 32.2544 31.2220 450841............................ 1.9217 0.9577 18.9468 20.9410 20.9412 20.3774 450844............................ 1.3103 1.0048 28.7296 30.7887 33.7961 31.3320 450845............................ 1.8427 0.9144 27.7461 29.4933 29.9243 29.0929 450847............................ 1.2704 1.0048 27.6854 28.5548 29.7336 28.6773 450848............................ 1.3004 1.0048 27.8100 29.5355 30.5537 29.3300 450850............................ 1.1195 1.0016 22.1335 21.9266 31.9567 24.7538 450851............................ 2.5569 0.9795 30.1213 32.6950 35.1080 32.6759 450852............................

***

* 30.0191

* 30.0191 450853............................ 1.9527 0.9795

* 36.1169 37.1028 36.6720 450854............................

***

* 27.1868

* 27.1868 450855............................ 1.5585 0.9577

* 30.8855 32.6866 31.8325 450856............................ 1.9086 0.8916

* 39.0865 37.7287 38.3752 450857............................

***

* 30.4632

* 30.4632 450860............................ 1.9631 1.0048

* 24.0171 29.1020 26.9520 450861............................

***

* 34.9290

* 34.9290 450862............................ 1.4583 1.0048

* 31.2224 31.8086 31.4626 450863............................

***

* 24.8825

* 24.8825 450864............................ 2.0626 0.9190

* 23.3765 24.5033 24.0201

[[Page 24912]]

450865............................ 1.0659 0.9518

* 29.1763 30.1175 29.6697 450866............................

***

* 15.2959

* 15.2959 450867............................ 1.1897 0.9518

* 28.2289 29.8401 29.0248 450868............................ 1.8341 0.9959

* 27.9579 25.3483 26.8245 450869............................ 2.0520 0.9140

* 22.6253 26.1586 24.9890 450870............................

***

* 37.4364

* 37.4364 450871............................ 1.8013 0.9518

* 28.6667 28.6667 450872............................ 1.3856 0.9681

* 27.2839 27.2839 450873............................

***

* 14.8808 14.8808 450874............................ 1.5449 0.9795

* 34.6069 34.6069 450875............................ 1.6403 0.9141

* 23.2771 23.2771 450876............................ 2.0787 0.8678

* 28.4327 28.4327 450877............................ 1.5503 0.9144

* 26.1823 26.1823 450878............................ 2.5581 0.8916

* 31.4363 31.4363 450879............................ 1.2943 0.8484

* 35.5585 35.5585 450880............................ 1.6579 0.9681

* 35.9522 35.9522 450881............................

***

* 24.5455 24.5455 450882............................

***

* 27.8226 27.8226 450883............................ 2.5235 0.9795

* 35.2632 35.2632 450884............................ 0.9913 0.8925

* 27.8171 27.8171 450885............................ 1.4982 0.9795

* 34.1144 34.1144 450886............................ 1.9390 0.9670

* 450888............................ 1.4581 0.9670

* 450889............................ 1.5257 0.9795

* 450890............................ 2.0977 0.9795

* 450891............................ 1.3643 0.9795

* 450893............................ 1.2518 0.9795

* 450894............................ 1.7048 0.9795

* 450895............................

***

* 18.4129 18.4129 460001............................ 1.8847 0.9488 27.0757 28.7150 30.0024 28.5948 460003............................ 1.5181 0.9482 26.1372 31.4135 32.3411 29.8766 460004............................ 1.7332 0.9482 26.4498 28.2040 29.6502 28.1059 460005............................ 1.4390 0.9482 23.5633 25.0239 26.0927 24.8850 460006............................ 1.3709 0.9482 25.4787 27.1392 28.3673 27.0130 460007............................ 1.3738 0.9546 25.6686 27.1308 28.0016 26.9924 460008............................ 1.4054 0.9482 26.5672 29.5907 31.5474 29.1767 460009............................ 1.9494 0.9482 26.2833 27.2885 28.3813 27.3950 460010............................ 2.0931 0.9482 27.4648 29.0063 30.4873 29.0186 460011............................ 1.3207 0.9388 23.4023 24.4402 24.9677 24.2736 460013............................ 1.4115 0.9488 25.2448 27.7381 29.2708 27.3700 460014............................ 1.1337 0.9482 24.1412 28.2647 29.5924 27.3264 460015............................ 1.3650 0.9219 25.6576 27.2506 29.1301 27.3608 460017............................ 1.3070 0.8631 23.0388 24.3030 26.1574 24.4631 460018............................ 0.9383 0.8267 20.3756 22.0517 22.7973 21.8331 460019............................ 1.1647 0.8267 19.9901 24.3756 23.2172 22.4666 460020............................ 1.0141 0.8267 19.5669 18.5159 29.5332 21.7927 460021............................ 1.6947 1.1205 26.3420 28.0291 29.5906 28.1994 460023............................ 1.1933 0.9488 25.3094 26.9512 28.6509 26.9991 460026............................ 1.0465 0.9388 24.1547 26.9295 27.9463 26.3205 460030............................ 1.1799 0.8267 23.4679 23.5942 24.3597 23.8093 460033............................ 0.9138 0.8267 22.0249 25.3422 26.6541 24.7026 460035............................ 0.9491 0.8267 17.5723 20.6322 21.9077 20.1162 460036............................ 1.4454

* 27.2866

* 27.2866 460037............................ 0.8447

* 21.1035

* 21.1035 460039............................ 1.0810 0.9219 28.5657 29.5651 30.4903 29.5979 460041............................ 1.3613 0.9482 25.2744 26.4640 26.3798 26.0597 460042............................ 1.3920 0.9482 22.9949 24.9454 26.8365 24.8864 460043............................ 1.2796 0.9488 28.2089 28.2008 28.6673 28.3617 460044............................ 1.3114 0.9482 26.6795 27.4928 28.7017 27.6432 460047............................ 1.6716 0.9482 25.7920 28.2336 30.0498 27.9926 460049............................ 1.9965 0.9482 24.5165 26.6702 28.5026 26.6084

[[Page 24913]]

460051............................ 1.2358 0.9482 25.5881 27.0160 27.8836 26.8632 460052............................ 1.6310 0.9488 25.3163 26.1629 27.1991 26.2809 460054............................ 1.5970 0.9219 25.8668 24.9926 25.7860 25.5261 470001............................ 1.2954 1.0782 27.7329 28.3017 29.7537 28.6008 470003............................ 1.9062 1.0401 26.4919 28.1137 30.1959 28.2585 470005............................ 1.3073 1.0401 29.8255 30.7872 33.1968 31.2956 470006............................ 1.2524

* 26.9651

* 26.9651 470010............................

***

* 26.1273

* 26.1273 470011............................ 1.1764 1.0401 28.3911 28.1330 29.6899 28.7438 470012............................ 1.1947 1.0401 24.3425 26.0225 27.0128 25.8090 470018............................ 1.1133

* 28.3419

* 28.3419 470024............................ 1.2025 1.0401 25.2427 27.0394 26.6344 26.3232 490001............................ 1.0892 0.8095 21.9953 23.2174 24.0349 23.1144 490002............................ 1.0509 0.8095 19.5613 20.8609 21.7073 20.6687 490003............................

***

* 27.3456

* 27.3456 490004............................ 1.3087 0.9353 25.4597 27.1676 27.8236 26.8453 490005............................ 1.6418 1.0679 28.5744 29.8215 30.5335 29.6408 490007............................ 2.1943 0.8785 26.2481 27.6572 29.3084 27.7570 490009............................ 2.0098 0.9555 29.0740 30.4722 29.9383 29.8425 490011............................ 1.5283 0.8785 24.5687 26.4766 27.4750 26.2046 490012............................ 1.0128 0.8095 19.2276 21.0605 22.9898 21.0346 490013............................ 1.3401 0.8490 22.4771 24.7521 25.5532 24.2689 490017............................ 1.5004 0.8785 24.6845 25.8216 27.5878 26.0263 490018............................ 1.3289 0.9353 24.5196 26.2510 27.3895 26.0937 490019............................ 1.1905 1.0679 25.9761 25.9885 25.8263 25.9276 490020............................ 1.2411 0.9238 24.8001 27.3142 29.4572 27.1534 490021............................ 1.4774 0.8490 24.6440 25.7938 26.5838 25.6856 490022............................ 1.4247 1.0679 28.0749 32.2676 30.1180 30.1134 490023............................ 1.3034 1.0679 29.7774 30.3416 30.9919 30.3865 490024............................ 1.7719 0.9441 23.0982 26.1125 30.6195 26.5180 490027............................ 1.0552 0.8095 18.9409 24.0288 22.9996 21.9117 490031............................

***

* 22.0579

* 22.0579 490032............................ 1.9589 0.9238 25.1381 25.2654 28.5886 26.3873 490033............................ 1.1071 1.0679 30.0909 31.2922 31.8266 31.1174 490037............................ 1.2023 0.8095 21.3035 24.7711 25.2813 23.7322 490038............................ 1.2572 0.8095 22.3976 21.8509 22.6326 22.2914 490040............................ 1.4793 1.0679 32.8738 32.6564 34.1837 33.2336 490041............................ 1.5146 0.8785 24.5738 26.0897 27.1598 25.9088 490042............................ 1.2796 0.9190 21.8749 24.4650 25.3578 23.9261 490043............................ 1.2498 1.0679 30.8871 33.7096 35.8792 33.5666 490044............................ 1.4529 0.8785 20.8352 23.3527 23.3777 22.5138 490045............................ 1.2636 1.0679 28.8279 32.0937 30.3765 30.3674 490046............................ 1.5194 0.8785 25.6328 26.6517 27.9583 26.7669 490047............................ 1.2301

* 22.5423

* 22.5423 490048............................ 1.4151 0.8490 25.0097 26.2828 26.7581 26.0497 490050............................ 1.4886 1.0679 30.5037 31.3885 32.3078 31.4093 490052............................ 1.6969 0.8785 22.8889 23.5973 25.0037 23.8192 490053............................ 1.2119 0.8095 21.8432 23.3315 23.7979 22.9784 490057............................ 1.6179 0.8785 26.1128 26.6898 27.5153 26.7785 490059............................ 1.6454 0.9238 28.7276 27.3611 30.8668 28.9526 490060............................ 1.0540 0.8095 22.4201 23.6113 24.3180 23.4563 490063............................ 1.8510 1.0679 30.3632 31.3619 31.6067 31.1276 490066............................ 1.3614 0.8785 24.7146 27.8250 29.6170 27.4591 490067............................ 1.2603 0.9238 22.9188 24.9021 25.9475 24.5479 490069............................ 1.6015 0.9238 26.8791 27.3181 29.1513 27.7948 490071............................ 1.3203 0.9238 28.4381 29.7186 31.6505 29.9219 490073............................ 2.0908 1.0679 31.7743 33.1829 36.6050 33.5942 490075............................ 1.4310 0.8486 23.8191 25.2022 26.3059 25.1154 490077............................ 1.4141 0.9555 26.0800 26.6806 28.1502 26.9962 490079............................ 1.2496 0.9083 23.4728 25.3103 25.2294 24.6362 490084............................ 1.1764 0.8240 24.5965 24.9007 25.7656 25.0947

[[Page 24914]]

490088............................ 1.1004 0.8490 22.4186 24.1471 24.8101 23.7857 490089............................ 1.1026 0.9441 22.6461 24.9438 25.7992 24.4734 490090............................ 1.1074 0.8095 22.2907 25.1157 26.3608 24.4717 490092............................ 1.0927 0.9238 23.8655 23.3439 25.7387 24.2720 490093............................ 1.4711 0.8785 25.0751 25.6531 26.7886 25.8819 490094............................ 0.9852 0.9238 26.5726 28.2165 28.9146 27.8967 490097............................ 1.0622 0.9238 23.8005 26.5322 27.1435 25.8270 490098............................ 1.2549 0.8095 21.7231 23.2782 25.1610 23.3955 490101............................ 1.4013 1.0679 30.4285 31.2377 32.3688 31.3628 490104............................ 0.7733 0.9238 17.3295

* 17.0546 17.1727 490105............................ 0.7178 0.8095 24.7922 25.5329 26.3828 25.5156 490106............................ 0.9111 0.9353 23.0199 23.8334 25.7350 23.7423 490107............................ 1.3335 1.0679 29.7000 32.2672 33.5401 31.8912 490108............................ 1.0684 0.8490 22.4345 22.9076 23.3193 22.8875 490109............................ 0.8787 0.9238 21.9877 22.7854 24.2291 22.9552 490110............................ 1.3524 0.8422 22.5974 24.2887 24.9849 24.0081 490111............................ 1.1951 0.8095 22.0199 22.1476 22.8937 22.3629 490112............................ 1.7156 0.9238 26.6453 27.1932 29.0813 27.6671 490113............................ 1.3105 1.0679 29.5698 31.8177 32.4544 31.3269 490114............................ 1.1475 0.8095 20.9116 22.5255 22.1360 21.8649 490115............................ 1.1533 0.8095 21.4666 22.4058 23.7163 22.5107 490116............................ 1.1776 0.8095 22.9017 24.2258 24.3840 23.8562 490117............................ 1.1522 0.8095 18.0277 19.6398 18.1119 18.6014 490118............................ 1.6600 0.9238 27.4050 27.6749 29.0567 28.0590 490119............................ 1.3035 0.8785 25.2549 26.5756 27.8859 26.6077 490120............................ 1.3981 0.8785 24.4434 25.8795 26.0093 25.4236 490122............................ 1.5549 1.0679 31.0449 32.0743 33.3710 32.1670 490123............................ 1.1545 0.8095 23.9233 24.3490 24.2251 24.1637 490126............................ 1.1651 0.8095 22.2859 23.6690 24.0884 23.3590 490127............................ 1.1307 0.8095 20.4289 21.3735 23.4863 21.6178 490130............................ 1.2696 0.8785 22.8512 23.9982 25.3343 24.0812 490133............................

***

* 26.5684

* 26.5684 490134............................ 0.7623 0.8095

* 33.2227 33.2227 490135............................ 0.7016 0.9441

* 25.9889 25.9889 490136............................ 1.4665 0.9238

* 490137............................ 1.2895 0.8785

* 500001............................ 1.6372 1.1351 29.3707 31.1605 33.0888 31.2052 500002............................ 1.4278 1.0565 25.3347 27.6400 29.1442 27.3385 500003............................ 1.3314 1.1202 29.6341 30.6939 32.1259 30.7329 500005............................ 1.7732 1.1351 32.0972 33.5117 34.8686 33.4895 500007............................ 1.3448 1.1202 28.0476 29.2869 30.5261 29.3452 500008............................ 1.8942 1.1351 31.8837 32.6052 33.5666 32.7102 500011............................ 1.3613 1.1351 30.6508 31.4514 32.6218 31.5867 500012............................ 1.7433 1.0565 30.6856 30.0509 33.8239 31.3893 500014............................ 1.6985 1.1351 33.7536 36.1380 36.5850 35.5229 500015............................ 1.4709 1.1351 32.0592 34.5877 35.6715 34.1465 500016............................ 1.6475 1.1202 31.4222 31.4905 32.9165 31.9509 500019............................ 1.2779 1.0705 28.6669 30.5594 31.6230 30.2717 500021............................ 1.2936 1.1202 30.1690 30.7927 32.4667 31.1930 500024............................ 1.7694 1.1060 30.7917 32.6171 36.1640 33.1799 500025............................ 1.8307 1.1351 34.7252 37.7952 40.6368 37.5370 500026............................ 1.3949 1.1351 33.2937 32.8369 34.5879 33.5879 500027............................ 1.5119 1.1351 34.2175 34.6164 39.2906 36.0226 500030............................ 1.6945 1.1264 32.7446 32.4426 34.9165 33.4025 500031............................ 1.2753 1.1325 31.2186 32.8833 33.2375 32.4927 500033............................ 1.3149 1.0565 29.4627 30.6292 31.9177 30.6609 500036............................ 1.3431 1.0565 27.0072 28.7096 30.5911 28.8233 500037............................ 1.0254 1.0565 26.9969 28.1056 31.2642 28.7442 500039............................ 1.4951 1.1202 29.8808 32.2245 33.5585 31.9341 500041............................ 1.4362 1.1233 26.7829 30.3627 34.1983 30.2983 500044............................ 1.9634 1.0565 30.3164 29.0214 31.0921 30.1178

[[Page 24915]]

500049............................ 1.3525 1.0565 27.1819 27.7170 29.8189 28.3097 500050............................ 1.4984 1.1233 29.9791 32.6751 33.7695 32.1377 500051............................ 1.7936 1.1351 31.9406 32.5764 34.7579 33.0980 500052............................ 1.4374 1.1351

* 500053............................ 1.2887 1.0565 28.4130 28.2901 30.2803 28.9863 500054............................ 1.9955 1.0565 30.8067 31.6595 32.4524 31.6451 500058............................ 1.6535 1.0565 30.4699 30.7487 30.7029 30.6482 500060............................ 1.3750 1.1351 34.1523 37.4869 38.7650 36.8212 500064............................ 1.7330 1.1351 31.5371 31.6112 32.3570 31.8420 500072............................ 1.2310 1.0826 33.4863 31.2000 32.5263 32.3947 500077............................ 1.4551 1.0565 29.4199 31.6153 33.2185 31.3933 500079............................ 1.3757 1.1202 29.6623 31.3280 32.5802 31.1943 500084............................ 1.3885 1.1351 29.3484 30.2411 32.7883 30.8053 500088............................ 1.3961 1.1351 33.4302 35.3770 36.7929 35.2125 500108............................ 1.6412 1.1202 29.4244 31.8483 34.3853 31.9453 500119............................ 1.3894 1.0565 30.9999 29.7028 31.2216 30.6353 500122............................ 1.3587

* 30.1396

* 30.1396 500124............................ 1.4290 1.1351 31.5438 32.3505 34.4763 32.8201 500129............................ 1.5751 1.1202 30.7536 32.1102 34.4437 32.4983 500134............................ 0.4907 1.1351 26.8607 27.2428 28.1308 27.5250 500138............................ 0.8731

* 500139............................ 1.5216 1.1060 31.6591 33.9739 35.2459 33.5975 500141............................ 1.3178 1.1351 30.5456 31.3308 33.7520 31.9219 500143............................ 0.4729 1.1060 22.1419 23.6766 25.3064 23.6837 500147............................ 0.8772

* 24.5744

* 24.5744 500148............................ 1.1794 1.0565 22.2161 26.4206 37.7820 30.2226 500150............................ 1.2175 1.1233

* 510001............................ 1.9235 0.8388 23.4477 25.2973 25.8670 24.9189 510002............................ 1.2868 0.9190 25.9597 23.8921 23.7257 24.4599 510006............................ 1.3373 0.8244 23.5727 24.9627 24.8754 24.4761 510007............................ 1.7217 0.8845 25.2835 24.7264 26.7129 25.5735 510008............................ 1.3063 0.9259 24.6959 26.3554 27.5208 26.2143 510012............................ 0.9607 0.7568 18.2845 18.8984 20.8441 19.3184 510013............................ 1.1241 0.7568 20.8782 22.7882 22.8762 22.1595 510018............................ 1.0603 0.8294 20.5556 22.4597 22.8896 21.9850 510022............................ 1.8404 0.8397 24.2125 26.9511 26.8298 25.9931 510023............................ 1.2851 0.7893 20.4908 20.6435 21.0931 20.7442 510024............................ 1.8413 0.8388 24.0444 25.5634 26.6600 25.4522 510026............................ 0.9974 0.7568 16.6192 17.9908 19.0716 17.8791 510028............................

***

* 21.7135

* 21.7135 510029............................ 1.3222 0.8397 22.4556 22.7104 24.0871 23.0837 510030............................ 1.0974 0.8244 21.5583 24.3936 23.7105 23.2332 510031............................ 1.4320 0.8397 21.7637 23.2624 24.0220 22.9918 510033............................ 1.7286 0.8238 23.0305 22.6189 24.0772 23.2692 510038............................ 1.0547 0.7568 17.2832 20.6565 20.9131 19.6268 510039............................ 1.2513 0.7568 19.5468 19.8751 20.4713 19.9553 510046............................ 1.3473 0.7744 21.2540 22.1712 22.7403 22.0415 510047............................ 1.1464 0.8388 24.0954 27.1214 27.6830 26.2412 510048............................ 1.1744 0.7568 17.5096 18.8576 22.7921 19.5218 510050............................ 1.6023 0.7568 19.9766 21.0772 21.8994 20.9834 510053............................ 1.1036 0.7568 20.8608 22.3318 21.5331 21.5796 510055............................ 1.5345 0.8845 30.7868 28.4615 29.4112 29.5183 510058............................ 1.3454 0.8238 22.6976 23.9015 25.1425 23.9213 510059............................ 0.7138 0.8397 21.9551 22.1435 20.8799 21.6736 510062............................ 1.1596 0.8294 23.3216 26.2296 26.5027 25.3360 510067............................ 1.1080 0.7568 21.2099 25.0437 25.2094 23.8467 510068............................ 1.1378

* 23.1011

* 23.1011 510070............................ 1.2252 0.8294 23.2382 23.5639 23.9714 23.5982 510071............................ 1.3169 0.7744 23.1685 23.4508 23.2773 23.3001 510072............................ 1.1600 0.7568 20.1997 20.5146 19.4366 20.0240 510077............................ 1.0539 0.8706 23.6584 24.5010 25.9500 24.6968

[[Page 24916]]

510082............................ 1.1114 0.7568 19.1878 19.9081 20.3265 19.7900 510085............................ 1.2935 0.8397 23.7174 26.3877 26.2593 25.5454 510086............................ 1.1756 0.7568 17.5933 19.8735 19.2574 18.9116 510089............................

***

* 27.7061

* 27.7061 510090............................ 1.8498 0.8845

* 520002............................ 1.3411 1.0011 24.9950 27.7705 29.0603 27.3244 520004............................ 1.3936 0.9704 25.4639 27.6530 28.9833 27.3808 520008............................ 1.5354 1.0296 29.8353 30.7553 33.8038 31.4979 520009............................ 1.7192 0.9635 26.1503 27.4044 28.8585 27.4835 520011............................ 1.3034 0.9635 25.2747 26.6268 27.2708 26.4030 520013............................ 1.4596 0.9635 26.6225 29.0018 30.1823 28.6557 520017............................ 1.1205 0.9635 24.6677 28.4699 29.3257 27.4741 520019............................ 1.3648 0.9635 26.7433 28.6971 29.8641 28.5157 520021............................ 1.3025 1.0455 26.6935 28.4182 29.1110 28.1498 520027............................ 1.3706 1.0296 27.6771 31.4284 32.4107 30.5705 520028............................ 1.3493 1.1002 25.4164 26.7260 28.0802 26.7497 520030............................ 1.7235 1.0011 27.0184 29.4678 30.5699 29.0605 520033............................ 1.2657 0.9635 25.0853 28.0662 29.0213 27.5155 520034............................ 1.2320 0.9635 23.9850 26.1094 26.8901 25.6373 520035............................ 1.3589 0.9718 24.7767 27.3276 28.1023 26.7456 520037............................ 1.8171 1.0011 29.7234 30.1799 32.2126 30.7297 520038............................ 1.2386 1.0296 26.6470 29.3134 29.6455 28.5972 520040............................ 1.2129 1.0296 27.2325 29.1262 31.2019 29.0313 520041............................ 1.0714 1.1181 22.7595 23.5495 25.3745 23.9555 520044............................ 1.3514 0.9718 26.0191 27.3685 28.2371 27.2569 520045............................ 1.6541 0.9635 26.0030 27.3336 29.3743 27.5624 520048............................ 1.5682 0.9635 25.1724 26.8080 29.1861 26.9820 520049............................ 2.1341 0.9635 25.9256 26.9851 28.0930 26.9956 520051............................ 1.5581 1.0296 28.4880 31.9949 31.3100 30.6580 520057............................ 1.1719 0.9819 25.3745 27.7528 29.1146 27.4372 520059............................ 1.3032 1.0287 28.0907 29.5801 30.4575 29.3881 520060............................ 1.3697 0.9635 23.8817 24.8638 26.3170 25.0791 520062............................ 1.2461 1.0296 28.2215 28.8510 32.8572 30.1180 520063............................ 1.1387 1.0296 27.4100 29.0993 30.3381 28.9449 520064............................ 1.5995 1.0296 28.6101 30.3225 31.5710 30.0467 520066............................ 1.4385 0.9813 27.1657 29.2088 31.0608 29.1271 520068............................

***

* 24.8184

* 24.8184 520070............................ 1.7753 0.9635 24.8935 27.6771 28.0835 26.9326 520071............................ 1.1682 1.0296 27.6202 30.0262 30.6902 29.4705 520075............................ 1.5608 0.9635 27.1699 29.2920 30.1577 28.8340 520076............................ 1.2408 1.1002 26.1697 27.3335 27.4423 26.9220 520078............................ 1.5176 1.0296 27.5989 29.9837 31.6930 29.7364 520083............................ 1.7380 1.1181 28.8407 30.8826 32.7720 30.8982 520087............................ 1.7746 0.9704 27.3374 28.5810 30.5643 28.8727 520088............................ 1.4249 0.9892 26.9936 30.7450 30.6626 29.5642 520089............................ 1.5701 1.1181 30.0448 33.8793 33.4077 32.4828 520091............................ 1.2952 0.9635 24.6320 25.4593 27.3437 25.8208 520094............................

***

* 25.7567

* 25.7567 520095............................ 1.2940 1.1002 26.7863 30.4216 32.0328 29.8101 520096............................ 1.3768 0.9824 24.5758 27.8896 29.5966 27.4533 520097............................ 1.3988 0.9635 26.3321 29.1479 30.0078 28.4894 520098............................ 2.0280 1.1181 30.6150 32.5785 36.5735 33.3161 520100............................ 1.2790 0.9813 26.2161 29.3243 29.6404 28.4022 520102............................ 1.1731 1.0296 26.8234 29.1680 30.7969 28.9921 520103............................ 1.5503 1.0296 27.9147 30.3165 32.6253 30.3606 520107............................ 1.2785 0.9721 28.3431 28.9878 29.4173 28.9353 520109............................ 1.0385 0.9635 23.3271 24.7228 25.0675 24.3755 520113............................ 1.3265 0.9635 27.4135 31.4708 33.3448 30.7246 520116............................ 1.2670 1.0296 26.9902 27.9688 30.2148 28.3943 520132............................

***

* 23.1941 25.0006 27.3413 25.0303 520136............................ 1.7254 1.0296 27.7703 30.6522 32.2056 30.1520

[[Page 24917]]

520138............................ 1.8836 1.0296 28.4394 30.8016 31.6560 30.2955 520139............................ 1.2882 1.0296 26.5110 28.8870 30.4880 28.6146 520140............................ 0.3793

* 28.4433 31.0043 31.0603 30.2033 520152............................ 1.0909

* 24.9392 29.7308

* 27.4042 520160............................ 1.8643 0.9635 25.7588 27.9548 29.7288 27.8043 520170............................ 1.4772 1.0296 27.2221 30.4309 31.4684 29.7182 520173............................ 1.0835 0.9635 28.0995 29.2429 31.0590 29.4644 520177............................ 1.6145 1.0296 30.7317 31.4555 32.5695 31.6043 520178............................ 1.0240

* 20.2666

* 20.2666 520189............................ 1.2031 1.0455 28.4720 28.0014 29.0284 28.4995 520193............................ 1.6998 0.9635 26.0885 27.8113 29.2005 27.7864 520194............................ 1.7148 1.0296 24.9408 30.1668 31.4969 28.9141 520195............................ 0.3556 1.0296 36.6973 36.3116 36.2864 36.4358 520196............................ 1.6798 0.9635 35.1043 36.9266 31.1197 34.0263 520197............................

***

* 30.1026 30.1026 520198............................ 1.4193 0.9635

* 28.5962 28.5962 520199............................ 2.2788 1.0296

* 36.5679 36.5679 520200............................ 0.9180

* 520201............................ 0.6866

* 520202............................ 1.4519 1.0011

* 530002............................ 1.1242 0.9214 26.8356 28.3063 29.2066 28.1166 530006............................ 1.1836 0.9214 24.9318 27.2421 29.2091 27.0634 530007............................

***

* 20.4391

* 20.4391 530008............................ 1.1673 0.9214 23.8589 24.0090 26.5170 24.7922 530009............................ 0.9239 0.9214 26.8316 24.6719 25.9366 25.7848 530010............................ 1.3065 0.9214 25.8482 25.9852 27.4111 26.4398 530011............................ 1.1127 0.9214 24.8245 27.8772 27.8600 26.9105 530012............................ 1.7049 0.9277 25.2526 26.9582 28.7554 26.9872 530014............................ 1.5650 0.9219 24.5947 26.7156 28.5771 26.7011 530015............................ 1.1585 0.9352 27.6876 29.8310 31.1119 29.5109 530017............................ 1.1052 0.9214 25.3362 29.8503 31.1044 28.7212 530023............................

***

* 21.3813

* 21.3813 530025............................ 1.2406 0.9214 28.6938 24.4392 29.3697 27.4106 530032............................ 1.0164 0.9214 25.7728 23.9004 24.6562 24.7327

\1\ Based on salaries adjusted occupational mix, according to the calculation in section II.D.6. of the preamble to this final rule. \2\ The transfer-adjusted case-mix index is based on the billed DRG on the FY 2006 MedPAR. * Denotes wage data not available for the provider for that year. ** Based on the sum of the salaries and hours computed for Federal FYs 2006, 2007, and 2008. *** Denotes MedPAR data not available for the provider for FY 2006.

[[Page 24917]]

Table 3A.--FY 2008 and 3-Year* Average Hourly Wage for Uurban Areas by CBSA [*Based on the salaries and hours computed for Federal FYs 2006, 2007, and 2008.]

FY 2008 3-Year CBSA code

Urban area

average average hourly wage hourly wage

10180.............. Abilene, TX.............. 25.5538 24.1331 10380.............. Aguadilla-Isabela-San

10.2251 11.4341 Sebasti[aacute]n, PR. 10420.............. Akron, OH................ 27.1423 25.9140 10500.............. Albany, GA............... 26.5075 25.8661 10580.............. Albany-Schenectady-Troy, 26.8799 25.7658 NY. 10740.............. Albuquerque, NM.......... 30.1918 28.6362 10780.............. Alexandria, LA........... 24.6475 23.5445 10900.............. Allentown-Bethlehem-

31.0725 29.5625 Easton, PA-NJ. 11020.............. Altoona, PA.............. 25.8968 25.4011 11100.............. Amarillo, TX............. 28.3367 27.1348 11180.............. Ames, IA................. 30.9401 28.8517 11260.............. Anchorage, AK............ 36.4624 35.0341 11300.............. Anderson, IN............. 27.8019 26.0238 11340.............. Anderson, SC............. 28.1687 26.6066 11460.............. Ann Arbor, MI............ 32.5597 31.5914 11500.............. Anniston-Oxford, AL...... 24.7339 23.2894 11540.............. Appleton, WI............. 29.3844 27.6794

[[Page 24918]]

11700.............. Asheville, NC............ 28.5462 27.3747 12020.............. Athens-Clarke County, GA. 32.6801 28.9702 12060.............. Atlanta-Sandy Springs-

30.5185 28.9861 Marietta, GA. 12100.............. Atlantic City, NJ........ 37.4892 34.9547 12220.............. Auburn-Opelika, AL....... 25.0667 23.9196 12260.............. Augusta-Richmond County, 29.7570 28.5673 GA-SC. 12420.............. Austin-Round Rock, TX.... 29.5055 27.8771 12540.............. Bakersfield, CA.......... 35.1655 32.3553 12580.............. Baltimore-Towson, MD..... 31.3329 29.4975 12620.............. Bangor, ME............... 30.5654 29.0449 12700.............. Barnstable Town, MA...... 39.1116 37.3016 12940.............. Baton Rouge, LA.......... 24.8394 24.3027 12980.............. Battle Creek, MI......... 31.1266 28.7337 13020.............. Bay City, MI............. 27.9569 27.3833 13140.............. Beaumont-Port Arthur, TX. 26.6188 25.3168 13380.............. Bellingham, WA........... 34.9165 33.4025 13460.............. Bend, OR................. 32.8324 31.4061 13644.............. Bethesda-Gaithersburg-

32.4256 32.2302 Frederick, MD. 13740.............. Billings, MT............. 27.5180 26.3023 13780.............. Binghamton, NY........... 28.1230 26.2431 13820.............. Birmingham-Hoover, AL.... 27.5033 26.3180 13900.............. Bismarck, ND............. 22.5429 21.8622 13980.............. Blacksburg-Christiansburg- 25.0343 23.9362 Radford, VA. 14020.............. Bloomington, IN.......... 28.9114 26.4833 14060.............. Bloomington-Normal, IL... 29.4126 27.2841 14260.............. Boise City-Nampa, ID..... 29.4529 27.5811 14484.............. Boston-Quincy, MA........ 36.2971 34.5496 14500.............. Boulder, CO.............. 31.3644 29.5797 14540.............. Bowling Green, KY........ 25.0757 24.0238 14740.............. Bremerton-Silverdale, WA. 33.5585 31.9341 14860.............. Bridgeport-Stamford-

39.9455 37.7175 Norwalk, CT. 15180.............. Brownsville-Harlingen, TX 29.6861 28.6894 15260.............. Brunswick, GA............ 30.2808 29.1365 15380.............. Buffalo-Niagara Falls, NY 29.7130 28.1438 15500.............. Burlington, NC........... 26.6539 25.6456 15540.............. Burlington-South

29.7238 28.0154 Burlington, VT. 15764.............. Cambridge-Newton-

34.6193 32.8465 Framingham, MA. 15804.............. Camden, NJ............... 32.6154 31.0734 15940.............. Canton-Massillon, OH..... 27.6520 26.5054 15980.............. Cape Coral-Fort Myers, FL 29.4170 27.9198 16180.............. Carson City, NV.......... 29.0596 29.0305 16220.............. Casper, WY............... 28.7554 26.9872 16300.............. Cedar Rapids, IA......... 26.9340 25.8161 16580.............. Champaign-Urbana, IL..... 28.8897 28.0705 16620.............. Charleston, WV........... 26.0301 25.1455 16700.............. Charleston-North

28.3391 27.1402 Charleston, SC. 16740.............. Charlotte-Gastonia-

29.4846 28.2167 Concord, NC-SC. 16820.............. Charlottesville, VA...... 29.6186 29.3212 16860.............. Chattanooga, TN-GA....... 27.7965 26.6064 16940.............. Cheyenne, WY............. 28.5771 26.7011 16974.............. Chicago-Naperville-

32.4104 31.4301 Joliet, IL. 17020.............. Chico, CA................ 34.8348 32.3528 17140.............. Cincinnati-Middletown, OH- 29.9257 28.3705 KY-IN. 17300.............. Clarksville, TN-KY....... 25.4889 24.5649 17420.............. Cleveland, TN............ 25.3391 24.1812 17460.............. Cleveland-Elyria-Mentor, 29.0283 27.5817 OH. 17660.............. Coeur d'Alene, ID........ 29.0137 27.8488 17780.............. College Station-Bryan, TX 28.4460 26.5695 17820.............. Colorado Springs, CO..... 29.3600 27.9536 17860.............. Columbia, MO............. 26.4878 24.9744 17900.............. Columbia, SC............. 27.2473 26.4178 17980.............. Columbus, GA-AL.......... 27.9688 25.7747 18020.............. Columbus, IN............. 29.8515 28.2562 18140.............. Columbus, OH............. 31.1465 29.5977 18580.............. Corpus Christi, TX....... 26.2244 25.0629 18700.............. Corvallis, OR............ 33.1920 32.2199 19060.............. Cumberland, MD-WV........ 24.6964 24.8721 19124.............. Dallas-Plano-Irving, TX.. 30.3645 29.5263 19140.............. Dalton, GA............... 26.6179 26.1939

[[Page 24919]]

19180.............. Danville, IL............. 28.6735 27.3133 19260.............. Danville, VA............. 26.3059 25.1154 19340.............. Davenport-Moline-Rock

27.2960 25.9226 Island, IA-IL. 19380.............. Dayton, OH............... 28.7758 27.1442 19460.............. Decatur, AL.............. 24.4009 24.0134 19500.............. Decatur, IL.............. 25.1642 24.0538 19660.............. Deltona-Daytona Beach-

27.7363 27.0490 Ormond Beach, FL. 19740.............. Denver-Aurora, CO........ 32.5162 31.4369 19780.............. Des Moines-West Des

28.4004 27.5531 Moines, IA. 19804.............. Detroit-Livonia-Dearborn, 31.1509 30.3767 MI. 20020.............. Dothan, AL............... 22.9355 22.3197 20100.............. Dover, DE................ 32.2239 29.9990 20220.............. Dubuque, IA.............. 27.5076 26.4788 20260.............. Duluth, MN-WI............ 31.4670 30.1024 20500.............. Durham, NC............... 30.4233 29.2561 20740.............. Eau Claire, WI........... 29.1319 27.8408 20764.............. Edison, NJ............... 34.3248 32.9557 20940.............. El Centro, CA............ 28.4214 26.8331 21060.............. Elizabethtown, KY........ 26.7267 25.6686 21140.............. Elkhart-Goshen, IN....... 29.2579 28.0411 21300.............. Elmira, NY............... 25.8434 24.6042 21340.............. El Paso, TX.............. 28.3459 26.9978 21500.............. Erie, PA................. 26.3706 25.6869 21660.............. Eugene-Springfield, OR... 34.1215 32.3046 21780.............. Evansville, IN-KY........ 26.2541 25.6720 21820.............. Fairbanks, AK............ 33.9363 32.8387 21940.............. Fajardo, PR.............. 12.7755 12.1173 22020.............. Fargo, ND-MN............. 24.6368 24.1979 22140.............. Farmington, NM........... 28.7944 25.7110 22180.............. Fayetteville, NC......... 30.7692 28.3815 22220.............. Fayetteville-Springdale- 27.5150 26.2034 Rogers, AR-MO. 22380.............. Flagstaff, AZ............ 35.8265 34.6818 22420.............. Flint, MI................ 34.3384 32.0516 22500.............. Florence, SC............. 26.5418 25.8347 22520.............. Florence-Muscle Shoals,

24.6505 23.6965 AL. 22540.............. Fond du Lac, WI.......... 30.6626 29.5642 22660.............. Fort Collins-Loveland, CO 29.6510 28.4242 22744.............. Fort Lauderdale-Pompano

31.1393 30.0154 Beach-Deerfield Beach, FL. 22900.............. Fort Smith, AR-OK........ 24.9728 23.7472 23020.............. Fort Walton Beach-

26.8666 25.7305 Crestview-Destin, FL. 23060.............. Fort Wayne, IN........... 28.0400 27.6656 23104.............. Fort Worth-Arlington, TX. 29.9000 28.3094 23420.............. Fresno, CA............... 34.2325 32.2418 23460.............. Gadsden, AL.............. 25.1998 23.7672 23540.............. Gainesville, FL.......... 28.8449 27.7112 23580.............. Gainesville, GA.......... 29.2101 27.2811 23844.............. Gary, IN................. 28.6613 27.6146 24020.............. Glens Falls, NY.......... 26.4297 25.3758 24140.............. Goldsboro, NC............ 28.7525 26.8565 24220.............. Grand Forks, ND-MN....... 23.9585 23.1800 24300.............. Grand Junction, CO....... 30.0980 28.4996 24340.............. Grand Rapids-Wyoming, MI. 29.0748 27.9448 24500.............. Great Falls, MT.......... 26.4350 25.6359 24540.............. Greeley, CO.............. 30.9980 29.1621 24580.............. Green Bay, WI............ 29.4038 28.1020 24660.............. Greensboro-High Point, NC 28.2420 26.8372 24780.............. Greenville, NC........... 28.7422 27.6117 24860.............. Greenville-Mauldin-

29.9557 28.7860 Easley, SC. 25020.............. Guayama, PR.............. 09.1324 09.2033 25060.............. Gulfport-Biloxi, MS...... 26.7144 25.8323 25180.............. Hagerstown-Martinsburg,

28.7017 27.6848 MD-WV. 25260.............. Hanford-Corcoran, CA..... 33.0694 30.9554 25420.............. Harrisburg-Carlisle, PA.. 28.6428 27.5304 25500.............. Harrisonburg, VA......... 27.8236 26.8453 25540.............. Hartford-West Hartford-

33.9586 32.5097 East Hartford, CT. 25620.............. Hattiesburg, MS.......... 23.3662 22.3924 25860.............. Hickory-Lenoir-Morganton, 27.8269 26.5087 NC. 25980.............. \1\Hinesville-Fort

........... ........... Stewart, GA. 26100.............. Holland-Grand Haven, MI.. 28.1052 26.9690

[[Page 24920]]

26180.............. Honolulu, HI............. 34.9939 32.9065 26300.............. Hot Springs, AR.......... 28.2398 26.5588 26380.............. Houma-Bayou Cane-

24.7338 23.6332 Thibodaux, LA. 26420.............. Houston- Sugar Land-

31.1464 29.7094 Baytown, TX. 26580.............. Huntington-Ashland, WV-KY- 27.4177 26.7237 OH. 26620.............. Huntsville, AL........... 28.4420 26.8784 26820.............. Idaho Falls, ID.......... 28.6678 27.2911 26900.............. Indianapolis-Carmel, IN.. 30.1383 28.9656 26980.............. Iowa City, IA............ 29.2276 28.3307 27060.............. Ithaca, NY............... 29.5522 28.8425 27100.............. Jackson, MI.............. 29.3419 28.0558 27140.............. Jackson, MS.............. 24.9313 24.1807 27180.............. Jackson, TN.............. 26.6283 25.9384 27260.............. Jacksonville, FL......... 28.2991 27.3023 27340.............. Jacksonville, NC......... 25.6323 24.5577 27500.............. Janesville, WI........... 30.4182 28.8010 27620.............. Jefferson City, MO....... 26.9868 25.3369 27740.............. Johnson City, TN......... 24.0384 23.4502 27780.............. Johnstown, PA............ 23.6933 24.1218 27860.............. Jonesboro, AR............ 24.5409 23.3826 27900.............. Joplin, MO............... 28.8838 26.2169 28020.............. Kalamazoo-Portage, MI.... 32.5642 31.2112 28100.............. Kankakee-Bradley, IL..... 36.1982 31.8459 28140.............. Kansas City, MO-KS....... 28.8920 27.7054 28420.............. Kennewick-Richland-Pasco, 30.5712 30.0865 WA. 28660.............. Killeen-Temple-Fort Hood, 25.7516 25.4181 TX. 28700.............. Kingsport-Bristol-

24.1118 23.5801 Bristol, TN-VA. 28740.............. Kingston, NY............. 29.5032 27.8057 28940.............. Knoxville, TN............ 24.9295 24.3432 29020.............. Kokomo, IN............... 29.3510 28.2549 29100.............. La Crosse, WI-MN......... 30.0801 28.4068 29140.............. Lafayette, IN............ 26.9108 25.7887 29180.............. Lafayette, LA............ 25.7276 24.7355 29340.............. Lake Charles, LA......... 24.1373 23.1806 29404.............. Lake County-Kenosha

31.8873 30.9559 County, IL-WI. 29420.............. \2\Lake Havasu City-

28.9023 27.6036 Kingman, AZ. 29460.............. Lakeland, FL............. 27.3993 26.4643 29540.............. Lancaster, PA............ 29.5748 28.7392 29620.............. Lansing-East Lansing, MI. 31.1620 29.4193 29700.............. Laredo, TX............... 26.2982 24.3954 29740.............. Las Cruces, NM........... 26.4505 25.6128 29820.............. Las Vegas-Paradise, NV... 35.4313 33.5557 29940.............. Lawrence, KS............. 25.4425 24.7034 30020.............. Lawton, OK............... 26.0576 24.4695 30140.............. Lebanon, PA.............. 25.4393 25.2120 30300.............. Lewiston, ID-WA.......... 28.6132 28.2893 30340.............. Lewiston-Auburn, ME...... 28.8104 27.4892 30460.............. Lexington-Fayette, KY.... 27.9807 26.6659 30620.............. Lima, OH................. 28.7195 26.9710 30700.............. Lincoln, NE.............. 30.4893 29.5435 30780.............. Little Rock-North Little 27.7885 27.0599 Rock-Conway, AR. 30860.............. Logan, UT-ID............. 28.4774 27.0281 30980.............. Longview, TX............. 27.2722 26.0005 31020.............. Longview, WA............. 34.1983 30.2983 31084.............. Los Angeles-Long Beach-

36.0596 34.6113 Glendale, CA. 31140.............. Louisville-Jefferson

28.0357 27.0524 County, KY-IN. 31180.............. Lubbock, TX.............. 26.8986 25.6168 31340.............. Lynchburg, VA............ 26.2578 25.3812 31420.............. Macon, GA................ 30.2300 28.6691 31460.............. Madera, CA............... 26.0875 25.2903 31540.............. Madison, WI.............. 34.6597 32.2701 31700.............. Manchester-Nashua, NH.... 30.9773 30.1064 31900.............. Mansfield, OH............ 28.5629 27.8928 32420.............. Mayaguez, PR............. 11.3424 11.2954 32580.............. McAllen-Edinburg-Mission, 28.3334 26.4909 TX. 32780.............. Medford, OR.............. 31.9390 30.8468 32820.............. Memphis, TN-MS-AR........ 28.7998 27.5984 32900.............. Merced, CA............... 37.0756 33.9058 33124.............. Miami-Miami Beach-

31.0677 29.1861 Kendall, FL.

[[Page 24921]]

33140.............. Michigan City-La Porte,

27.2497 26.8086 IN. 33260.............. Midland, TX.............. 31.0460 28.6440 33340.............. Milwaukee-Waukesha-West

31.9156 30.3227 Allis, WI. 33460.............. Minneapolis-St. Paul-

33.9752 32.3063 Bloomington, MN-WI. 33540.............. Missoula, MT............. 26.9875 26.3725 33660.............. Mobile, AL............... 24.6422 23.3322 33700.............. Modesto, CA.............. 36.8586 35.0384 33740.............. Monroe, LA............... 24.4029 23.5967 33780.............. Monroe, MI............... 29.3700 28.3176 33860.............. Montgomery, AL........... 25.9300 24.5421 34060.............. Morgantown, WV........... 26.0745 25.0602 34100.............. Morristown, TN........... 22.9428 22.9786 34580.............. Mount Vernon-Anacortes,

31.5880 30.3305 WA. 34620.............. Muncie, IN............... 24.8038 24.8594 34740.............. Muskegon-Norton Shores,

30.7959 29.3584 MI. 34820.............. Myrtle Beach-Conway-North 26.8331 26.0529 Myrtle Beach, SC. 34900.............. Napa, CA................. 42.8545 38.8227 34940.............. Naples-Marco Island, FL.. 30.2428 29.5403 34980.............. Nashville-Davidson-

29.9892 28.8467 Murfreesboro-Franklin,. 35004.............. Nassau-Suffolk, NY....... 39.6471 37.9525 35084.............. Newark-Union, NJ-PA...... 36.2090 34.7675 35300.............. New Haven-Milford, CT.... 37.0244 35.4080 35380.............. New Orleans-Metairie-

27.0691 25.9597 Kenner, LA. 35644.............. New York-White Plains-

40.9653 39.1524 Wayne, NY-NJ. 35660.............. Niles-Benton Harbor, MI.. 28.3260 26.5609 35980.............. Norwich-New London, CT... 35.7729 34.4608 36084.............. Oakland-Fremont-Hayward, 47.2281 45.3887 CA. 36100.............. Ocala, FL................ 26.6182 25.7575 36140.............. Ocean City, NJ........... 33.3167 31.8219 36220.............. Odessa, TX............... 30.8710 29.4945 36260.............. Ogden-Clearfield, UT..... 28.0897 26.7604 36420.............. Oklahoma City, OK........ 27.1668 26.2084 36500.............. Olympia, WA.............. 35.5354 32.8563 36540.............. Omaha-Council Bluffs, NE- 29.1986 27.9651 IA. 36740.............. Orlando-Kissimmee, FL.... 29.0828 28.0089 36780.............. Oshkosh-Neenah, WI....... 29.1236 27.4235 36980.............. Owensboro, KY............ 27.2813 25.9999 37100.............. Oxnard-Thousand Oaks-

35.2562 33.6195 Ventura, CA. 37340.............. Palm Bay-Melbourne-

29.0897 28.3339 Titusville, FL. 37380.............. \2\Palm Coast, FL........ 27.0971 27.5184 37460.............. Panama City-Lynn Haven,

25.7289 24.1673 FL. 37620.............. Parkersburg-Marietta-

25.5355 24.2911 Vienna, WV-OH. 37700.............. Pascagoula, MS........... 26.4838 24.5080 37764.............. Peabody, MA (Formerly,

31.6602 30.7561 Essex County, MA). 37860.............. Pensacola-Ferry Pass-

25.1925 23.7365 Brent, FL. 37900.............. Peoria, IL............... 29.0576 26.9647 37964.............. Philadelphia, PA......... 33.8074 32.4521 38060.............. Phoenix-Mesa-Scottsdale, 31.3564 29.9787 AZ. 38220.............. Pine Bluff, AR........... 25.2804 25.1908 38300.............. Pittsburgh, PA........... 26.0038 25.3862 38340.............. Pittsfield, MA........... 31.2160 30.0714 38540.............. Pocatello, ID............ 28.3768 27.2635 38660.............. Ponce, PR................ 12.8969 13.5329 38860.............. Portland-South Portland- 31.0222 29.7900 Biddeford, ME. 38900.............. Portland-Vancouver-

34.8208 33.1815 Beaverton, OR-WA. 38940.............. Port St. Lucie, FL....... 30.9663 29.5522 39100.............. Poughkeepsie-Newburgh-

33.6441 32.2649 Middletown, NY. 39140.............. Prescott, AZ............. 30.7280 29.1556 39300.............. Providence-New Bedford-

33.0234 31.8841 Fall River, RI-MA. 39340.............. Provo-Orem, UT........... 29.4108 28.0315 39380.............. Pueblo, CO............... 27.0881 25.6375 39460.............. Punta Gorda, FL.......... 29.6415 28.1419 39540.............. Racine, WI............... 29.7218 27.6179 39580.............. Raleigh-Cary, NC......... 29.0544 28.3348 39660.............. Rapid City, SD........... 26.9357 25.9831 39740.............. Reading, PA.............. 29.1969 28.3935 39820.............. Redding, CA.............. 39.7597 36.7887 39900.............. Reno-Sparks, NV.......... 34.2896 33.6154 40060.............. Richmond, VA............. 28.6347 27.1477

[[Page 24922]]

40140.............. Riverside-San Bernardino- 33.2757 32.0240 Ontario, CA. 40220.............. Roanoke, VA.............. 29.2663 26.3177 40340.............. Rochester, MN............ 33.3540 32.6100 40380.............. Rochester, NY............ 27.5839 26.7250 40420.............. Rockford, IL............. 29.9396 29.2179 40484.............. Rockingham County-

31.1882 30.1242 Strafford County, NH. 40580.............. Rocky Mount, NC.......... 27.9510 26.4642 40660.............. Rome, GA................. 29.6009 28.2852 40900.............. Sacramento--Arden-Arcade-- 40.2929 38.4229 Roseville, CA. 40980.............. Saginaw-Saginaw Township 28.2929 27.0559 North, MI. 41060.............. St. Cloud, MN............ 34.2927 31.6151 41100.............. St. George, UT........... 29.5906 28.1994 41140.............. St. Joseph, MO-KS........ 27.3734 28.2406 41180.............. St. Louis, MO-IL......... 27.5406 26.4397 41420.............. Salem, OR................ 32.2483 30.6937 41500.............. Salinas, CA.............. 44.6611 42.1515 41540.............. Salisbury, MD............ 27.6293 26.4517 41620.............. Salt Lake City, UT....... 29.3945 28.0053 41660.............. San Angelo, TX........... 26.8517 25.0303 41700.............. San Antonio, TX.......... 27.6376 26.4378 41740.............. San Diego-Carlsbad-San

34.4952 33.2115 Marcos, CA. 41780.............. Sandusky, OH............. 27.1537 26.6087 41884.............. San Francisco-San Mateo- 45.7716 44.5272 Redwood City, CA. 41900.............. San Germ[aacute]n-Cabo

14.2741 13.8608 Rojo, PR. 41940.............. San Jose-Sunnyvale-Santa 47.5716 45.1683 Clara, CA. 41980.............. San Juan-Caguas-Guaynabo, 14.0009 13.3929 PR. 42020.............. San Luis Obispo-Paso

36.9259 33.8666 Robles, CA. 42044.............. Santa Ana-Anaheim-Irvine, 35.8808 33.9972 CA. 42060.............. Santa Barbara-Santa Maria- 35.4727 33.4432 Goleta, CA. 42100.............. Santa Cruz-Watsonville,

48.5637 45.3017 CA. 42140.............. Santa Fe, NM............. 33.1322 31.9531 42220.............. Santa Rosa-Petaluma, CA.. 44.2225 41.4919 42260.............. Sarasota-Bradenton-

30.2493 28.7208 Venice, FL. 42340.............. Savannah, GA............. 27.8554 27.1733 42540.............. Scranton-Wilkes-Barre, PA 25.8844 24.7507 42644.............. Seattle-Bellevue-Everett, 35.1860 33.6677 WA. 42680.............. Sebastian-Vero Beach, FL. 30.0922 28.6105 43100.............. Sheboygan, WI............ 28.0832 26.7407 43300.............. Sherman-Denison, TX...... 26.4564 26.2405 43340.............. Shreveport-Bossier City, 26.7055 25.8214 LA. 43580.............. Sioux City, IA-NE-SD..... 28.5808 27.2053 43620.............. Sioux Falls, SD.......... 29.6276 28.1066 43780.............. South Bend-Mishawaka, IN- 29.9084 28.9199 MI. 43900.............. Spartanburg, SC.......... 28.9299 27.1549 44060.............. Spokane, WA.............. 32.1950 31.1767 44100.............. Springfield, IL.......... 27.7341 26.2610 44140.............. Springfield, MA.......... 31.7303 30.1941 44180.............. Springfield, MO.......... 28.5068 25.6242 44220.............. Springfield, OH.......... 26.3899 25.0448 44300.............. State College, PA........ 26.7336 25.2069 44700.............. Stockton, CA............. 36.3757 34.0601 44940.............. Sumter, SC............... 27.5115 25.3139 45060.............. Syracuse, NY............. 30.7252 28.8799 45104.............. Tacoma, WA............... 33.9097 31.9619 45220.............. Tallahassee, FL.......... 27.9967 26.3266 45300.............. Tampa-St. Petersburg-

28.2629 27.2055 Clearwater, FL. 45460.............. Terre Haute, IN.......... 27.3665 25.3379 45500.............. Texarkana, TX-Texarkana, 25.2054 24.1254 AR. 45780.............. Toledo, OH............... 28.7526 27.8529 45820.............. Topeka, KS............... 26.5384 25.8360 45940.............. Trenton-Ewing, NJ........ 33.2291 31.9683 46060.............. Tucson, AZ............... 29.4005 27.5680 46140.............. Tulsa, OK................ 26.3616 25.0135 46220.............. Tuscaloosa, AL........... 26.4544 25.5476 46340.............. Tyler, TX................ 28.4878 26.8718 46540.............. Utica-Rome, NY........... 27.1982 25.5595 46660.............. Valdosta, GA............. 25.4416 25.1421 46700.............. Vallejo-Fairfield, CA.... 44.6372 43.5597 47020.............. Victoria, TX............. 25.1770 24.3401

[[Page 24923]]

47220.............. Vineland-Millville-

33.0209 30.4618 Bridgeton, NJ. 47260.............. Virginia Beach-Norfolk-

27.2314 26.0029 Newport News, VA-NC. 47300.............. Visalia-Porterville, CA.. 31.6337 30.0704 47380.............. Waco, TX................. 26.6527 25.4923 47580.............. Warner Robins, GA........ 29.8152 26.8109 47644.............. Warren-Troy-Farmington

31.1213 29.5882 Hills, MI. 47894.............. Washington-Arlington-

33.1020 32.0904 Alexandria, DC-VA-MD-WV. 47940.............. Waterloo-Cedar Falls, IA. 27.0404 25.5291 48140.............. Wausau, WI............... 30.5699 29.0605 48260.............. Weirton-Steubenville, WV- 24.4652 23.3430 OH. 48300.............. Wenatchee, WA............ 34.9702 31.3439 48424.............. West Palm Beach-Boca

29.7173 28.7189 Raton-Boynton Beach,. 48540.............. Wheeling, WV-OH.......... 21.7311 20.9330 48620.............. Wichita, KS.............. 27.9249 26.7367 48660.............. Wichita Falls, TX........ 26.3114 24.9937 48700.............. Williamsport, PA......... 24.6486 23.9556 48864.............. Wilmington, DE-MD-NJ..... 33.0781 31.3150 48900.............. Wilmington, NC........... 28.9440 28.2419 49020.............. Winchester, VA-WV........ 30.5335 29.6408 49180.............. Winston-Salem, NC........ 28.1564 26.9277 49340.............. Worcester, MA............ 35.1528 32.7168 49420.............. Yakima, WA............... 31.6557 29.7156 49500.............. Yauco, PR................ 09.9275 11.1279 49620.............. York-Hanover, PA......... 28.8489 27.7627 49660.............. Youngstown-Warren-

27.8858 25.9934 Boardman, OH-PA. 49700.............. Yuba City, CA............ 32.6357 31.5710 49740.............. Yuma, AZ................. 29.3504 27.3749

\1\ This area has no average hourly wage because there are no short- term, acute care hospitals in the area. \2\ This is a new CBSA for fiscal year 2008. To calculate the 3-year average hourly wage for this new area, we included the hospitals' data from their previous geographic location for fiscal year 2006 and fiscal year 2007.

Table 3B.--FY 2008 and 3-Year* Average Hourly Wage for Rural Areas by CBSA

[*Based on the sum of the salaries and hours computed for Federal fiscal years 2006, 2007, and 2008]

FY 2008 3-Year CBSA code

Nonurban area

average average hourly wage hourly wage

01................. Alabama.................. 23.5521 22.3676 02................. Alaska................... 36.6306 33.8985 03................. Arizona.................. 27.8285 26.2195 04................. Arkansas................. 23.2785 22.1149 05................. California............... 35.9780 33.1876 06................. Colorado................. 29.2965 27.4981 07................. Connecticut.............. 36.3353 34.8991 08................. Delaware................. 30.2968 28.8250 10................. Florida.................. 26.6274 25.5376 11................. Georgia.................. 24.3756 23.0319 12................. Hawaii................... 33.3239 31.5165 13................. Idaho.................... 24.4240 23.6078 14................. Illinois................. 25.8984 24.5999 15................. Indiana.................. 26.6535 25.3496 16................. Iowa..................... 26.2882 25.1297 17................. Kansas................... 24.6946 23.6039 18................. Kentucky................. 24.2146 23.0381 19................. Louisiana................ 23.5312 22.3366 20................. Maine.................... 26.0760 25.2175 21................. Maryland................. 27.6395 26.7366 22................. Massachusetts \1\........ ........... ........... 23................. Michigan................. 27.5837 26.4032 24................. Minnesota................ 28.5541 27.0433 25................. Mississippi.............. 24.5289 23.0377 26................. Missouri................. 25.0101 23.6921 27................. Montana.................. 25.8421 25.3487 28................. Nebraska................. 27.1777 25.6347 29................. Nevada................... 30.0298 27.4114 30................. New Hampshire............ 33.8547 32.1650 31................. New Jersey \1\........... ........... ...........

[[Page 24924]]

32................. New Mexico............... 27.7898 25.6380 33................. New York................. 25.8757 24.4927 34................. North Carolina........... 26.6830 25.3984 35................. North Dakota............. 22.6664 21.5961 36................. Ohio..................... 26.9698 25.8025 37................. Oklahoma................. 23.8387 22.7968 38................. Oregon................... 30.7212 28.9514 39................. Pennsylvania............. 25.8767 24.5786 40................. Puerto Rico \1\.......... ........... ........... 41................. Rhode Island \1\......... ........... ........... 42................. South Carolina........... 27.2502 25.7842 43................. South Dakota............. 25.8592 24.7950 44................. Tennessee................ 24.3749 23.4834 45................. Texas.................... 25.4299 24.0807 46................. Utah..................... 25.6240 24.2425 47................. Vermont.................. 30.2045 28.6321 49................. Virginia................. 25.0426 23.8317 50................. Washington............... 31.5068 30.3826 51................. West Virginia............ 23.4572 22.6937 52................. Wisconsin................ 29.8668 28.3189 53................. Wyoming.................. 28.5623 27.0729

\1\ All counties within the State or territory are classified as urban.

Table 4A.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas by CBSA--FY 2008

Urban area (constituent Wage CBSA code

counties)

index GAF

10180................ Abilene, TX................ 0.8244 0.8761 Callahan County, TX....... Jones County, TX.......... Taylor County, TX......... 10380................ Aguadilla-Isabela-San

0.3298 0.4678 Sebasti[aacute]n, PR. Aguada Municipio, PR...... Aguadilla Municipio, PR... A[ntilde]asco Municipio, PR. Isabela Municipio, PR..... Lares Municipio, PR....... Moca Municipio, PR........ Rinc[oacute]n Municipio, PR. San Sebasti[aacute]n Municipio, PR. 10420................ Akron, OH.................. 0.8854 0.9200 Portage County, OH........ Summit County, OH......... 10500................ Albany, GA................. 0.8671 0.9070 Baker County, GA.......... Dougherty County, GA...... Lee County, GA............ Terrell County, GA........ Worth County, GA.......... 10580................ Albany-Schenectady-Troy, NY 0.8672 0.9070 Albany County, NY......... Rensselaer County, NY..... Saratoga County, NY....... Schenectady County, NY.... Schoharie County, NY...... 10740................ Albuquerque, NM............ 0.9740 0.9821 Bernalillo County, NM..... Sandoval County, NM....... Torrance County, NM....... Valencia County, NM....... 10780................ Alexandria, LA............. 0.7982 0.8570 Grant Parish, LA.......... Rapides Parish, LA........ 10900................ Allentown-Bethlehem-Easton, 1.0024 1.0016 PA-NJ. Warren County, NJ......... Carbon County, PA.........

[[Page 24925]]

Lehigh County, PA......... Northampton County, PA.... 11020................ \2\ Altoona, PA............ 0.8366 0.8850 Blair County, PA.......... 11100................ Amarillo, TX............... 0.9141 0.9403 Armstrong County, TX...... Carson County, TX......... Potter County, TX......... Randall County, TX........ 11180................ Ames, IA................... 0.9982 0.9988 Story County, IA.......... 11260................ Anchorage, AK.............. 1.1840 1.1226 Anchorage Municipality, AK Matanuska-Susitna Borough, AK. 11300................ Anderson, IN............... 0.8969 0.9282 Madison County, IN........ 11340................ Anderson, SC............... 0.9087 0.9365 Anderson County, SC....... 11460................ Ann Arbor, MI.............. 1.0504 1.0342 Washtenaw County, MI...... 11500................ Anniston-Oxford, AL........ 0.8042 0.8614 Calhoun County, AL........ 11540................ \2\ Appleton, WI........... 0.9635 0.9749 Calumet County, WI........ Outagamie County, WI...... 11700................ Asheville, NC.............. 0.9209 0.9451 Buncombe County, NC....... Haywood County, NC........ Henderson County, NC...... Madison County, NC........ 12020................ Athens-Clarke County, GA... 1.0543 1.0369 Clarke County, GA......... Madison County, GA........ Oconee County, GA......... Oglethorpe County, GA..... 12060................ \1\ Atlanta-Sandy Springs- 0.9845 0.9894 Marietta, GA. Barrow County, GA......... Bartow County, GA......... Butts County, GA.......... Carroll County, GA........ Cherokee County, GA....... Clayton County, GA........ Cobb County, GA........... Coweta County, GA......... Dawson County, GA......... DeKalb County, GA......... Douglas County, GA........ Fayette County, GA........ Forsyth County, GA........ Fulton County, GA......... Gwinnett County, GA....... Haralson County, GA....... Heard County, GA.......... Henry County, GA.......... Jasper County, GA......... Lamar County, GA.......... Meriwether County, GA..... Newton County, GA......... Paulding County, GA....... Pickens County, GA........ Pike County, GA........... Rockdale County, GA....... Spalding County, GA....... Walton County, GA......... 12100................ Atlantic City, NJ.......... 1.2095 1.1391 Atlantic County, NJ....... 12220................ Auburn-Opelika, AL......... 0.8086 0.8646 Lee County, AL............ 12260................ Augusta-Richmond County, GA- 0.9600 0.9724 SC. Burke County, GA..........

[[Page 24926]]

Columbia County, GA....... McDuffie County, GA....... Richmond County, GA....... Aiken County, SC.......... Edgefield County, SC...... 12420................ \1\ Austin-Round Rock, TX.. 0.9518 0.9667 Bastrop County, TX........ Caldwell County, TX....... Hays County, TX........... Travis County, TX......... Williamson County, TX..... 12540................ \2\ Bakersfield, CA........ 1.1607 1.1074 Kern County, CA........... 12580................ \1\ Baltimore-Towson, MD... 1.0108 1.0074 Anne Arundel County, MD... Baltimore County, MD...... Carroll County, MD........ Harford County, MD........ Howard County, MD......... Queen Anne's County, MD... Baltimore City, MD........ 12620................ Bangor, ME................. 0.9860 0.9904 Penobscot County, ME...... 12700................ Barnstable Town, MA........ 1.2617 1.1726 Barnstable County, MA..... 12940................ Baton Rouge, LA............ 0.8014 0.8593 Ascension Parish, LA...... East Baton Rouge Parish, LA. East Feliciana Parish, LA. Iberville Parish, LA...... Livingston Parish, LA..... Pointe Coupee Parish, LA.. St. Helena Parish, LA..... West Baton Rouge Parish, LA. West Feliciana Parish, LA. 12980................ Battle Creek, MI........... 1.0042 1.0029 Calhoun County, MI........ 13020................ Bay City, MI............... 0.9399 0.9584 Bay County, MI............ 13140................ Beaumont-Port Arthur, TX... 0.8587 0.9009 Hardin County, TX......... Jefferson County, TX...... Orange County, TX......... 13380................ Bellingham, WA............. 1.1264 1.0849 Whatcom County, WA........ 13460................ Bend, OR................... 1.0592 1.0402 Deschutes County, OR...... 13644................ \1\ Bethesda-Gaithersburg- 1.0990 1.0668 Frederick, MD. Frederick County, MD...... Montgomery County, MD..... 13740................ Billings, MT............... 0.8877 0.9217 Carbon County, MT......... Yellowstone County, MT.... 13780................ Binghamton, NY............. 0.9072 0.9355 Broome County, NY......... Tioga County, NY.......... 13820................ \1\ Birmingham-Hoover, AL.. 0.8873 0.9214 Bibb County, AL........... Blount County, AL......... Chilton County, AL........ Jefferson County, AL...... St. Clair County, AL...... Shelby County, AL......... Walker County, AL......... 13900................ Bismarck, ND............... 0.7329 0.8083 Burleigh County, ND....... Morton County, ND......... 13980................ \2\ Blacksburg-

0.8095 0.8653 Christiansburg-Radford, VA. Giles County, VA.......... Montgomery County, VA.....

[[Continued on page 24929]]

From the Federal Register Online via GPO Access [wais.access.gpo.gov] ]

[[pp. 24929-24978]] Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates

[[Continued from page 24928]]

[[Page 24927]]

Pulaski County, VA........ Radford City, VA.......... 14020................ Bloomington, IN............ 0.9327 0.9534 Greene County, IN......... Monroe County, IN......... Owen County, IN........... 14060................ Bloomington-Normal, IL..... 0.9488 0.9646 McLean County, IL......... 14260................ Boise City-Nampa, ID....... 0.9501 0.9656 Ada County, ID............ Boise County, ID.......... Canyon County, ID......... Gem County, ID............ Owyhee County, ID......... 14484................ \1\ Boston-Quincy, MA...... 1.1710 1.1142 Norfolk County, MA........ Plymouth County, MA....... Suffolk County, MA........ 14500................ Boulder, CO................ 1.0118 1.0081 Boulder County, CO........ 14540................ Bowling Green, KY.......... 0.8089 0.8648 Edmonson County, KY....... Warren County, KY......... 14740................ Bremerton-Silverdale, WA... 1.0826 1.0559 Kitsap County, WA......... 14860................ Bridgeport-Stamford-

1.2886 1.1896 Norwalk, CT. Fairfield County, CT...... 15180................ Brownsville-Harlingen, TX.. 0.9577 0.9708 Cameron County, TX........ 15260................ Brunswick, GA.............. 0.9768 0.9841 Brantley County, GA....... Glynn County, GA.......... McIntosh County, GA....... 15380................ \1\ Buffalo-Niagara Falls, 0.9586 0.9715 NY. Erie County, NY........... Niagara County, NY........ 15500................ \2\ Burlington, NC......... 0.8608 0.9024 Alamance County, NC....... 15540................ \2\ Burlington-South

1.0401 1.0273 Burlington, VT. Chittenden County, VT..... Franklin County, VT....... Grand Isle County, VT..... 15764................ \1\ Cambridge-Newton-

1.1168 1.0786 Framingham, MA. Middlesex County, MA...... 15804................ \1\ Camden, NJ............. 1.0522 1.0355 Burlington County, NJ..... Camden County, NJ......... Gloucester County, NJ..... 15940................ Canton-Massillon, OH....... 0.8921 0.9248 Carroll County, OH........ Stark County, OH.......... 15980................ Cape Coral-Fort Myers, FL.. 0.9490 0.9648 Lee County, FL............ 16180................ \2\ Carson City, NV........ 0.9688 0.9785 Carson City, NV........... 16220................ Casper, WY................. 0.9277 0.9499 Natrona County, WY........ 16300................ Cedar Rapids, IA........... 0.8689 0.9083 Benton County, IA......... Jones County, IA.......... Linn County, IA........... 16580................ Champaign-Urbana, IL....... 0.9320 0.9529 Champaign County, IL...... Ford County, IL........... Piatt County, IL.......... 16620................ Charleston, WV............. 0.8397 0.8872 Boone County, WV.......... Clay County, WV........... Kanawha County, WV........ Lincoln County, WV........

[[Page 24928]]

Putnam County, WV......... 16700................ Charleston-North

0.9144 0.9406 Charleston, SC. Berkeley County, SC....... Charleston County, SC..... Dorchester County, SC..... 16740................ \1\ Charlotte-Gastonia-

0.9512 0.9663 Concord, NC-SC. Anson County, NC.......... Cabarrus County, NC....... Gaston County, NC......... Mecklenburg County, NC.... Union County, NC.......... York County, SC........... 16820................ Charlottesville, VA........ 0.9555 0.9693 Albemarle County, VA...... Fluvanna County, VA....... Greene County, VA......... Nelson County, VA......... Charlottesville City, VA.. 16860................ Chattanooga, TN-GA......... 0.8967 0.9281 Catoosa County, GA........ Dade County, GA........... Walker County, GA......... Hamilton County, TN....... Marion County, TN......... Sequatchie County, TN..... 16940................ Cheyenne, WY............... 0.9219 0.9458 Laramie County, WY........ 16974................ \1\ Chicago-Naperville-

1.0455 1.0309 Joliet, IL. Cook County, IL........... DeKalb County, IL......... DuPage County, IL......... Grundy County, IL......... Kane County, IL........... Kendall County, IL........ McHenry County, IL........ Will County, IL........... 17020................ \2\ Chico, CA.............. 1.1607 1.1074 Butte County, CA.......... 17140................ \1\ Cincinnati-Middletown, 0.9654 0.9762 OH-KY-IN. Dearborn County, IN....... Franklin County, IN....... Ohio County, IN........... Boone County, KY.......... Bracken County, KY........ Campbell County, KY....... Gallatin County, KY....... Grant County, KY.......... Kenton County, KY......... Pendleton County, KY...... Brown County, OH.......... Butler County, OH......... Clermont County, OH....... Hamilton County, OH....... Warren County, OH......... 17300................ Clarksville, TN-KY......... 0.8223 0.8746 Christian County, KY...... Trigg County, KY.......... Montgomery County, TN..... Stewart County, TN........ 17420................ Cleveland, TN.............. 0.8174 0.8710 Bradley County, TN........ Polk County, TN........... 17460................ \1\ Cleveland-Elyria-

0.9365 0.9561 Mentor, OH. Cuyahoga County, OH....... Geauga County, OH......... Lake County, OH........... Lorain County, OH......... Medina County, OH......... 17660................ Coeur d'Alene, ID.......... 0.9360 0.9557 Kootenai County, ID.......

[[Page 24929]]

17780................ College Station-Bryan, TX.. 0.9177 0.9429 Brazos County, TX......... Burleson County, TX....... Robertson County, TX...... 17820................ Colorado Springs, CO....... 0.9471 0.9635 El Paso County, CO........ Teller County, CO......... 17860................ Columbia, MO............... 0.8545 0.8979 Boone County, MO.......... Howard County, MO......... 17900................ \2\ Columbia, SC........... 0.8791 0.9155 Calhoun County, SC........ Fairfield County, SC...... Kershaw County, SC........ Lexington County, SC...... Richland County, SC....... Saluda County, SC......... 17980................ Columbus, GA-AL............ 0.9023 0.9320 Russell County, AL........ Chattahoochee County, GA.. Harris County, GA......... Marion County, GA......... Muscogee County, GA....... 18020................ Columbus, IN............... 0.9630 0.9745 Bartholomew County, IN.... 18140................ \1\ Columbus, OH........... 1.0048 1.0033 Delaware County, OH....... Fairfield County, OH...... Franklin County, OH....... Licking County, OH........ Madison County, OH........ Morrow County, OH......... Pickaway County, OH....... Union County, OH.......... 18580................ Corpus Christi, TX......... 0.8460 0.8918 Aransas County, TX........ Nueces County, TX......... San Patricio County, TX... 18700................ Corvallis, OR.............. 1.0708 1.0480 Benton County, OR......... 19060................ \2\ Cumberland, MD-WV (MD 0.8917 0.9245 Hospitals). Allegany County, MD....... Mineral County, WV........ 19060................ Cumberland, MD-WV (WV

0.7967 0.8559 Hospitals). Allegany County, MD....... Mineral County, WV........ 19124................ \1\ Dallas-Plano-Irving, TX 0.9795 0.9859 Collin County, TX......... Dallas County, TX......... Delta County, TX.......... Denton County, TX......... Ellis County, TX.......... Hunt County, TX........... Kaufman County, TX........ Rockwall County, TX....... 19140................ Dalton, GA................. 0.8587 0.9009 Murray County, GA......... Whitfield County, GA...... 19180................ Danville, IL............... 0.9250 0.9480 Vermilion County, IL...... 19260................ Danville, VA............... 0.8486 0.8937 Pittsylvania County, VA... Danville City, VA......... 19340................ Davenport-Moline-Rock

0.8898 0.9232 Island, IA-IL. Henry County, IL.......... Mercer County, IL......... Rock Island County, IL.... Scott County, IA.......... 19380................ Dayton, OH................. 0.9283 0.9503 Greene County, OH.........

[[Page 24930]]

Miami County, OH.......... Montgomery County, OH..... Preble County, OH......... 19460................ Decatur, AL................ 0.7927 0.8529 Lawrence County, AL....... Morgan County, AL......... 19500................ \2\ Decatur, IL............ 0.8355 0.8842 Macon County, IL.......... 19660................ Deltona-Daytona Beach-

0.8948 0.9267 Ormond Beach, FL. Volusia County, FL........ 19740................ \1\ Denver-Aurora, CO...... 1.0490 1.0333 Adams County, CO.......... Arapahoe County, CO....... Broomfield County, CO..... Clear Creek County, CO.... Denver County, CO......... Douglas County, CO........ Elbert County, CO......... Gilpin County, CO......... Jefferson County, CO...... Park County, CO........... 19780................ Des Moines-West Des Moines, 0.9162 0.9418 IA. Dallas County, IA......... Guthrie County, IA........ Madison County, IA........ Polk County, IA........... Warren County, IA......... 19804................ \1\ Detroit-Livonia-

1.0091 1.0062 Dearborn, MI. Wayne County, MI.......... 20020................ \2\ Dothan, AL............. 0.7598 0.8285 Geneva County, AL......... Henry County, AL.......... Houston County, AL........ 20100................ Dover, DE.................. 1.0396 1.0270 Kent County, DE........... 20220................ Dubuque, IA................ 0.8874 0.9215 Dubuque County, IA........ 20260................ Duluth, MN-WI.............. 1.0151 1.0103 Carlton County, MN........ St. Louis County, MN...... Douglas County, WI........ 20500................ Durham, NC................. 0.9814 0.9872 Chatham County, NC........ Durham County, NC......... Orange County, NC......... Person County, NC......... 20740................ \2\ Eau Claire, WI......... 0.9635 0.9749 Chippewa County, WI....... Eau Claire County, WI..... 20764................ \1\ Edison, NJ............. 1.1131 1.0761 Middlesex County, NJ...... Monmouth County, NJ....... Ocean County, NJ.......... Somerset County, NJ....... 20940................ \2\ El Centro, CA.......... 1.1607 1.1074 Imperial County, CA....... 21060................ Elizabethtown, KY.......... 0.8622 0.9035 Hardin County, KY......... Larue County, KY.......... 21140................ Elkhart-Goshen, IN......... 0.9438 0.9612 Elkhart County, IN........ 21300................ \2\ Elmira, NY............. 0.8440 0.8903 Chemung County, NY........ 21340................ El Paso, TX................ 0.9144 0.9406 El Paso County, TX........ 21500................ Erie, PA................... 0.8507 0.8952 Erie County, PA........... 21660................ Eugene-Springfield, OR..... 1.1008 1.0680 Lane County, OR........... 21780................ \2\ Evansville, IN-KY (IN 0.8599 0.9018 Hospitals).

[[Page 24931]]

Gibson County, IN......... Posey County, IN.......... Vanderburgh County, IN.... Warrick County, IN........ Henderson County, KY...... Webster County, KY........ 21780................ Evansville, IN-KY (KY

0.8469 0.8924 Hospitals). Gibson County, IN......... Posey County, IN.......... Vanderburgh County, IN.... Warrick County, IN........ Henderson County, KY...... Webster County, KY........ 21820................ \2\ Fairbanks, AK.......... 1.1817 1.1211 Fairbanks North Star Borough, AK. 21940................ Fajardo, PR................ 0.4121 0.5449 Ceiba Municipio, PR....... Fajardo Municipio, PR..... Luquillo Municipio, PR.... 22020................ \2\ Fargo, ND-MN (MN

0.9212 0.9453 Hospitals). Clay County, MN........... Cass County, ND........... 22020................ Fargo, ND-MN (ND Hospitals) 0.8189 0.8721 Clay County, MN........... Cass County, ND........... 22140................ Farmington, NM............. 0.9289 0.9507 San Juan County, NM....... 22180................ Fayetteville, NC........... 0.9926 0.9949 Cumberland County, NC..... Hoke County, NC........... 22220................ Fayetteville-Springdale-

0.8876 0.9216 Rogers, AR-MO. Benton County, AR......... Madison County, AR........ Washington County, AR..... McDonald County, MO....... 22380................ Flagstaff, AZ.............. 1.1558 1.1042 Coconino County, AZ....... 22420................ Flint, MI.................. 1.1078 1.0726 Genesee County, MI........ 22500................ \2\ Florence, SC........... 0.8791 0.9155 Darlington County, SC..... Florence County, SC....... 22520................ Florence-Muscle Shoals, AL. 0.7971 0.8562 Colbert County, AL........ Lauderdale County, AL..... 22540................ Fond du Lac, WI............ 0.9892 0.9926 Fond du Lac County, WI.... 22660................ Fort Collins-Loveland, CO.. 0.9577 0.9708 Larimer County, CO........ 22744................ \1\ Fort Lauderdale-Pompano 1.0245 1.0167 Beach-Deerfield Beach, FL. Broward County, FL........ 22900................ Fort Smith, AR-OK.......... 0.8056 0.8624 Crawford County, AR....... Franklin County, AR....... Sebastian County, AR...... Le Flore County, OK....... Sequoyah County, OK....... 23020................ \2\ Fort Walton Beach-

0.8749 0.9125 Crestview-Destin, FL. Okaloosa County, FL....... 23060................ Fort Wayne, IN............. 0.9046 0.9336 Allen County, IN.......... Wells County, IN.......... Whitley County, IN........ 23104................ \1\ Fort Worth-Arlington, 0.9646 0.9756 TX. Johnson County, TX........ Parker County, TX......... Tarrant County, TX........ Wise County, TX........... 23420................ \2\ Fresno, CA............. 1.1607 1.1074 Fresno County, CA.........

[[Page 24932]]

23460................ Gadsden, AL................ 0.8129 0.8677 Etowah County, AL......... 23540................ Gainesville, FL............ 0.9306 0.9519 Alachua County, FL........ Gilchrist County, FL...... 23580................ Gainesville, GA............ 0.9423 0.9601 Hall County, GA........... 23844................ Gary, IN................... 0.9246 0.9477 Jasper County, IN......... Lake County, IN........... Newton County, IN......... Porter County, IN......... 24020................ Glens Falls, NY............ 0.8526 0.8965 Warren County, NY......... Washington County, NY..... 24140................ Goldsboro, NC.............. 0.9276 0.9498 Wayne County, NC.......... 24220................ \2\ Grand Forks, ND-MN (MN 0.9212 0.9453 Hospitals). Polk County, MN........... Grand Forks County, ND.... 24220................ Grand Forks, ND-MN (ND

0.7729 0.8383 Hospitals). Polk County, MN........... Grand Forks County, ND.... 24300................ Grand Junction, CO......... 1.0141 1.0096 Mesa County, CO........... 24340................ Grand Rapids-Wyoming, MI... 0.9380 0.9571 Barry County, MI.......... Ionia County, MI.......... Kent County, MI........... Newaygo County, MI........ 24500................ Great Falls, MT............ 0.8765 0.9137 Cascade County, MT........ 24540................ Greeley, CO................ 1.0000 1.0000 Weld County, CO........... 24580................ \2\ Green Bay, WI.......... 0.9635 0.9749 Brown County, WI.......... Kewaunee County, WI....... Oconto County, WI......... 24660................ Greensboro-High Point, NC.. 0.9111 0.9382 Guilford County, NC....... Randolph County, NC....... Rockingham County, NC..... 24780................ Greenville, NC............. 0.9272 0.9496 Greene County, NC......... Pitt County, NC........... 24860................ Greenville-Mauldin-Easley, 0.9664 0.9769 SC. Greenville County, SC..... Laurens County, SC........ Pickens County, SC........ 25020................ Guayama, PR................ 0.2946 0.4330 Arroyo Municipio, PR...... Guayama Municipio, PR..... Patillas Municipio, PR.... 25060................ Gulfport-Biloxi, MS........ 0.8618 0.9032 Hancock County, MS........ Harrison County, MS....... Stone County, MS.......... 25180................ Hagerstown-Martinsburg, MD- 0.9259 0.9486 WV. Washington County, MD..... Berkeley County, WV....... Morgan County, WV......... 25260................ \2\ Hanford-Corcoran, CA... 1.1607 1.1074 Kings County, CA.......... 25420................ Harrisburg-Carlisle, PA.... 0.9240 0.9473 Cumberland County, PA..... Dauphin County, PA........ Perry County, PA.......... 25500................ Harrisonburg, VA........... 0.8976 0.9287 Rockingham County, VA..... Harrisonburg City, VA.....

[[Page 24933]]

25540................ \1\ \2\ Hartford-West

1.2439 1.1612 Hartford-East Hartford, CT. Hartford County, CT....... Litchfield County, CT..... Middlesex County, CT...... Tolland County, CT........ 25620................ \2\ Hattiesburg, MS........ 0.7915 0.8520 Forrest County, MS........ Lamar County, MS.......... Perry County, MS.......... 25860................ Hickory-Lenoir-Morganton, 0.8977 0.9288 NC. Alexander County, NC...... Burke County, NC.......... Caldwell County, NC....... Catawba County, NC........ 25980................ Hinesville-Fort Stewart, GA 0.7864 0.8483 Liberty County, GA........ Long County, GA........... 26100................ Holland-Grand Haven, MI.... 0.9066 0.9351 Ottawa County, MI......... 26180................ Honolulu, HI............... 1.1289 1.0866 Honolulu County, HI....... 26300................ Hot Springs, AR............ 0.9110 0.9382 Garland County, AR........ 26380................ Houma-Bayou Cane-Thibodaux, 0.7980 0.8568 LA. Lafourche Parish, LA...... Terrebonne Parish, LA..... 26420................ \1\ Houston-Sugar Land-

1.0048 1.0033 Baytown, TX. Austin County, TX......... Brazoria County, TX....... Chambers County, TX....... Fort Bend County, TX...... Galveston County, TX...... Harris County, TX......... Liberty County, TX........ Montgomery County, TX..... San Jacinto County, TX.... Waller County, TX......... 26580................ Huntington-Ashland, WV-KY- 0.8845 0.9194 OH. Boyd County, KY........... Greenup County, KY........ Lawrence County, OH....... Cabell County, WV......... Wayne County, WV.......... 26620................ Huntsville, AL............. 0.9175 0.9427 Limestone County, AL...... Madison County, AL........ 26820................ Idaho Falls, ID............ 0.9352 0.9552 Bonneville County, ID..... Jefferson County, ID...... 26900................ \1\ Indianapolis-Carmel, IN 0.9723 0.9809 Boone County, IN.......... Brown County, IN.......... Hamilton County, IN....... Hancock County, IN........ Hendricks County, IN...... Johnson County, IN........ Marion County, IN......... Morgan County, IN......... Putnam County, IN......... Shelby County, IN......... 26980................ Iowa City, IA.............. 0.9428 0.9605 Johnson County, IA........ Washington County, IA..... 27060................ Ithaca, NY................. 0.9715 0.9804 Tompkins County, NY....... 27100................ Jackson, MI................ 0.9465 0.9630 Jackson County, MI........ 27140................ Jackson, MS................ 0.8273 0.8782 Copiah County, MS......... Hinds County, MS..........

[[Page 24934]]

Madison County, MS........ Rankin County, MS......... Simpson County, MS........ 27180................ Jackson, TN................ 0.8590 0.9012 Chester County, TN........ Madison County, TN........ 27260................ \1\ Jacksonville, FL....... 0.9129 0.9395 Baker County, FL.......... Clay County, FL........... Duval County, FL.......... Nassau County, FL......... St. Johns County, FL...... 27340................ \2\ Jacksonville, NC....... 0.8608 0.9024 Onslow County, NC......... 27500................ Janesville, WI............. 0.9813 0.9872 Rock County, WI........... 27620................ Jefferson City, MO......... 0.8706 0.9095 Callaway County, MO....... Cole County, MO........... Moniteau County, MO....... Osage County, MO.......... 27740................ \2\ Johnson City, TN....... 0.7916 0.8521 Carter County, TN......... Unicoi County, TN......... Washington County, TN..... 27780................ \2\ Johnstown, PA.......... 0.8366 0.8850 Cambria County, PA........ 27860................ Jonesboro, AR.............. 0.8507 0.8952 Craighead County, AR...... Poinsett County, AR....... 27900................ Joplin, MO................. 0.9318 0.9528 Jasper County, MO......... Newton County, MO......... 28020................ Kalamazoo-Portage, MI...... 1.0505 1.0343 Kalamazoo County, MI...... Van Buren County, MI...... 28100................ Kankakee-Bradley, IL....... 1.1678 1.1121 Kankakee County, IL....... 28140................ \1\ Kansas City, MO-KS..... 0.9321 0.9530 Franklin County, KS....... Johnson County, KS........ Leavenworth County, KS.... Linn County, KS........... Miami County, KS.......... Wyandotte County, KS...... Bates County, MO.......... Caldwell County, MO....... Cass County, MO........... Clay County, MO........... Clinton County, MO........ Jackson County, MO........ Lafayette County, MO...... Platte County, MO......... Ray County, MO............ 28420................ \2\ Kennewick-Richland-

1.0565 1.0384 Pasco, WA. Benton County, WA......... Franklin County, WA....... 28660................ Killeen-Temple-Fort Hood, 0.8308 0.8808 TX. Bell County, TX........... Coryell County, TX........ Lampasas County, TX....... 28700................ \2\ Kingsport-Bristol-

0.7916 0.8521 Bristol, TN-VA (TN Hospitals). Hawkins County, TN........ Sullivan County, TN....... Bristol City, VA.......... Scott County, VA.......... Washington County, VA..... 28700................ \2\ Kingsport-Bristol-

0.8095 0.8653 Bristol, TN-VA (VA Hospitals). Hawkins County, TN........ Sullivan County, TN.......

[[Page 24935]]

Bristol City, VA.......... Scott County, VA.......... Washington County, VA..... 28740................ Kingston, NY............... 0.9518 0.9667 Ulster County, NY......... 28940................ Knoxville, TN.............. 0.8042 0.8614 Anderson County, TN....... Blount County, TN......... Knox County, TN........... Loudon County, TN......... Union County, TN.......... 29020................ Kokomo, IN................. 0.9468 0.9633 Howard County, IN......... Tipton County, IN......... 29100................ La Crosse, WI-MN........... 0.9704 0.9796 Houston County, MN........ La Crosse County, WI...... 29140................ Lafayette, IN.............. 0.8682 0.9078 Benton County, IN......... Carroll County, IN........ Tippecanoe County, IN..... 29180................ Lafayette, LA.............. 0.8323 0.8819 Lafayette Parish, LA...... St. Martin Parish, LA..... 29340................ Lake Charles, LA........... 0.7787 0.8426 Calcasieu Parish, LA...... Cameron Parish, LA........ 29404................ Lake County-Kenosha County, 1.0287 1.0196 IL-WI. Lake County, IL........... Kenosha County, WI........ 29420................ \2\ Lake Havasu City-

0.9386 0.9575 Kingman, AZ. Mohave County, AZ......... 29460................ Lakeland, FL............... 0.8839 0.9190 Polk County, FL........... 29540................ Lancaster, PA.............. 0.9589 0.9717 Lancaster County, PA...... 29620................ Lansing-East Lansing, MI... 1.0053 1.0036 Clinton County, MI........ Eaton County, MI.......... Ingham County, MI......... 29700................ Laredo, TX................. 0.8484 0.8935 Webb County, TX........... 29740................ \2\ Las Cruces, NM......... 0.8965 0.9279 Dona Ana County, NM....... 29820................ \1\ Las Vegas-Paradise, NV. 1.1431 1.0959 Clark County, NV.......... 29940................ Lawrence, KS............... 0.8208 0.8735 Douglas County, KS........ 30020................ Lawton, OK................. 0.8406 0.8879 Comanche County, OK....... 30140................ \2\ Lebanon, PA............ 0.8366 0.8850 Lebanon County, PA........ 30300................ Lewiston, ID-WA (ID

0.9231 0.9467 Hospitals). Nez Perce County, ID...... Asotin County, WA......... 30300................ \2\ Lewiston, ID-WA (WA

1.0565 1.0384 Hospitals). Nez Perce County, ID...... Asotin County, WA......... 30340................ Lewiston-Auburn, ME........ 0.9295 0.9512 Androscoggin County, ME... 30460................ Lexington-Fayette, KY...... 0.9027 0.9323 Bourbon County, KY........ Clark County, KY.......... Fayette County, KY........ Jessamine County, KY...... Scott County, KY.......... Woodford County, KY....... 30620................ Lima, OH................... 0.9312 0.9524 Allen County, OH.......... 30700................ Lincoln, NE................ 0.9836 0.9887

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Lancaster County, NE...... Seward County, NE......... 30780................ Little Rock-North Little

0.8965 0.9279 Rock-Conway, AR. Faulkner County, AR....... Grant County, AR.......... Lonoke County, AR......... Perry County, AR.......... Pulaski County, AR........ Saline County, AR......... 30860................ Logan, UT-ID............... 0.9219 0.9458 Franklin County, ID....... Cache County, UT.......... 30980................ Longview, TX............... 0.8875 0.9215 Gregg County, TX.......... Rusk County, TX........... Upshur County, TX......... 31020................ Longview, WA............... 1.1033 1.0696 Cowlitz County, WA........ 31084................ \1\ Los Angeles-Long Beach- 1.1633 1.1091 Glendale, CA. Los Angeles County, CA.... 31140................ \1\ Louisville-Jefferson

0.9045 0.9336 County, KY-IN. Clark County, IN.......... Floyd County, IN.......... Harrison County, IN....... Washington County, IN..... Bullitt County, KY........ Henry County, KY.......... Jefferson County, KY...... Meade County, KY.......... Nelson County, KY......... Oldham County, KY......... Shelby County, KY......... Spencer County, KY........ Trimble County, KY........ 31180................ Lubbock, TX................ 0.8678 0.9075 Crosby County, TX......... Lubbock County, TX........ 31340................ Lynchburg, VA.............. 0.8490 0.8940 Amherst County, VA........ Appomattox County, VA..... Bedford County, VA........ Campbell County, VA....... Bedford City, VA.......... Lynchburg City, VA........ 31420................ Macon, GA.................. 0.9752 0.9829 Bibb County, GA........... Crawford County, GA....... Jones County, GA.......... Monroe County, GA......... Twiggs County, GA......... 31460................ \2\ Madera, CA............. 1.1607 1.1074 Madera County, CA......... 31540................ Madison, WI................ 1.1181 1.0794 Columbia County, WI....... Dane County, WI........... Iowa County, WI........... 31700................ \2\ Manchester-Nashua, NH.. 1.1266 1.0851 Hillsborough County, NH... Merrimack County, NH...... 31900................ Mansfield, OH.............. 0.9214 0.9455 Richland County, OH....... 32420................ Mayag[uuml]ez, PR.......... 0.3659 0.5023 Hormigueros Municipio, PR. Mayag[uuml]ez Municipio, PR. 32580................ McAllen-Edinburg-Mission, 0.9140 0.9403 TX. Hidalgo County, TX........ 32780................ Medford, OR................ 1.0304 1.0207 Jackson County, OR........ 32820................ \1\ Memphis, TN-MS-AR...... 0.9291 0.9509 Crittenden County, AR.....

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DeSoto County, MS......... Marshall County, MS....... Tate County, MS........... Tunica County, MS......... Fayette County, TN........ Shelby County, TN......... Tipton County, TN......... 32900................ Merced, CA................. 1.1961 1.1305 Merced County, CA......... 33124................ \1\ Miami-Miami Beach-

1.0023 1.0016 Kendall, FL. Miami-Dade County, FL..... 33140................ Michigan City-La Porte, IN. 0.8791 0.9155 LaPorte County, IN........ 33260................ Midland, TX................ 1.0016 1.0011 Midland County, TX........ 33340................ \1\ Milwaukee-Waukesha-West 1.0296 1.0202 Allis, WI. Milwaukee County, WI...... Ozaukee County, WI........ Washington County, WI..... Waukesha County, WI....... 33460................ \1\ Minneapolis-St. Paul- 1.0961 1.0649 Bloomington, MN-WI. Anoka County, MN.......... Carver County, MN......... Chisago County, MN........ Dakota County, MN......... Hennepin County, MN....... Isanti County, MN......... Ramsey County, MN......... Scott County, MN.......... Sherburne County, MN...... Washington County, MN..... Wright County, MN......... Pierce County, WI......... St. Croix County, WI...... 33540................ Missoula, MT............... 0.8737 0.9117 Missoula County, MT....... 33660................ Mobile, AL................. 0.7950 0.8546 Mobile County, AL......... 33700................ Modesto, CA................ 1.1989 1.1323 Stanislaus County, CA..... 33740................ Monroe, LA................. 0.7872 0.8489 Ouachita Parish, LA....... Union Parish, LA.......... 33780................ Monroe, MI................. 0.9475 0.9637 Monroe County, MI......... 33860................ Montgomery, AL............. 0.8366 0.8850 Autauga County, AL........ Elmore County, AL......... Lowndes County, AL........ Montgomery County, AL..... 34060................ Morgantown, WV............. 0.8411 0.8883 Monongalia County, WV..... Preston County, WV........ 34100................ \2\ Morristown, TN......... 0.7916 0.8521 Grainger County, TN....... Hamblen County, TN........ Jefferson County, TN...... 34580................ \2\ Mount Vernon-Anacortes, 1.0565 1.0384 WA. Skagit County, WA......... 34620................ \2\ Muncie, IN............. 0.8599 0.9018 Delaware County, IN....... 34740................ Muskegon-Norton Shores, MI. 0.9935 0.9955 Muskegon County, MI....... 34820................ \2\ Myrtle Beach-Conway-

0.8791 0.9155 North Myrtle Beach, SC. Horry County, SC.......... 34900................ Napa, CA................... 1.3825 1.2483 Napa County, CA........... 34940................ Naples-Marco Island, FL.... 0.9756 0.9832 Collier County, FL........ 34980................ \1\ Nashville-Davidson-

0.9675 0.9776 Murfreesboro-Franklin, TN.

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Cannon County, TN......... Cheatham County, TN....... Davidson County, TN....... Dickson County, TN........ Hickman County, TN........ Macon County, TN.......... Robertson County, TN...... Rutherford County, TN..... Smith County, TN.......... Sumner County, TN......... Trousdale County, TN...... Williamson County, TN..... Wilson County, TN......... 35004................ \1\ Nassau-Suffolk, NY..... 1.2791 1.1836 Nassau County, NY......... Suffolk County, NY........ 35084................ \1\ Newark-Union, NJ-PA.... 1.1681 1.1123 Essex County, NJ.......... Hunterdon County, NJ...... Morris County, NJ......... Sussex County, NJ......... Union County, NJ.......... Pike County, PA........... 35300................ \2\ New Haven-Milford, CT.. 1.2439 1.1612 New Haven County, CT...... 35380................ \1\ New Orleans-Metairie- 0.8732 0.9113 Kenner, LA. Jefferson Parish, LA...... Orleans Parish, LA........ Plaquemines Parish, LA.... St. Bernard Parish, LA.... St. Charles Parish, LA.... St. John the Baptist Parish, LA. St. Tammany Parish, LA.... 35644................ \1\ New York-White Plains- 1.3215 1.2103 Wayne, NY-NJ. Bergen County, NJ......... Hudson County, NJ......... Passaic County, NJ........ Bronx County, NY.......... Kings County, NY.......... New York County, NY....... Putnam County, NY......... Queens County, NY......... Richmond County, NY....... Rockland County, NY....... Westchester County, NY.... 35660................ Niles-Benton Harbor, MI.... 0.9138 0.9401 Berrien County, MI........ 35980................ \2\ Norwich-New London, CT. 1.2439 1.1612 New London County, CT..... 36084................ \1\ Oakland-Fremont-

1.5299 1.3380 Hayward, CA. Alameda County, CA........ Contra Costa County, CA... 36100................ \2\ Ocala, FL.............. 0.8749 0.9125 Marion County, FL......... 36140................ Ocean City, NJ............. 1.0749 1.0507 Cape May County, NJ....... 36220................ Odessa, TX................. 0.9959 0.9972 Ector County, TX.......... 36260................ Ogden-Clearfield, UT....... 0.9061 0.9347 Davis County, UT.......... Morgan County, UT......... Weber County, UT.......... 36420................ \1\ Oklahoma City, OK...... 0.8764 0.9136 Canadian County, OK....... Cleveland County, OK...... Grady County, OK.......... Lincoln County, OK........ Logan County, OK.......... McClain County, OK........ Oklahoma County, OK.......

[[Page 24939]]

36500................ Olympia, WA................ 1.1463 1.0980 Thurston County, WA....... 36540................ Omaha-Council Bluffs, NE-IA 0.9419 0.9598 Harrison County, IA....... Mills County, IA.......... Pottawattamie County, IA.. Cass County, NE........... Douglas County, NE........ Sarpy County, NE.......... Saunders County, NE....... Washington County, NE..... 36740................ \1\ Orlando-Kissimmee, FL.. 0.9383 0.9573 Lake County, FL........... Orange County, FL......... Osceola County, FL........ Seminole County, FL....... 36780................ \2\ Oshkosh-Neenah, WI..... 0.9635 0.9749 Winnebago County, WI...... 36980................ Owensboro, KY.............. 0.8801 0.9163 Daviess County, KY........ Hancock County, KY........ McLean County, KY......... 37100................ \2\ Oxnard-Thousand Oaks- 1.1607 1.1074 Ventura, CA. Ventura County, CA........ 37340................ Palm Bay-Melbourne-

0.9385 0.9575 Titusville, FL. Brevard County, FL........ 37380................ \2\ Palm Coast, FL......... 0.8749 0.9125 Flager County, FL......... 37460................ \2\ Panama City-Lynn Haven, 0.8749 0.9125 FL. Bay County, FL............ 37620................ \2\ Parkersburg-Marietta- 0.8701 0.9091 Vienna, WV-OH (OH Hospitals). Washington County, OH..... Pleasants County, WV...... Wirt County, WV........... Wood County, WV........... 37620................ Parkersburg-Marietta-

0.8238 0.8757 Vienna, WV-OH (WV Hospitals). Washington County, OH..... Pleasants County, WV...... Wirt County, WV........... Wood County, WV........... 37700................ Pascagoula, MS............. 0.8544 0.8978 George County, MS......... Jackson County, MS........ 37764................ Peabody, MA................ 1.0214 1.0146 Essex County, MA.......... 37860................ \2\ Pensacola-Ferry Pass- 0.8749 0.9125 Brent, FL. Escambia County, FL....... Santa Rosa County, FL..... 37900................ Peoria, IL................. 0.9374 0.9567 Marshall County, IL....... Peoria County, IL......... Stark County, IL.......... Tazewell County, IL....... Woodford County, IL....... 37964................ \1\ Philadelphia, PA....... 1.0906 1.0612 Bucks County, PA.......... Chester County, PA........ Delaware County, PA....... Montgomery County, PA..... Philadelphia County, PA... 38060................ \1\ Phoenix-Mesa-

1.0115 1.0079 Scottsdale, AZ. Maricopa County, AZ....... Pinal County, AZ.......... 38220................ Pine Bluff, AR............. 0.8155 0.8696 Cleveland County, AR...... Jefferson County, AR...... Lincoln County, AR........ 38300................ \1\ Pittsburgh, PA......... 0.8388 0.8866 Allegheny County, PA...... Armstrong County, PA......

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Beaver County, PA......... Butler County, PA......... Fayette County, PA........ Washington County, PA..... Westmoreland County, PA... 38340................ Pittsfield, MA............. 1.0071 1.0049 Berkshire County, MA...... 38540................ Pocatello, ID.............. 0.9158 0.9415 Bannock County, ID........ Power County, ID.......... 38660................ Ponce, PR.................. 0.4161 0.5486 Juana D[iacute]az Municipio, PR. Ponce Municipio, PR....... Villalba Municipio, PR.... 38860................ Portland-South Portland-

1.0008 1.0005 Biddeford, ME. Cumberland County, ME..... Sagadahoc County, ME...... York County, ME........... 38900................ \1\ Portland-Vancouver-

1.1233 1.0829 Beaverton, OR-WA. Clackamas County, OR...... Columbia County, OR....... Multnomah County, OR...... Washington County, OR..... Yamhill County, OR........ Clark County, WA.......... Skamania County, WA....... 38940................ Port St. Lucie, FL......... 0.9990 0.9993 Martin County, FL......... St. Lucie County, FL...... 39100................ Poughkeepsie-Newburgh-

1.0853 1.0577 Middletown, NY. Dutchess County, NY....... Orange County, NY......... 39140................ Prescott, AZ............... 0.9913 0.9940 Yavapai County, AZ........ 39300................ \1\ Providence-New Bedford- 1.0654 1.0443 Fall River, RI-MA. Bristol County, MA........ Bristol County, RI........ Kent County, RI........... Newport County, RI........ Providence County, RI..... Washington County, RI..... 39340................ Provo-Orem, UT............. 0.9488 0.9646 Juab County, UT........... Utah County, UT........... 39380................ \2\ Pueblo, CO............. 0.9451 0.9621 Pueblo County, CO......... 39460................ Punta Gorda, FL............ 0.9562 0.9698 Charlotte County, FL...... 39540................ \2\ Racine, WI............. 0.9635 0.9749 Racine County, WI......... 39580................ Raleigh-Cary, NC........... 0.9373 0.9566 Franklin County, NC....... Johnston County, NC....... Wake County, NC........... 39660................ Rapid City, SD............. 0.8690 0.9083 Meade County, SD.......... Pennington County, SD..... 39740................ Reading, PA................ 0.9419 0.9598 Berks County, PA.......... 39820................ Redding, CA................ 1.2826 1.1858 Shasta County, CA......... 39900................ Reno-Sparks, NV............ 1.1062 1.0716 Storey County, NV......... Washoe County, NV......... 40060................ \1\ Richmond, VA........... 0.9238 0.9472 Amelia County, VA......... Caroline County, VA....... Charles City County, VA... Chesterfield County, VA... Cumberland County, VA.....

[[Page 24941]]

Dinwiddie County, VA...... Goochland County, VA...... Hanover County, VA........ Henrico County, VA........ King and Queen County, VA. King William County, VA... Louisa County, VA......... New Kent County, VA....... Powhatan County, VA....... Prince George County, VA.. Sussex County, VA......... Colonial Heights City, VA. Hopewell City, VA......... Petersburg City, VA....... Richmond City, VA......... 40140................ \1, 2\ Riverside-San

1.1607 1.1074 Bernardino-Ontario, CA. Riverside County, CA...... San Bernardino County, CA. 40220................ Roanoke, VA................ 0.9441 0.9614 Botetourt County, VA...... Craig County, VA.......... Franklin County, VA....... Roanoke County, VA........ Roanoke City, VA.......... Salem City, VA............ 40340................ Rochester, MN.............. 1.0761 1.0515 Dodge County, MN.......... Olmsted County, MN........ Wabasha County, MN........ 40380................ \1\ Rochester, NY.......... 0.8899 0.9232 Livingston County, NY..... Monroe County, NY......... Ontario County, NY........ Orleans County, NY........ Wayne County, NY.......... 40420................ Rockford, IL............... 0.9659 0.9765 Boone County, IL.......... Winnebago County, IL...... 40484................ \2\ Rockingham County-

1.1266 1.0851 Strafford County, NH. Rockingham County, NH..... Strafford County, NH...... 40580................ Rocky Mount, NC............ 0.9017 0.9316 Nash County, NC........... 40660................ Rome, GA................... 0.9549 0.9689 Floyd County, GA.......... 40900................ \1\ Sacramento--Arden-

1.2999 1.1968 Arcade--Roseville, CA. El Dorado County, CA...... Placer County, CA......... Sacramento County, CA..... Yolo County, CA........... 40980................ Saginaw-Saginaw Township

0.9127 0.9394 North, MI. Saginaw County, MI........ 41060................ St. Cloud, MN.............. 1.1063 1.0716 Benton County, MN......... Stearns County, MN........ 41100................ St. George, UT............. 0.9546 0.9687 Washington County, UT..... 41140................ St. Joseph, MO-KS.......... 0.8831 0.9184 Doniphan County, KS....... Andrew County, MO......... Buchanan County, MO....... DeKalb County, MO......... 41180................ \1\ St. Louis, MO-IL....... 0.8885 0.9222 Bond County, IL........... Calhoun County, IL........ Clinton County, IL........ Jersey County, IL......... Macoupin County, IL....... Madison County, IL........ Monroe County, IL.........

[[Page 24942]]

St. Clair County, IL...... Crawford County, MO....... Franklin County, MO....... Jefferson County, MO...... Lincoln County, MO........ St. Charles County, MO.... St. Louis County, MO...... Warren County, MO......... Washington County, MO..... St. Louis City, MO........ 41420................ Salem, OR.................. 1.0404 1.0275 Marion County, OR......... Polk County, OR........... 41500................ Salinas, CA................ 1.4408 1.2841 Monterey County, CA....... 41540................ \2\ Salisbury, MD.......... 0.8917 0.9245 Somerset County, MD....... Wicomico County, MD....... 41620................ Salt Lake City, UT......... 0.9482 0.9642 Salt Lake County, UT...... Summit County, UT......... Tooele County, UT......... 41660................ San Angelo, TX............. 0.8663 0.9064 Irion County, TX.......... Tom Green County, TX...... 41700................ \1\ San Antonio, TX........ 0.8916 0.9244 Atascosa County, TX....... Bandera County, TX........ Bexar County, TX.......... Comal County, TX.......... Guadalupe County, TX...... Kendall County, TX........ Medina County, TX......... Wilson County, TX......... 41740................ \1, 2\ San Diego-Carlsbad- 1.1607 1.1074 San Marcos, CA. San Diego County, CA...... 41780................ Sandusky, OH............... 0.8760 0.9133 Erie County, OH........... 41884................ \1\ San Francisco-San Mateo- 1.4766 1.3059 Redwood City, CA. Marin County, CA.......... San Francisco County, CA.. San Mateo County, CA...... 41900................ San Germ[aacute]n-Cabo

0.4605 0.5880 Rojo, PR. Cabo Rojo Municipio, PR... Lajas Municipio, PR....... Sabana Grande Municipio, PR. San Germ[aacute]n Municipio, PR. 41940................ \1\ San Jose-Sunnyvale-

1.5378 1.3427 Santa Clara, CA. San Benito County, CA..... Santa Clara County, CA.... 41980................ \1\ San Juan-Caguas-

0.4517 0.5803 Guaynabo, PR. Aguas Buenas Municipio, PR Aibonito Municipio, PR.... Arecibo Municipio, PR..... Barceloneta Municipio, PR. Barranquitas Municipio, PR Bayam[oacute]n Municipio, PR. Caguas Municipio, PR...... Camuy Municipio, PR....... Can[oacute]vanas Municipio, PR. Carolina Municipio, PR.... Cata[ntilde]o Municipio, PR. Cayey Municipio, PR....... Ciales Municipio, PR...... Cidra Municipio, PR....... Comer[iacute]o Municipio, PR. Corozal Municipio, PR..... Dorado Municipio, PR...... Florida Municipio, PR..... Guaynabo Municipio, PR....

[[Page 24943]]

Gurabo Municipio, PR...... Hatillo Municipio, PR..... Humacao Municipio, PR..... Juncos Municipio, PR...... Las Piedras Municipio, PR. Lo[iacute]za Municipio, PR Manat[iacute] Municipio, PR. Maunabo Municipio, PR..... Morovis Municipio, PR..... Naguabo Municipio, PR..... Naranjito Municipio, PR... Orocovis Municipio, PR.... Quebradillas Municipio, PR R[iacute]o Grande Municipio, PR. San Juan Municipio, PR.... San Lorenzo Municipio, PR. Toa Alta Municipio, PR.... Toa Baja Municipio, PR.... Trujillo Alto Municipio, PR. Vega Alta Municipio, PR... Vega Baja Municipio, PR... Yabucoa Municipio, PR..... 42020................ San Luis Obispo-Paso

1.1912 1.1273 Robles, CA. San Luis Obispo County, CA 42044................ \1, 2\ Santa Ana-Anaheim- 1.1607 1.1074 Irvine, CA. Orange County, CA......... 42060................ \2\ Santa Barbara-Santa

1.1607 1.1074 Maria-Goleta, CA. Santa Barbara County, CA.. 42100................ Santa Cruz-Watsonville, CA. 1.5667 1.3600 Santa Cruz County, CA..... 42140................ Santa Fe, NM............... 1.0689 1.0467 Santa Fe County, NM....... 42220................ Santa Rosa-Petaluma, CA.... 1.4266 1.2755 Sonoma County, CA......... 42260................ Sarasota-Bradenton-Venice, 0.9758 0.9834 FL. Manatee County, FL........ Sarasota County, FL....... 42340................ Savannah, GA............... 0.8987 0.9295 Bryan County, GA.......... Chatham County, GA........ Effingham County, GA...... 42540................ \2\ Scranton--Wilkes-Barre, 0.8366 0.8850 PA. Lackawanna County, PA..... Luzerne County, PA........ Wyoming County, PA........ 42644................ \1\ Seattle-Bellevue-

1.1351 1.0907 Everett, WA. King County, WA........... Snohomish County, WA...... 42680................ Sebastian-Vero Beach, FL... 0.9708 0.9799 Indian River County, FL... 43100................ \2\ Sheboygan, WI.......... 0.9635 0.9749 Sheboygan County, WI...... 43300................ Sherman-Denison, TX........ 0.8535 0.8972 Grayson County, TX........ 43340................ Shreveport-Bossier City, LA 0.8615 0.9029 Bossier Parish, LA........ Caddo Parish, LA.......... De Soto Parish, LA........ 43580................ Sioux City, IA-NE-SD....... 0.9220 0.9459 Woodbury County, IA....... Dakota County, NE......... Dixon County, NE.......... Union County, SD.......... 43620................ Sioux Falls, SD............ 0.9558 0.9695 Lincoln County, SD........ McCook County, SD......... Minnehaha County, SD...... Turner County, SD......... 43780................ South Bend-Mishawaka, IN-MI 0.9649 0.9758 St. Joseph County, IN.....

[[Page 24944]]

Cass County, MI........... 43900................ Spartanburg, SC............ 0.9334 0.9539 Spartanburg County, SC.... 44060................ \2\ Spokane, WA............ 1.0565 1.0384 Spokane County, WA........ 44100................ Springfield, IL............ 0.8947 0.9266 Menard County, IL......... Sangamon County, IL....... 44140................ Springfield, MA............ 1.0236 1.0161 Franklin County, MA....... Hampden County, MA........ Hampshire County, MA...... 44180................ Springfield, MO............ 0.9196 0.9442 Christian County, MO...... Dallas County, MO......... Greene County, MO......... Polk County, MO........... Webster County, MO........ 44220................ \2\ Springfield, OH........ 0.8701 0.9091 Clark County, OH.......... 44300................ State College, PA.......... 0.8625 0.9037 Centre County, PA......... 44700................ Stockton, CA............... 1.1735 1.1158 San Joaquin County, CA.... 44940................ Sumter, SC................. 0.8875 0.9215 Sumter County, SC......... 45060................ Syracuse, NY............... 0.9912 0.9940 Madison County, NY........ Onondaga County, NY....... Oswego County, NY......... 45104................ Tacoma, WA................. 1.1060 1.0714 Pierce County, WA......... 45220................ Tallahassee, FL............ 0.9032 0.9327 Gadsden County, FL........ Jefferson County, FL...... Leon County, FL........... Wakulla County, FL........ 45300................ \1\ Tampa-St. Petersburg- 0.9174 0.9427 Clearwater, FL. Hernando County, FL....... Hillsborough County, FL... Pasco County, FL.......... Pinellas County, FL....... 45460................ Terre Haute, IN............ 0.8828 0.9182 Clay County, IN........... Sullivan County, IN....... Vermillion County, IN..... Vigo County, IN........... 45500................ Texarkana, TX-Texarkana, AR 0.8131 0.8679 (AR Hospitals). Miller County, AR......... Bowie County, TX.......... 45500................ \2\ Texarkana, TX-

0.8204 0.8732 Texarkana, AR (TX Hospitals). Miller County, AR......... Bowie County, TX.......... 45780................ Toledo, OH................. 0.9276 0.9498 Fulton County, OH......... Lucas County, OH.......... Ottawa County, OH......... Wood County, OH........... 45820................ Topeka, KS................. 0.8561 0.8991 Jackson County, KS........ Jefferson County, KS...... Osage County, KS.......... Shawnee County, KS........ Wabaunsee County, KS...... 45940................ Trenton-Ewing, NJ.......... 1.0720 1.0488 Mercer County, NJ......... 46060................ Tucson, AZ................. 0.9484 0.9644 Pima County, AZ........... 46140................ Tulsa, OK.................. 0.8504 0.8950 Creek County, OK..........

[[Page 24945]]

Okmulgee County, OK....... Osage County, OK.......... Pawnee County, OK......... Rogers County, OK......... Tulsa County, OK.......... Wagoner County, OK........ 46220................ Tuscaloosa, AL............. 0.8534 0.8971 Greene County, AL......... Hale County, AL........... Tuscaloosa County, AL..... 46340................ Tyler, TX.................. 0.9190 0.9438 Smith County, TX.......... 46540................ Utica-Rome, NY............. 0.8774 0.9143 Herkimer County, NY....... Oneida County, NY......... 46660................ Valdosta, GA............... 0.8208 0.8735 Brooks County, GA......... Echols County, GA......... Lanier County, GA......... Lowndes County, GA........ 46700................ Vallejo-Fairfield, CA...... 1.4400 1.2837 Solano County, CA......... 47020................ \2\ Victoria, TX........... 0.8204 0.8732 Calhoun County, TX........ Goliad County, TX......... Victoria County, TX....... 47220................ Vineland-Millville-

1.0653 1.0443 Bridgeton, NJ. Cumberland County, NJ..... 47260................ \1\ Virginia Beach-Norfolk- 0.8785 0.9151 Newport News, VA-NC. Currituck County, NC...... Gloucester County, VA..... Isle of Wight County, VA.. James City County, VA..... Mathews County, VA........ Surry County, VA.......... York County, VA........... Chesapeake City, VA....... Hampton City, VA.......... Newport News City, VA..... Norfolk City, VA.......... Poquoson City, VA......... Portsmouth City, VA....... Suffolk City, VA.......... Virginia Beach City, VA... Williamsburg City, VA..... 47300................ \2\ Visalia-Porterville, CA 1.1607 1.1074 Tulare County, CA......... 47380................ Waco, TX................... 0.8598 0.9017 McLennan County, TX....... 47580................ Warner Robins, GA.......... 0.9619 0.9737 Houston County, GA........ 47644................ \1\ Warren-Troy-Farmington 1.0040 1.0027 Hills, MI. Lapeer County, MI......... Livingston County, MI..... Macomb County, MI......... Oakland County, MI........ St. Clair County, MI...... 47894................ \1\ Washington-Arlington- 1.0679 1.0460 Alexandria, DC-VA-MD-WV. District of Columbia, DC.. Calvert County, MD........ Charles County, MD........ Prince George's County, MD Arlington County, VA...... Clarke County, VA......... Fairfax County, VA........ Fauquier County, VA....... Loudoun County, VA........ Prince William County, VA. Spotsylvania County, VA... Stafford County, VA.......

[[Page 24946]]

Warren County, VA......... Alexandria City, VA....... Fairfax City, VA.......... Falls Church City, VA..... Fredericksburg City, VA... Manassas City, VA......... Manassas Park City, VA.... Jefferson County, WV...... 47940................ Waterloo-Cedar Falls, IA... 0.8891 0.9227 Black Hawk County, IA..... Bremer County, IA......... Grundy County, IA......... 48140................ Wausau, WI................. 1.0011 1.0008 Marathon County, WI....... 48260................ \2\ Weirton-Steubenville, 0.8701 0.9091 WV-OH (OH Hospitals). Jefferson County, OH...... Brooke County, WV......... Hancock County, WV........ 48260................ Weirton-Steubenville, WV-OH 0.7893 0.8504 (WV Hospitals). Jefferson County, OH...... Brooke County, WV......... Hancock County, WV........ 48300................ Wenatchee, WA.............. 1.1281 1.0860 Chelan County, WA......... Douglas County, WA........ 48424................ \1\ West Palm Beach-Boca

0.9587 0.9715 Raton-Boynton Beach, FL. Palm Beach County, FL..... 48540................ \2\ Wheeling, WV-OH (OH

0.8701 0.9091 Hospitals). Belmont County, OH........ Marshall County, WV....... Ohio County, WV........... 48540................ \2\ Wheeling, WV-OH (WV

0.7568 0.8263 Hospitals). Belmont County, OH........ Marshall County, WV....... Ohio County, WV........... 48620................ Wichita, KS................ 0.9009 0.9310 Butler County, KS......... Harvey County, KS......... Sedgwick County, KS....... Sumner County, KS......... 48660................ Wichita Falls, TX.......... 0.8488 0.8938 Archer County, TX......... Clay County, TX........... Wichita County, TX........ 48700................ \2\ Williamsport, PA....... 0.8366 0.8850 Lycoming County, PA....... 48864................ Wilmington, DE-MD-NJ....... 1.0752 1.0509 New Castle County, DE..... Cecil County, MD.......... Salem County, NJ.......... 48900................ Wilmington, NC............. 0.9338 0.9542 Brunswick County, NC...... New Hanover County, NC.... Pender County, NC......... 49020................ Winchester, VA-WV.......... 0.9850 0.9897 Frederick County, VA...... Winchester City, VA....... Hampshire County, WV...... 49180................ Winston-Salem, NC.......... 0.9083 0.9363 Davie County, NC.......... Forsyth County, NC........ Stokes County, NC......... Yadkin County, NC......... 49340................ Worcester, MA.............. 1.1341 1.0900 Worcester County, MA...... 49420................ \2\ Yakima, WA............. 1.0565 1.0384 Yakima County, WA......... 49500................ Yauco, PR.................. 0.3203 0.4586 Gu[aacute]nica Municipio, PR. Guayanilla Municipio, PR..

[[Page 24947]]

Pe[ntilde]uelas Municipio, PR. Yauco Municipio, PR....... 49620................ York-Hanover, PA........... 0.9307 0.9520 York County, PA........... 49660................ Youngstown-Warren-Boardman, 0.8996 0.9301 OH-PA. Mahoning County, OH....... Trumbull County, OH....... Mercer County, PA......... 49700................ \2\ Yuba City, CA.......... 1.1607 1.1074 Sutter County, CA......... Yuba County, CA........... 49740................ Yuma, AZ................... 0.9468 0.9633 Yuma County, AZ ..........

\1\ Large urban area. \2\ Hospitals geographically located in the area are assigned the statewide rural wage index for FY 2008.

Table 4B.--Wage Index and Capital Geographic Adjustment (GAF) for Rural Areas by CBSA--FY 2008

Wage CBSA code

Nonurban area

index GAF

01................... Alabama.................... 0.7598 0.8285 02................... Alaska..................... 1.1817 1.1211 03................... Arizona.................... 0.9386 0.9575 04................... Arkansas................... 0.7519 0.8226 05................... California................. 1.1607 1.1074 06................... Colorado................... 0.9451 0.9621 07................... Connecticut................ 1.2439 1.1612 08................... Delaware................... 0.9825 0.9880 10................... Florida.................... 0.8749 0.9125 11................... Georgia.................... 0.7864 0.8483 12................... Hawaii..................... 1.0751 1.0508 13................... Idaho...................... 0.7879 0.8494 14................... Illinois................... 0.8355 0.8842 15................... Indiana.................... 0.8599 0.9018 16................... Iowa....................... 0.8480 0.8932 17................... Kansas..................... 0.7989 0.8575 18................... Kentucky................... 0.7812 0.8444 19................... Louisiana.................. 0.7591 0.8280 20................... Maine...................... 0.8412 0.8883 21................... Maryland................... 0.8917 0.9245 22................... Massachusetts.............. 0.9739 0.9821 23................... Michigan................... 0.8899 0.9232 24................... Minnesota.................. 0.9212 0.9453 25................... Mississippi................ 0.7915 0.8520 26................... Missouri................... 0.8145 0.8689 27................... Montana.................... 0.8337 0.8829 28................... Nebraska................... 0.8848 0.9196 29................... Nevada..................... 0.9688 0.9785 30................... New Hampshire.............. 1.1266 1.0851 31................... New Jersey \1\............. ......... ......... 32................... New Mexico................. 0.8965 0.9279 33................... New York................... 0.8440 0.8903 34................... North Carolina............. 0.8608 0.9024 35................... North Dakota............... 0.7313 0.8071 36................... Ohio....................... 0.8701 0.9091 37................... Oklahoma................... 0.7702 0.8363 38................... Oregon..................... 0.9950 0.9966 39................... Pennsylvania............... 0.8366 0.8850 40................... Puerto Rico \1\............ ......... ......... 41................... Rhode Island \1\........... ......... ......... 42................... South Carolina............. 0.8791 0.9155 43................... South Dakota............... 0.8343 0.8833 44................... Tennessee.................. 0.7916 0.8521 45................... Texas...................... 0.8204 0.8732 46................... Utah....................... 0.8267 0.8778 47................... Vermont.................... 1.0401 1.0273 49................... Virginia................... 0.8095 0.8653 50................... Washington................. 1.0565 1.0384

[[Page 24948]]

51................... West Virginia.............. 0.7568 0.8263 52................... Wisconsin.................. 0.9635 0.9749 53................... Wyoming.................... 0.9214 0.9455

\1\ All counties in the State or Territory are classified as urban.

Table 4C.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified by CBSA--FY 2008

Wage CBSA code

Area

index GAF

10420................ Akron, OH.................. 0.8854 0.9200 10500................ Albany, GA................. 0.8671 0.9070 10580................ Albany-Schenectady-Troy, NY 0.8672 0.9070 10740................ Albuquerque, NM............ 0.9740 0.9821 10780................ Alexandria, LA............. 0.7982 0.8570 10900................ Allentown-Bethlehem-Easton, 1.0024 1.0016 PAN-J. 11100................ Amarillo, TX............... 0.9141 0.9403 11180................ Ames, IA................... 0.9227 0.9464 11260................ Anchorage, AK.............. 1.1840 1.1226 11460................ Ann Arbor, MI.............. 1.0138 1.0094 11500................ Anniston-Oxford, AL........ 0.8042 0.8614 12060................ Atlanta-Sandy Springs-

0.9845 0.9894 Marietta, GA. 12420................ Austin-Round Rock, TX...... 0.9518 0.9667 12580................ Baltimore-Towson, MD....... 1.0108 1.0074 12620................ Bangor, ME................. 0.9860 0.9904 12940................ Baton Rouge, LA............ 0.8014 0.8593 13020................ Bay City, MI............... 0.9399 0.9584 13644................ Bethesda-Gaithersburg-

1.0990 1.0668 Frederick, MD. 13780................ Binghamton, NY............. 0.8779 0.9147 13820................ Birmingham-Hoover, AL...... 0.8737 0.9117 13900................ Bismarck, ND............... 0.7329 0.8083 13980................ Blacksburg-Christiansburg- 0.7744 0.8394 Radford, VA. 14020................ Bloomington, IN............ 0.8828 0.9182 14484................ Boston-Quincy, MA.......... 1.1256 1.0844 14540................ Bowling Green, KY.......... 0.8089 0.8648 14740................ Bremerton-Silverdale, WA... 1.0826 1.0559 14860................ Bridgeport-Stamford-

1.2380 1.1574 Norwalk, CT. 15380................ Buffalo-Niagara Falls, NY.. 0.9586 0.9715 15540................ Burlington-South

0.9589 0.9717 Burlington, VT. 15764................ Cambridge-Newton-

1.1266 1.0851 Framingham, MA. 15940................ Canton-Massillon, OH....... 0.8810 0.9169 16180................ Carson City, NV............ 0.9688 0.9785 16620................ Charleston, WV............. 0.8294 0.8798 16700................ Charleston-North

0.9144 0.9406 Charleston, SC. 16740................ Charlotte-Gastonia-Concord, 0.9348 0.9549 NC-SC. 16820................ Charlottesville, VA........ 0.9353 0.9552 16860................ Chattanooga, TN-GA......... 0.8967 0.9281 16974................ Chicago-Naperville-Joliet, 1.0455 1.0309 IL. 17140................ Cincinnati-Middletown, OH- 0.9654 0.9762 KY-IN. 17300................ Clarksville, TN-KY......... 0.8116 0.8668 17460................ Cleveland-Elyria-Mentor, OH 0.9238 0.9472 17780................ College Station-Bryan, TX.. 0.9177 0.9429 17860................ Columbia, MO............... 0.8545 0.8979 17980................ Columbus, GA-AL............ 0.8594 0.9014 18140................ Columbus, OH............... 0.9840 0.9890 18700................ Corvallis, OR.............. 1.0322 1.0219 19124................ Dallas-Plano-Irving, TX.... 0.9681 0.9780 19340................ Davenport-Moline-Rock

0.8898 0.9232 Island, IA-IL. 19380................ Dayton, OH................. 0.9283 0.9503 19460................ Decatur, AL................ 0.7927 0.8529 19740................ Denver-Aurora, CO.......... 1.0490 1.0333 19804................ Detroit-Livonia-Dearborn, 1.0091 1.0062 MI. 20100................ Dover, DE.................. 1.0023 1.0016 20260................ Duluth, MN-WI.............. 1.0020 1.0014 20500................ Durham, NC................. 0.9603 0.9726 20764................ Edison, NJ................. 1.1131 1.0761 21060................ Elizabethtown, KY.......... 0.7983 0.8570 21500................ Erie, PA................... 0.8440 0.8903

[[Page 24949]]

21660................ Eugene-Springfield, OR..... 1.0713 1.0483 21780................ Evansville, IN-KY (KY

0.8127 0.8676 Hospitals). 21780................ Evansville, IN-KY (IN

0.8599 0.9018 Hospitals). 22020................ Fargo, ND-MN (ND Hospitals) 0.8189 0.8721 22020................ Fargo, ND-MN (SD Hospitals) 0.8343 0.8833 22180................ Fayetteville, NC........... 0.9600 0.9724 22220................ Fayetteville-Springdale-

0.8719 0.9104 Rogers, AR-MO. 22380................ Flagstaff, AZ.............. 1.1310 1.0880 22420................ Flint, MI.................. 1.0272 1.0185 22520................ Florence-Muscle Shoals, AL. 0.7971 0.8562 22540................ Fond du Lac, WI............ 0.9721 0.9808 22660................ Fort Collins-Loveland, CO.. 0.9577 0.9708 22744................ Fort Lauderdale-Pompano

1.0245 1.0167 Beach-Deerfield Beach, FL. 23020................ Fort Walton Beach-Crestview- 0.8749 0.9125 Destin, FL. 23060................ Fort Wayne, IN............. 0.9046 0.9336 23104................ Fort Worth-Arlington, TX... 0.9646 0.9756 23540................ Gainesville, FL............ 0.9306 0.9519 23844................ Gary, IN................... 0.9246 0.9477 24300................ Grand Junction, CO......... 1.0141 1.0096 24340................ Grand Rapids-Wyoming, MI... 0.9380 0.9571 24500................ Great Falls, MT............ 0.8765 0.9137 24540................ Greeley, CO................ 0.9746 0.9825 24580................ Green Bay, WI (MI

0.9339 0.9542 Hospitals). 24580................ Green Bay, WI (WI

0.9635 0.9749 Hospitals). 24660................ Greensboro-High Point, NC.. 0.9111 0.9382 24780................ Greenville, NC............. 0.9272 0.9496 24860................ Greenville-Mauldin-Easley, 0.9386 0.9575 SC. 25060................ Gulfport-Biloxi, MS........ 0.8223 0.8746 25420................ Harrisburg-Carlisle, PA.... 0.9130 0.9396 25540................ Hartford-West Hartford-East 1.2439 1.1612 Hartford, CT (CT Hospitals). 25540................ Hartford-West Hartford-East 1.0955 1.0645 Hartford, CT (MA Hospitals). 25860................ Hickory-Lenoir-Morganton, 0.8819 0.9175 NC. 26100................ Holland-Grand Haven, MI.... 0.9066 0.9351 26180................ Honolulu, HI............... 1.1289 1.0866 26420................ Houston-Sugar Land-Baytown, 1.0048 1.0033 TX. 26580................ Huntington-Ashland, WV-KY- 0.8706 0.9095 OH. 26620................ Huntsville, AL............. 0.8760 0.9133 26820................ Idaho Falls, ID............ 0.9352 0.9552 26900................ Indianapolis-Carmel, IN.... 0.9723 0.9809 26980................ Iowa City, IA.............. 0.9142 0.9404 27060................ Ithaca, NY................. 0.9715 0.9804 27140................ Jackson, MS................ 0.8273 0.8782 27180................ Jackson, TN................ 0.8432 0.8898 27260................ Jacksonville, FL........... 0.9129 0.9395 27620................ Jefferson City, MO......... 0.8706 0.9095 27780................ Johnstown, PA.............. 0.8366 0.8850 27860................ Jonesboro, AR.............. 0.8507 0.8952 27900................ Joplin, MO................. 0.9040 0.9332 28020................ Kalamazoo-Portage, MI...... 1.0151 1.0103 28100................ Kankakee-Bradley, IL....... 1.1678 1.1121 28140................ Kansas City, MO-KS......... 0.9321 0.9530 28420................ Kennewick-Richland-Pasco, 0.9620 0.9738 WA (ID Hospitals). 28420................ Kennewick-Richland-Pasco, 1.0565 1.0384 WA (WA Hospitals). 28700................ Kingsport-Bristol-Bristol, 0.7840 0.8465 TN-VA (KY Hospitals). 28700................ Kingsport-Bristol-Bristol, 0.7916 0.8521 TN-VA (TN Hospitals). 28700................ Kingsport-Bristol-Bristol, 0.8095 0.8653 TN-VA (VA Hospitals). 28740................ Kingston, NY............... 0.9231 0.9467 28940................ Knoxville, TN.............. 0.8042 0.8614 29180................ Lafayette, LA.............. 0.8323 0.8819 29404................ Lake County-Kenosha County, 1.0287 1.0196 IL-WI. 29460................ Lakeland, FL............... 0.8839 0.9190 29540................ Lancaster, PA.............. 0.9589 0.9717 29620................ Lansing-East Lansing, MI... 0.9933 0.9954 29740................ Las Cruces, NM............. 0.8965 0.9279 29820................ Las Vegas-Paradise, NV..... 1.1205 1.0810 30020................ Lawton, OK................. 0.8071 0.8635 30460................ Lexington-Fayette, KY...... 0.8815 0.9173 30620................ Lima, OH................... 0.9312 0.9524 30700................ Lincoln, NE................ 0.9603 0.9726 30780................ Little Rock-North Little

0.8720 0.9105 Rock-Conway, AR.

[[Page 24950]]

30860................ Logan, UT-ID............... 0.9219 0.9458 30980................ Longview, TX............... 0.8875 0.9215 31084................ Los Angeles-Long Beach-

1.1607 1.1074 Santa Ana, CA. 31140................ Louisville-Jefferson

0.9045 0.9336 County, KY-IN. 31340................ Lynchburg, VA.............. 0.8490 0.8940 31420................ Macon, GA.................. 0.9571 0.9704 31540................ Madison, WI................ 1.1002 1.0676 31700................ Manchester-Nashua, NH...... 1.1266 1.0851 32780................ Medford, OR................ 1.0151 1.0103 32820................ Memphis, TN-MS-AR.......... 0.8951 0.9269 33124................ Miami-Miami Beach-Kendall, 1.0023 1.0016 FL. 33340................ Milwaukee-Waukesha-West

1.0296 1.0202 Allis, WI. 33460................ Minneapolis-St. Paul-

1.0961 1.0649 Bloomington, MN-WI. 33540................ Missoula, MT............... 0.8737 0.9117 33660................ Mobile, AL................. 0.7950 0.8546 33700................ Modesto, CA................ 1.1989 1.1323 33740................ Monroe, LA................. 0.7766 0.8410 33860................ Montgomery, AL............. 0.8366 0.8850 34060................ Morgantown, WV............. 0.8244 0.8761 34740................ Muskegon-Norton Shores, MI. 0.9472 0.9635 34820................ Myrtle Beach-Conway-North 0.8791 0.9155 Myrtle Beach, SC. 34980................ Nashville-Davidson-

0.9407 0.9590 Murfreesboro-Franklin, TN. 35004................ Nassau-Suffolk, NY......... 1.2565 1.1692 35084................ Newark-Union, NJPA......... 1.1578 1.1055 35300................ New Haven-Milford, CT...... 1.2439 1.1612 35380................ New Orleans-Metairie-

0.8732 0.9113 Kenner, LA. 35644................ New York-White Plains-

1.2993 1.1964 Wayne, NY-NJ. 35980................ Norwich-New London, CT..... 1.1794 1.1196 36084................ Oakland-Fremont-Hayward, CA 1.5299 1.3380 36140................ Ocean City, NJ............. 1.0358 1.0244 36220................ Odessa, TX................. 0.9527 0.9674 36420................ Oklahoma City, OK.......... 0.8764 0.9136 36500................ Olympia, WA................ 1.1325 1.0889 36740................ Orlando-Kissimmee, FL...... 0.9245 0.9477 37700................ Pascagoula, MS............. 0.8544 0.8978 37860................ Pensacola-Ferry Pass-Brent, 0.8127 0.8676 FL. 37900................ Peoria, IL................. 0.9217 0.9457 37964................ Philadelphia, PA........... 1.0777 1.0526 38220................ Pine Bluff, AR............. 0.7959 0.8553 38300................ Pittsburgh, PA (PA and WV 0.8388 0.8866 Hospitals). 38300................ Pittsburgh, PA (OH

0.8701 0.9091 Hospitals). 38340................ Pittsfield, MA............. 1.0401 1.0273 38540................ Pocatello, ID.............. 0.9158 0.9415 38860................ Portland-South Portland-

0.9601 0.9725 Biddeford, ME. 38900................ Portland-Vancouver-

1.1233 1.0829 Beaverton, OR-WA. 38940................ Port St. Lucie, FL......... 0.9990 0.9993 39100................ Poughkeepsie-Newburgh-

1.0644 1.0437 Middletown, NY. 39140................ Prescott, AZ............... 0.9534 0.9678 39340................ Provo-Orem, UT............. 0.9388 0.9577 39580................ Raleigh-Cary, NC........... 0.9373 0.9566 39740................ Reading, PA................ 0.9419 0.9598 39820................ Redding, CA................ 1.2666 1.1757 39900................ Reno-Sparks, NV............ 1.0851 1.0575 40060................ Richmond, VA............... 0.9238 0.9472 40220................ Roanoke, VA................ 0.9190 0.9438 40340................ Rochester, MN.............. 1.0761 1.0515 40380................ Rochester, NY.............. 0.8899 0.9232 40420................ Rockford, IL............... 0.9659 0.9765 40484................ Rockingham County, NH...... 1.0179 1.0122 40660................ Rome, GA................... 0.9391 0.9579 40900................ Sacramento-Arden-Arcade-

1.2853 1.1875 Roseville, CA. 40980................ Saginaw-Saginaw Township

0.8979 0.9289 North, MI. 41060................ St. Cloud, MN.............. 1.0390 1.0265 41100................ St. George, UT............. 0.9546 0.9687 41140................ St. Joseph, MO-KS.......... 0.8831 0.9184 41180................ St. Louis, MO-IL........... 0.8885 0.9222 41620................ Salt Lake City, UT (UT

0.9482 0.9642 Hospitals). 41620................ Salt Lake City, UT (NV

0.9688 0.9785 Hospitals). 41700................ San Antonio, TX............ 0.8916 0.9244 41884................ San Francisco-San Mateo-

1.4766 1.3059 Redwood City, CA.

[[Page 24951]]

41940................ San Jose-Sunnyvale-Santa

1.5378 1.3427 Clara, CA. 41980................ San Juan-Caguas-Guaynabo, 0.4517 0.5803 PR. 42044................ Santa Ana-Anaheim-Irvine, 1.1607 1.1074 CA. 42140................ Santa Fe, NM............... 1.0376 1.0256 42220................ Santa Rosa-Petaluma, CA.... 1.3959 1.2566 42260................ Sarasota-Bradenton-Venice, 0.9758 0.9834 FL. 42340................ Savannah, GA............... 0.8987 0.9295 42644................ Seattle-Bellevue-Everett, 1.1202 1.0808 WA. 42680................ Sebastian-Vero Beach, FL... 0.9482 0.9642 43300................ Sherman-Denison, TX........ 0.8535 0.8972 43340................ Shreveport-Bossier City, LA 0.8615 0.9029 43580................ Sioux City, IA-NE-SD....... 0.8848 0.9196 43620................ Sioux Falls, SD............ 0.9395 0.9582 43780................ South Bend-Mishawaka, IN-MI 0.9488 0.9646 43900................ Spartanburg, SC............ 0.9334 0.9539 44060................ Spokane, WA................ 1.0220 1.0150 44180................ Springfield, MO............ 0.8943 0.9264 44940................ Sumter, SC................. 0.8791 0.9155 45060................ Syracuse, NY............... 0.9577 0.9708 45104................ Tacoma, WA................. 1.1060 1.0714 45220................ Tallahassee, FL............ 0.8458 0.8916 45300................ Tampa-St. Petersburg-

0.9174 0.9427 Clearwater, FL. 45500................ Texarkana, TX-Texarkana, AR 0.8131 0.8679 45780................ Toledo, OH................. 0.9276 0.9498 45820................ Topeka, KS................. 0.8455 0.8914 46140................ Tulsa, OK.................. 0.8504 0.8950 46220................ Tuscaloosa, AL............. 0.8166 0.8705 46340................ Tyler, TX.................. 0.9190 0.9438 46700................ Vallejo-Fairfield, CA...... 1.4200 1.2714 47260................ Virginia Beach-Norfolk-

0.8785 0.9151 Newport News, VA. 47894................ Washington-Arlington-

1.0679 1.0460 Alexandria DC-VA. 47940................ Waterloo-Cedar Falls, IA... 0.8891 0.9227 48140................ Wausau, WI................. 1.0011 1.0008 48620................ Wichita, KS................ 0.8761 0.9134 48700................ Williamsport, PA........... 0.8366 0.8850 48864................ Wilmington, DE-MD-NJ....... 1.0752 1.0509 48900................ Wilmington, NC............. 0.9172 0.9425 49180................ Winston-Salem, NC.......... 0.9083 0.9363 49660................ Youngstown-Warren-Boardman, 0.8775 0.9144 OH-PA. 03................... Rural Arizona.............. 0.9386 0.9575 04................... Rural Arkansas............. 0.7591 0.8280 05................... Rural California........... 1.1607 1.1074 07................... Rural Connecticut.......... 1.2439 1.1612 10................... Rural Florida.............. 0.8749 0.9125 14................... Rural Illinois............. 0.8355 0.8842 16................... Rural Iowa................. 0.8480 0.8932 17................... Rural Kansas............... 0.7989 0.8575 22................... Rural Massachusetts........ 0.9739 0.9821 23................... Rural Michigan............. 0.8899 0.9232 25................... Rural Mississippi.......... 0.7915 0.8520 26................... Rural Missouri............. 0.8145 0.8689 29................... Rural Nevada............... 0.8780 0.9148 30................... Rural New Hampshire........ 1.0782 1.0529 33................... Rural New York............. 0.8440 0.8903 34................... Rural North Carolina....... 0.8608 0.9024 36................... Rural Ohio................. 0.8701 0.9091 37................... Rural Oklahoma............. 0.7702 0.8363 38................... Rural Oregon............... 0.9950 0.9966 39................... Rural Pennsylvania (PA

0.8366 0.8850 Hospitals). 39................... Rural Pennsylvania (NY

0.8440 0.8903 Hospitals). 44................... Rural Tennessee............ 0.7916 0.8521 45................... Rural Texas................ 0.8204 0.8732 47................... Rural Vermont.............. 0.9431 0.9607 49................... Rural Virginia............. 0.8095 0.8653 50................... Rural Washington........... 1.0565 1.0384 52................... Rural Wisconsin............ 0.9635 0.9749 53................... Rural Wyoming.............. 0.9049 0.9339

[[Page 24952]]

Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) by CBSA--FY 2008

Wage index-- CBSA code

Area

Wage GAF

reclassified GAF--reclassified index

hospitals

10380................ Aguadilla-Isabela-San

0.7690 0.8354 ................... ................. Sebasti[aacute]n, PR. 21940................ Fajardo, PR................ 0.9543 0.9685 ................... ................. 25020................ Guayama, PR................ 0.6904 0.7759 ................... ................. 32420................ Mayag[uuml]ez, PR.......... 0.8532 0.8970 ................... ................. 38660................ Ponce, PR.................. 0.9692 0.9788 ................... ................. 41900................ San Germ[aacute]n-Cabo

1.0616 1.0418 ................... ................. Rojo, PR. 41980................ San Juan-Caguas-Guaynabo, 1.0437 1.0297

1.0437

1.0297 PR. 49500................ Yauco, PR.................. 0.7478 0.8195 ................... .................

The following list represents all hospitals that are eligible to have their wage index increased by the outmigration adjustment listed in this table. Hospitals cannot receive the outmigration adjustment if they are reclassified under section 1886(d)(10) of the Act or redesignated under section 1886(d)(8) of the Act. Hospitals that have already been reclassified under section 1886(d)(10) of the Act or redesignated under section 1886(d)(8(B)) of the Act are designated with an asterisk. We will automatically assume that hospitals that have already been reclassified under section 1886(d)(10) of the Act or redesignated under section 1886(d)(8) of the Act wish to retain their reclassification/redesignation status and waive the application of the outmigration adjustment. Section 1886(d)(10) hospitals that wish to receive the outmigration adjustment, rather than their reclassification, should follow the termination/withdrawal procedures specified in 42 CFR 412.273 and section III.I.3. of the preamble of this proposed rule. Otherwise, they will be deemed to have waived the outmigration adjustment. Hospitals redesignated under section 1886(d)(8) of the Act will be deemed to have waived the outmigration adjustment, unless they explicitly notify CMS that they elect to receive the outmigration adjustment instead within 45 days from the publication of this proposed rule. These notifications should be sent to the following address: Centers for Medicare and Medicaid Services, Center for Medicare Management, Attention: Wage Index Adjustment Waivers, Division of Acute Care, Room C40806, 7500 Security Boulevard, Baltimore, MD 21244-1850.

Table 4J.--Out-Migration Adjustment--FY 2008

Reclassified for Out-migration Qualifying county Provider No.

FY 2008

Adjustment

name

County code

010005.............................

0.0322 MARSHALL.............

01470 010008............................. ................

0.0245 CRENSHAW.............

01200 010009.............................

0.0177 MORGAN...............

01510 010010.............................

0.0322 MARSHALL.............

01470 010012.............................

0.0182 DE KALB..............

01240 010015............................. ................

0.0043 CLARKE...............

01120 010022.............................

0.1106 CHEROKEE.............

01090 010025.............................

0.0188 CHAMBERS.............

01080 010029.............................

0.0281 LEE..................

01400 010032............................. ................

0.0320 RANDOLPH.............

01550 010035.............................

0.0263 CULLMAN..............

01210 010038............................. ................

0.0038 CALHOUN..............

01070 010045.............................

0.0216 FAYETTE..............

01280 010047............................. ................

0.0179 BUTLER...............

01060 010052............................. ................

0.0124 TALLAPOOSA...........

01610 010054.............................

0.0177 MORGAN...............

01510 010061............................. ................

0.0566 JACKSON..............

01350 010065.............................

0.0124 TALLAPOOSA...........

01610 010078............................. ................

0.0038 CALHOUN..............

01070 010083.............................

0.0125 BALDWIN..............

01010 010085.............................

0.0177 MORGAN...............

01510 010091............................. ................

0.0043 CLARKE...............

01120 010100.............................

0.0125 BALDWIN..............

01010 010101.............................

0.0209 TALLADEGA............

01600 010109............................. ................

0.0369 PICKENS..............

01530 010110............................. ................

0.0303 BULLOCK..............

01050 010125............................. ................

0.0471 WINSTON..............

01660 010128............................. ................

0.0043 CLARKE...............

01120 010129............................. ................

0.0125 BALDWIN..............

01010 010138............................. ................

0.0113 SUMTER...............

01590 010143.............................

0.0263 CULLMAN..............

01210 010146............................. ................

0.0038 CALHOUN..............

01070 010150.............................

0.0179 BUTLER...............

01060 010158.............................

0.0067 FRANKLIN.............

01290 010164.............................

0.0209 TALLADEGA............

01600

[[Page 24953]]

030040............................. ................

0.0012 SANTA CRUZ...........

03110 030067............................. ................

0.0230 LAPAZ................

03055 040014.............................

0.0163 WHITE................

04720 040019.............................

0.0254 ST. FRANCIS..........

04610 040039.............................

0.0172 GREENE...............

04270 040047............................. ................

0.0117 RANDOLPH.............

04600 040067............................. ................

0.0008 COLUMBIA.............

04130 040071.............................

0.0149 JEFFERSON............

04340 040076.............................

0.1001 HOT SPRING...........

04290 040081............................. ................

0.0358 PIKE.................

04540 040100.............................

0.0163 WHITE................

04720 050002............................. ................

0.0009 ALAMEDA..............

05000 050007............................. ................

0.0140 SAN MATEO............

05510 050009.............................

0.0196 NAPA.................

05380 050013.............................

0.0196 NAPA.................

05380 050014.............................

0.0147 AMADOR...............

05020 050042.............................

0.0184 TEHAMA...............

05620 050043............................. ................

0.0009 ALAMEDA..............

05000 050069.............................

0.0006 ORANGE...............

05400 050070............................. ................

0.0140 SAN MATEO............

05510 050073.............................

0.0169 SOLANO...............

05580 050075............................. ................

0.0009 ALAMEDA..............

05000 050084............................. ................

0.0135 SAN JOAQUIN..........

05490 050089.............................

0.0005 SAN BERNARDINO.......

05460 050090.............................

0.0085 SONOMA...............

05590 050099.............................

0.0005 SAN BERNARDINO.......

05460 050101.............................

0.0169 SOLANO...............

05580 050113............................. ................

0.0140 SAN MATEO............

05510 050118.............................

0.0135 SAN JOAQUIN..........

05490 050122............................. ................

0.0135 SAN JOAQUIN..........

05490 050129.............................

0.0005 SAN BERNARDINO.......

05460 050133.............................

0.0186 YUBA.................

05680 050136.............................

0.0085 SONOMA...............

05590 050140.............................

0.0005 SAN BERNARDINO.......

05460 050150.............................

0.0357 NEVADA...............

05390 050167............................. ................

0.0135 SAN JOAQUIN..........

05490 050168.............................

0.0006 ORANGE...............

05400 050173.............................

0.0006 ORANGE...............

05400 050174.............................

0.0085 SONOMA...............

05590 050193.............................

0.0006 ORANGE...............

05400 050195............................. ................

0.0009 ALAMEDA..............

05000 050197.............................

0.0140 SAN MATEO............

05510 050211............................. ................

0.0009 ALAMEDA..............

05000 050224.............................

0.0006 ORANGE...............

05400 050226.............................

0.0006 ORANGE...............

05400 050230.............................

0.0006 ORANGE...............

05400 050245.............................

0.0005 SAN BERNARDINO.......

05460 050264............................. ................

0.0009 ALAMEDA..............

05000 050272.............................

0.0005 SAN BERNARDINO.......

05460 050279.............................

0.0005 SAN BERNARDINO.......

05460 050283............................. ................

0.0009 ALAMEDA..............

05000 050289............................. ................

0.0140 SAN MATEO............

05510 050291.............................

0.0085 SONOMA...............

05590 050298.............................

0.0005 SAN BERNARDINO.......

05460 050300.............................

0.0005 SAN BERNARDINO.......

05460 050305............................. ................

0.0009 ALAMEDA..............

05000 050313............................. ................

0.0135 SAN JOAQUIN..........

05490 050320............................. ................

0.0009 ALAMEDA..............

05000 050325............................. ................

0.0046 TUOLUMNE.............

05650 050327.............................

0.0005 SAN BERNARDINO.......

05460 050335............................. ................

0.0046 TUOLUMNE.............

05650 050336............................. ................

0.0135 SAN JOAQUIN..........

05490 050348.............................

0.0006 ORANGE...............

05400 050366............................. ................

0.0025 CALAVERAS............

05040 050367.............................

0.0169 SOLANO...............

05580 050385.............................

0.0085 SONOMA...............

05590 050426.............................

0.0006 ORANGE...............

05400 050444............................. ................

0.0229 MERCED...............

05340 050476.............................

0.0275 LAKE.................

05160 050488............................. ................

0.0009 ALAMEDA..............

05000

[[Page 24954]]

050494.............................

0.0357 NEVADA...............

05390 050512............................. ................

0.0009 ALAMEDA..............

05000 050517.............................

0.0005 SAN BERNARDINO.......

05460 050526.............................

0.0006 ORANGE...............

05400 050528.............................

0.0229 MERCED...............

05340 050541.............................

0.0140 SAN MATEO............

05510 050543.............................

0.0006 ORANGE...............

05400 050547.............................

0.0085 SONOMA...............

05590 050548.............................

0.0006 ORANGE...............

05400 050551.............................

0.0006 ORANGE...............

05400 050567.............................

0.0006 ORANGE...............

05400 050570.............................

0.0006 ORANGE...............

05400 050580.............................

0.0006 ORANGE...............

05400 050584.............................

0.0005 SAN BERNARDINO.......

05460 050586.............................

0.0005 SAN BERNARDINO.......

05460 050589.............................

0.0006 ORANGE...............

05400 050603.............................

0.0006 ORANGE...............

05400 050609.............................

0.0006 ORANGE...............

05400 050618.............................

0.0005 SAN BERNARDINO.......

05460 050667.............................

0.0196 NAPA.................

05380 050678.............................

0.0006 ORANGE...............

05400 050680.............................

0.0169 SOLANO...............

05580 050690.............................

0.0085 SONOMA...............

05590 050693.............................

0.0006 ORANGE...............

05400 050707............................. ................

0.0140 SAN MATEO............

05510 050720.............................

0.0006 ORANGE...............

05400 050744............................. ................

0.0006 ORANGE...............

05400 050745............................. ................

0.0006 ORANGE...............

05400 050746............................. ................

0.0006 ORANGE...............

05400 050747............................. ................

0.0006 ORANGE...............

05400 050748............................. ................

0.0135 SAN JOAQUIN..........

05490 050754............................. ................

0.0140 SAN MATEO............

05510 050756............................. ................

0.0005 SAN BERNARDINO.......

05460 060001.............................

0.0045 WELD.................

06610 060003.............................

0.0075 BOULDER..............

06060 060010............................. ................

0.0087 LARIMER..............

06340 060027.............................

0.0075 BOULDER..............

06060 060030............................. ................

0.0087 LARIMER..............

06340 060103.............................

0.0075 BOULDER..............

06060 060116.............................

0.0075 BOULDER..............

06060 080001.............................

0.0018 NEW CASTLE...........

08010 080003.............................

0.0018 NEW CASTLE...........

08010 100014.............................

0.0059 VOLUSIA..............

10630 100017.............................

0.0059 VOLUSIA..............

10630 100045.............................

0.0059 VOLUSIA..............

10630 100047.............................

0.0026 CHARLOTTE............

10070 100068.............................

0.0059 VOLUSIA..............

10630 100072.............................

0.0059 VOLUSIA..............

10630 100077.............................

0.0026 CHARLOTTE............

10070 100118.............................

0.0179 FLAGLER..............

10170 100232.............................

0.0057 PUTNAM...............

10530 100236.............................

0.0026 CHARLOTTE............

10070 100252.............................

0.0146 OKEECHOBEE...........

10460 100290............................. ................

0.0390 SUMTER...............

10590 110023.............................

0.0416 GORDON...............

11500 110029.............................

0.0056 HALL.................

11550 110040.............................

0.1727 JACKSON..............

11610 110041.............................

0.0624 HABERSHAM............

11540 110100............................. ................

0.0789 JEFFERSON............

11620 110101............................. ................

0.0067 COOK.................

11311 110142............................. ................

0.0202 EVANS................

11441 110146.............................

0.0438 CAMDEN...............

11170 110150.............................

0.0227 BALDWIN..............

11030 110187.............................

0.0643 LUMPKIN..............

11701 110190............................. ................

0.0242 MACON................

11710 110205............................. ................

0.0514 GILMER...............

11471 130024............................. ................

0.0422 BONNER...............

13080 130049.............................

0.0319 KOOTENAI.............

13270 130066............................. ................

0.0319 KOOTENAI.............

13270 130067.............................

0.0697 BINGHAM..............

13050

[[Page 24955]]

130068............................. ................

0.0319 KOOTENAI.............

13270 140001............................. ................

0.0362 FULTON...............

14370 140026............................. ................

0.0288 LA SALLE.............

14580 140043.............................

0.0055 WHITESIDE............

14988 140058.............................

0.0125 MORGAN...............

14770 140110.............................

0.0288 LA SALLE.............

14580 140160.............................

0.0302 STEPHENSON...........

14970 140161.............................

0.0193 LIVINGSTON...........

14610 140167.............................

0.1054 IROQUOIS.............

14460 140234............................. ................

0.0288 LA SALLE.............

14580 150006.............................

0.0085 LA PORTE.............

15450 150015............................. ................

0.0085 LA PORTE.............

15450 150022............................. ................

0.0151 MONTGOMERY...........

15530 150030.............................

0.0186 HENRY................

15320 150072............................. ................

0.0101 CASS.................

15080 150076.............................

0.0210 MARSHALL.............

15490 150088.............................

0.0111 MADISON..............

15470 150091.............................

0.0047 HUNTINGTON...........

15340 150102.............................

0.0103 STARKE...............

15740 150113.............................

0.0111 MADISON..............

15470 150133.............................

0.0167 KOSCIUSKO............

15420 150146.............................

0.0081 NOBLE................

15560 160013............................. ................

0.0179 MUSCATINE............

16690 160032............................. ................

0.0235 JASPER...............

16490 160080.............................

0.0066 CLINTON..............

16220 170137.............................

0.0387 DOUGLAS..............

17220 170150............................. ................

0.0176 COWLEY...............

17170 180012.............................

0.0081 HARDIN...............

18460 180017.............................

0.0035 BARREN...............

18040 180049.............................

0.0497 MADISON..............

18750 180064............................. ................

0.0320 MONTGOMERY...........

18860 180066.............................

0.0450 LOGAN................

18700 180070............................. ................

0.0240 GRAYSON..............

18420 180079............................. ................

0.0264 HARRISON.............

18480 190003.............................

0.0085 IBERIA...............

19220 190015.............................

0.0231 TANGIPAHOA...........

19520 190017.............................

0.0184 ST. LANDRY...........

19480 190034............................. ................

0.0188 VERMILION............

19560 190044............................. ................

0.0259 ACADIA...............

19000 190050............................. ................

0.0044 BEAUREGARD...........

19050 190053............................. ................

0.0100 JEFFRSON DAVIS.......

19260 190054............................. ................

0.0085 IBERIA...............

19220 190078............................. ................

0.0184 ST. LANDRY...........

19480 190086.............................

0.0050 LINCOLN..............

19300 190088.............................

0.0410 WEBSTER..............

19590 190099.............................

0.0189 AVOYELLES............

19040 190106.............................

0.0101 ALLEN................

19010 190116............................. ................

0.0084 MOREHOUSE............

19330 190133............................. ................

0.0101 ALLEN................

19010 190140............................. ................

0.0034 FRANKLIN.............

19200 190144.............................

0.0410 WEBSTER..............

19590 190145............................. ................

0.0090 LA SALLE.............

19290 190184.............................

0.0075 CALDWELL.............

19100 190190............................. ................

0.0075 CALDWELL.............

19100 190191.............................

0.0184 ST. LANDRY...........

19480 190246............................. ................

0.0075 CALDWELL.............

19100 190257............................. ................

0.0050 LINCOLN..............

19300 200024.............................

0.0092 ANDROSCOGGIN.........

20000 200032............................. ................

0.0316 OXFORD...............

20080 200034.............................

0.0092 ANDROSCOGGIN.........

20000 200050.............................

0.0223 HANCOCK..............

20040 210001............................. ................

0.0184 WASHINGTON...........

21210 210023............................. ................

0.0070 ANNE ARUNDEL.........

21010 210028............................. ................

0.0356 ST. MARYS............

21180 210043............................. ................

0.0070 ANNE ARUNDEL.........

21010 220002.............................

0.0235 MIDDLESEX............

22090 220010.............................

0.0461 ESSEX................

22040 220011.............................

0.0235 MIDDLESEX............

22090 220029.............................

0.0461 ESSEX................

22040 220033.............................

0.0461 ESSEX................

22040

[[Page 24956]]

220035.............................

0.0461 ESSEX................

22040 220049.............................

0.0235 MIDDLESEX............

22090 220063.............................

0.0235 MIDDLESEX............

22090 220070.............................

0.0235 MIDDLESEX............

22090 220080.............................

0.0461 ESSEX................

22040 220082.............................

0.0235 MIDDLESEX............

22090 220084.............................

0.0235 MIDDLESEX............

22090 220098.............................

0.0235 MIDDLESEX............

22090 220101.............................

0.0235 MIDDLESEX............

22090 220105.............................

0.0235 MIDDLESEX............

22090 220171.............................

0.0235 MIDDLESEX............

22090 220174.............................

0.0461 ESSEX................

22040 230003.............................

0.0217 OTTAWA...............

23690 230005............................. ................

0.0473 LENAWEE..............

23450 230013.............................

0.0023 OAKLAND..............

23620 230015............................. ................

0.0297 ST. JOSEPH...........

23740 230019.............................

0.0023 OAKLAND..............

23620 230021.............................

0.0099 BERRIEN..............

23100 230022.............................

0.0212 BRANCH...............

23110 230029.............................

0.0023 OAKLAND..............

23620 230035.............................

0.0096 MONTCALM.............

23580 230037.............................

0.0211 HILLSDALE............

23290 230047.............................

0.0018 MACOMB...............

23490 230069.............................

0.0208 LIVINGSTON...........

23460 230071.............................

0.0023 OAKLAND..............

23620 230072.............................

0.0217 OTTAWA...............

23690 230075............................. ................

0.0048 CALHOUN..............

23120 230078.............................

0.0099 BERRIEN..............

23100 230092.............................

0.0221 JACKSON..............

23370 230093............................. ................

0.0060 MECOSTA..............

23530 230096.............................

0.0297 ST. JOSEPH...........

23740 230099.............................

0.0230 MONROE...............

23570 230121.............................

0.0695 SHIAWASSEE...........

23770 230130.............................

0.0023 OAKLAND..............

23620 230151.............................

0.0023 OAKLAND..............

23620 230174.............................

0.0217 OTTAWA...............

23690 230195.............................

0.0018 MACOMB...............

23490 230204.............................

0.0018 MACOMB...............

23490 230207.............................

0.0023 OAKLAND..............

23620 230208.............................

0.0096 MONTCALM.............

23580 230217.............................

0.0048 CALHOUN..............

23120 230222.............................

0.0037 MIDLAND..............

23550 230223.............................

0.0023 OAKLAND..............

23620 230227.............................

0.0018 MACOMB...............

23490 230254.............................

0.0023 OAKLAND..............

23620 230257.............................

0.0018 MACOMB...............

23490 230264.............................

0.0018 MACOMB...............

23490 230269.............................

0.0023 OAKLAND..............

23620 230277.............................

0.0023 OAKLAND..............

23620 230279.............................

0.0208 LIVINGSTON...........

23460 240018............................. ................

0.0873 GOODHUE..............

24240 240044............................. ................

0.0671 WINONA...............

24840 240064.............................

0.0130 ITASCA...............

24300 240069.............................

0.0301 STEELE...............

24730 240071.............................

0.0377 RICE.................

24650 240117............................. ................

0.0593 MOWER................

24490 240211............................. ................

0.0386 PINE.................

24570 250023.............................

0.0430 PEARL RIVER..........

25540 250040.............................

0.0022 JACKSON..............

25290 250117.............................

0.0430 PEARL RIVER..........

25540 250128............................. ................

0.0393 PANOLA...............

25530 250160............................. ................

0.0393 PANOLA...............

25530 260059............................. ................

0.0127 LACLEDE..............

26520 260064.............................

0.0092 AUDRAIN..............

26030 260097............................. ................

0.0295 JOHNSON..............

26500 270081............................. ................

0.0236 MUSSELSHELL..........

27320 280077............................. ................

0.0057 DODGE................

28260 280123............................. ................

0.0118 GAGE.................

28330 290002.............................

0.0280 LYON.................

29090 310002.............................

0.0264 ESSEX................

31200

[[Page 24957]]

310009.............................

0.0264 ESSEX................

31200 310010.............................

0.0159 MERCER...............

31260 310013.............................

0.0264 ESSEX................

31200 310018.............................

0.0264 ESSEX................

31200 310021............................. ................

0.0159 MERCER...............

31260 310031.............................

0.0130 BURLINGTON...........

31150 310032.............................

0.0027 CUMBERLAND...........

31190 310038.............................

0.0368 MIDDLESEX............

31270 310039.............................

0.0368 MIDDLESEX............

31270 310044.............................

0.0159 MERCER...............

31260 310054.............................

0.0264 ESSEX................

31200 310057............................. ................

0.0130 BURLINGTON...........

31150 310061............................. ................

0.0130 BURLINGTON...........

31150 310070.............................

0.0368 MIDDLESEX............

31270 310076.............................

0.0264 ESSEX................

31200 310083.............................

0.0264 ESSEX................

31200 310092.............................

0.0159 MERCER...............

31260 310093.............................

0.0264 ESSEX................

31200 310096.............................

0.0264 ESSEX................

31200 310108.............................

0.0368 MIDDLESEX............

31270 310110............................. ................

0.0159 MERCER...............

31260 310119.............................

0.0264 ESSEX................

31200 310127............................. ................

0.0130 BURLINGTON...........

31150 320003.............................

0.0480 SAN MIGUEL...........

32230 320011............................. ................

0.0337 RIO ARRIBA...........

32190 320018............................. ................

0.0025 DONA ANA.............

32060 320085............................. ................

0.0025 DONA ANA.............

32060 330004.............................

0.0615 ULSTER...............

33740 330008.............................

0.0102 WYOMING..............

33900 330010............................. ................

0.0042 MONTGOMERY...........

33380 330027.............................

0.0148 NASSAU...............

33400 330033............................. ................

0.0205 CHENANGO.............

33080 330047............................. ................

0.0042 MONTGOMERY...........

33380 330073.............................

0.0122 GENESEE..............

33290 330094.............................

0.0463 COLUMBIA.............

33200 330103............................. ................

0.0121 CATTARAUGUS..........

33040 330106.............................

0.0148 NASSAU...............

33400 330126.............................

0.0675 ORANGE...............

33540 330132.............................

0.0121 CATTARAUGUS..........

33040 330135.............................

0.0675 ORANGE...............

33540 330167.............................

0.0148 NASSAU...............

33400 330175............................. ................

0.0241 CORTLAND.............

33210 330181.............................

0.0148 NASSAU...............

33400 330182.............................

0.0148 NASSAU...............

33400 330191.............................

0.0017 WARREN...............

33750 330198.............................

0.0148 NASSAU...............

33400 330205.............................

0.0675 ORANGE...............

33540 330224.............................

0.0615 ULSTER...............

33740 330225.............................

0.0148 NASSAU...............

33400 330235.............................

0.0281 CAYUGA...............

33050 330259.............................

0.0148 NASSAU...............

33400 330264.............................

0.0675 ORANGE...............

33540 330331.............................

0.0148 NASSAU...............

33400 330332.............................

0.0148 NASSAU...............

33400 330372.............................

0.0148 NASSAU...............

33400 330386.............................

0.0687 SULLIVAN.............

33710 340020............................. ................

0.0143 LEE..................

34520 340021.............................

0.0162 CLEVELAND............

34220 340024............................. ................

0.0171 SAMPSON..............

34810 340027.............................

0.0125 LENOIR...............

34530 340037............................. ................

0.0162 CLEVELAND............

34220 340038.............................

0.0253 BEAUFORT.............

34060 340039.............................

0.0101 IREDELL..............

34480 340068.............................

0.0094 COLUMBUS.............

34230 340069.............................

0.0083 WAKE.................

34910 340070.............................

0.0417 ALAMANCE.............

34000 340071.............................

0.0168 HARNETT..............

34420 340073.............................

0.0083 WAKE.................

34910 340085............................. ................

0.0250 DAVIDSON.............

34280 340096............................. ................

0.0250 DAVIDSON.............

34280

[[Page 24958]]

340104.............................

0.0162 CLEVELAND............

34220 340114.............................

0.0083 WAKE.................

34910 340124.............................

0.0168 HARNETT..............

34420 340126.............................

0.0084 WILSON...............

34970 340129.............................

0.0101 IREDELL..............

34480 340133............................. ................

0.0242 MARTIN...............

34580 340138.............................

0.0083 WAKE.................

34910 340144.............................

0.0101 IREDELL..............

34480 340145.............................

0.0337 LINCOLN..............

34540 340151............................. ................

0.0053 HALIFAX..............

34410 340173.............................

0.0083 WAKE.................

34910 360002............................. ................

0.0142 ASHLAND..............

36020 360010.............................

0.0075 TUSCARAWAS...........

36800 360013.............................

0.0135 SHELBY...............

36760 360025.............................

0.0073 ERIE.................

36220 360036.............................

0.0168 WAYNE................

36860 360040............................. ................

0.0392 KNOX.................

36430 360044............................. ................

0.0123 DARKE................

36190 360065.............................

0.0077 HURON................

36400 360071............................. ................

0.0035 VAN WERT.............

36820 360086.............................

0.0187 CLARK................

36110 360096.............................

0.0071 COLUMBIANA...........

36140 360107.............................

0.0095 SANDUSKY.............

36730 360125.............................

0.0137 ASHTABULA............

36030 360156............................. ................

0.0095 SANDUSKY.............

36730 360175.............................

0.0175 CLINTON..............

36130 360185.............................

0.0071 COLUMBIANA...........

36140 360187.............................

0.0187 CLARK................

36110 360245.............................

0.0137 ASHTABULA............

36030 370014.............................

0.0363 BRYAN................

37060 370015.............................

0.0369 MAYES................

37480 370023............................. ................

0.0090 STEPHENS.............

37680 370065............................. ................

0.0097 CRAIG................

37170 370072............................. ................

0.0260 LATIMER..............

37380 370083............................. ................

0.0051 PUSHMATAHA...........

37630 370100............................. ................

0.0101 CHOCTAW..............

37110 370149.............................

0.0292 POTTAWATOMIE.........

37620 370156............................. ................

0.0122 GARVIN...............

37240 370169............................. ................

0.0164 MCINTOSH.............

37450 370172............................. ................

0.0260 LATIMER..............

37380 370214............................. ................

0.0122 GARVIN...............

37240 380022.............................

0.0069 LINN.................

38210 390008............................. ................

0.0055 LAWRENCE.............

39450 390016.............................

0.0055 LAWRENCE.............

39450 390030.............................

0.0163 SCHUYLKILL...........

39650 390031.............................

0.0163 SCHUYLKILL...........

39650 390044.............................

0.0191 BERKS................

39110 390052............................. ................

0.0044 CLEARFIELD...........

39230 390065.............................

0.0489 ADAMS................

39000 390066.............................

0.0364 LEBANON..............

39460 390086.............................

0.0044 CLEARFIELD...........

39230 390096.............................

0.0191 BERKS................

39110 390113.............................

0.0049 CRAWFORD.............

39260 390122............................. ................

0.0049 CRAWFORD.............

39260 390138.............................

0.0212 FRANKLIN.............

39350 390146............................. ................

0.0019 WARREN...............

39740 390150.............................

0.0019 GREENE...............

39370 390151.............................

0.0212 FRANKLIN.............

39350 390181.............................

0.0163 SCHUYLKILL...........

39650 390183.............................

0.0163 SCHUYLKILL...........

39650 390201.............................

0.1091 MONROE...............

39550 390313.............................

0.0163 SCHUYLKILL...........

39650 420007.............................

0.0037 SPARTANBURG..........

42410 420019............................. ................

0.0142 CHESTER..............

42110 420027.............................

0.0145 ANDERSON.............

42030 420030.............................

0.0051 COLLETON.............

42140 420039.............................

0.0148 UNION................

42430 420043............................. ................

0.0132 CHEROKEE.............

42100 420062.............................

0.0096 CHESTERFIELD.........

42120 420069.............................

0.0023 CLARENDON............

42130

[[Page 24959]]

420083.............................

0.0037 SPARTANBURG..........

42410 430008............................. ................

0.0537 BROOKINGS............

43050 430048.............................

0.0055 LAWRENCE.............

43400 430094............................. ................

0.0055 LAWRENCE.............

43400 440007............................. ................

0.0226 COFFEE...............

44150 440008.............................

0.0449 HENDERSON............

44380 440016............................. ................

0.0144 CARROLL..............

44080 440024.............................

0.0230 BRADLEY..............

44050 440030............................. ................

0.0015 HAMBLEN..............

44310 440031............................. ................

0.0025 ROANE................

44720 440033............................. ................

0.0036 CAMPBELL.............

44060 440035.............................

0.0309 MONTGOMERY...........

44620 440047............................. ................

0.0338 GIBSON...............

44260 440051............................. ................

0.0071 MCNAIRY..............

44540 440057............................. ................

0.0028 CLAIBORNE............

44120 440060.............................

0.0338 GIBSON...............

44260 440067.............................

0.0015 HAMBLEN..............

44310 440070............................. ................

0.0109 DECATUR..............

44190 440081............................. ................

0.0069 SEVIER...............

44770 440084............................. ................

0.0034 MONROE...............

44610 440109............................. ................

0.0070 HARDIN...............

44350 440115............................. ................

0.0338 GIBSON...............

44260 440137............................. ................

0.0763 BEDFORD..............

44010 440144.............................

0.0226 COFFEE...............

44150 440148.............................

0.0306 DE KALB..............

44200 440174............................. ................

0.0310 HAYWOOD..............

44370 440180............................. ................

0.0036 CAMPBELL.............

44060 440181............................. ................

0.0361 HARDEMAN.............

44340 440182............................. ................

0.0144 CARROLL..............

44080 440185.............................

0.0230 BRADLEY..............

44050 450032.............................

0.0253 HARRISON.............

45620 450039.............................

0.0024 TARRANT..............

45910 450052.............................

0.0276 BOSQUE...............

45160 450059.............................

0.0074 COMAL................

45320 450064.............................

0.0024 TARRANT..............

45910 450087.............................

0.0024 TARRANT..............

45910 450090............................. ................

0.0651 COOKE................

45340 450099.............................

0.0143 GRAY.................

45563 450135.............................

0.0024 TARRANT..............

45910 450137.............................

0.0024 TARRANT..............

45910 450144............................. ................

0.0558 ANDREWS..............

45010 450163............................. ................

0.0053 KLEBERG..............

45743 450192............................. ................

0.0271 HILL.................

45651 450194............................. ................

0.0213 CHEROKEE.............

45281 450210............................. ................

0.0150 PANOLA...............

45842 450224.............................

0.0195 WOOD.................

45974 450236............................. ................

0.0389 HOPKINS..............

45654 450270............................. ................

0.0271 HILL.................

45651 450283.............................

0.0655 VAN ZANDT............

45947 450347.............................

0.0379 WALKER...............

45949 450348.............................

0.0058 FALLS................

45500 450370............................. ................

0.0241 COLORADO.............

45312 450389.............................

0.0619 HENDERSON............

45640 450395.............................

0.0452 POLK.................

45850 450419.............................

0.0024 TARRANT..............

45910 450438.............................

0.0241 COLORADO.............

45312 450451............................. ................

0.0537 SOMERVELL............

45893 450460............................. ................

0.0048 TYLER................

45942 450497............................. ................

0.0395 MONTAGUE.............

45800 450539............................. ................

0.0071 HALE.................

45582 450547............................. ................

0.0195 WOOD.................

45974 450563.............................

0.0024 TARRANT..............

45910 450565............................. ................

0.0481 PALO PINTO...........

45841 450573............................. ................

0.0115 JASPER...............

45690 450596.............................

0.0744 HOOD.................

45653 450639.............................

0.0024 TARRANT..............

45910 450641............................. ................

0.0395 MONTAGUE.............

45800 450672.............................

0.0024 TARRANT..............

45910 450675.............................

0.0024 TARRANT..............

45910 450677.............................

0.0024 TARRANT..............

45910

[[Page 24960]]

450698............................. ................

0.0135 LAMB.................

45751 450747.............................

0.0127 ANDERSON.............

45000 450755............................. ................

0.0295 HOCKLEY..............

45652 450770.............................

0.0182 MILAM................

45795 450779.............................

0.0024 TARRANT..............

45910 450813.............................

0.0127 ANDERSON.............

45000 450838............................. ................

0.0115 JASPER...............

45690 450872.............................

0.0024 TARRANT..............

45910 450880.............................

0.0024 TARRANT..............

45910 450884............................. ................

0.0050 UPSHUR...............

45943 450886............................. ................

0.0024 TARRANT..............

45910 450888............................. ................

0.0024 TARRANT..............

45910 460017............................. ................

0.0364 BOX ELDER............

46010 460039.............................

0.0364 BOX ELDER............

46010 490019.............................

0.1081 CULPEPER.............

49230 490084............................. ................

0.0145 ESSEX................

49280 490110............................. ................

0.0327 MONTGOMERY...........

49600 500003.............................

0.0164 SKAGIT...............

50280 500007.............................

0.0164 SKAGIT...............

50280 500019............................. ................

0.0140 LEWIS................

50200 500039.............................

0.0101 KITSAP...............

50170 500041.............................

0.0020 COWLITZ..............

50070 510018.............................

0.0187 JACKSON..............

51170 510047.............................

0.0270 MARION...............

51240 520028.............................

0.0297 GREEN................

52220 520035............................. ................

0.0083 SHEBOYGAN............

52580 520044............................. ................

0.0083 SHEBOYGAN............

52580 520057............................. ................

0.0184 SAUK.................

52550 520059.............................

0.0189 RACINE...............

52500 520060.............................

0.0048 GREEN LAKE...........

52230 520071.............................

0.0174 JEFFERSON............

52270 520076.............................

0.0159 DODGE................

52130 520095.............................

0.0184 SAUK.................

52550 520096............................. ................

0.0189 RACINE...............

52500 520102.............................

0.0242 WALWORTH.............

52630 520116.............................

0.0174 JEFFERSON............

52270

Table 5.--List of Proposed Medicare Severity-Diagnosis Related Groups (MS-DRGs), Relative Weighting Factors, and Geometric and Arithmetic Mean Length of Stay

Geometric Arithmetic FY 2008 proposed FY 2008 proposed

mean

mean MS-DRG

rule post-acute DRG rule special pay DRG MDC

TYPE

MS-DRG title

Weights length of length of stay

stay

1................. NO.................. NO.................. PRE SURG................ Heart transplant or

23.6378

30.5

44.2 implant of heart assist system w MCC. 2................. NO.................. NO.................. PRE SURG................ Heart transplant or

11.2998

16.0

22.8 implant of heart assist system w/o MCC. 3................. YES................. NO.................. PRE SURG................ ECMO or trach w MV 96+ 18.6118

36.2

43.2 hrs or PDX exc face, mouth & neck w maj O.R. 4................. YES................. NO.................. PRE SURG................ Trach w MV 96+ hrs or 11.5312

26.2

31.3 PDX exc face, mouth & neck w/o maj O.R. 5................. NO.................. NO.................. PRE SURG................ Liver transplant w MCC 10.3032

17.0

22.6 or intestinal transplant. 6................. NO.................. NO.................. PRE SURG................ Liver transplant w/o

4.7075

8.7

10.0 MCC. 7................. NO.................. NO.................. PRE SURG................ Lung transplant....... 7.6379

14.6

17.3 8................. NO.................. NO.................. PRE SURG................ Simultaneous pancreas/ 5.0633

10.2

11.9 kidney transplant. 9................. NO.................. NO.................. PRE SURG................ Bone marrow transplant 6.1059

18.1

21.6 10................ NO.................. NO.................. PRE SURG................ Pancreas transplant... 3.6839

9.1

10.2 11................ NO.................. NO.................. PRE SURG................ Tracheostomy for face, 4.8010

13.0

16.3 mouth & neck diagnoses w MCC. 12................ NO.................. NO.................. PRE SURG................ Tracheostomy for face, 2.9948

9.0

10.9 mouth & neck diagnoses w CC. 13................ NO.................. NO.................. PRE SURG................ Tracheostomy for face, 1.8882

6.1

7.3 mouth & neck diagnoses w/o CC/MCC. 20................ NO.................. NO.................. 01 SURG................ Intracranial vascular 8.2109

15.4

19.2 procedures w PDX hemorrhage w MCC.

[[Page 24961]]

21................ NO.................. NO.................. 01 SURG................ Intracranial vascular 6.1724

13.4

15.6 procedures w PDX hemorrhage w CC. 22................ NO.................. NO.................. 01 SURG................ Intracranial vascular 4.1017

7.9

9.7 procedures w PDX hemorrhage w/o CC/MCC. 23................ NO.................. NO.................. 01 SURG................ Craniotomy w major

5.1123

9.8

13.7 device implant or acute complex CNS PDX w MCC. 24................ NO.................. NO.................. 01 SURG................ Craniotomy w major

3.4316

6.1

8.7 device implant or acute complex CNS PDX w/o MCC. 25................ YES................. NO.................. 01 SURG................ Craniotomy &

4.9933

10.7

13.8 endovascular intracranial procedures w MCC. 26................ YES................. NO.................. 01 SURG................ Craniotomy &

2.9515

6.7

8.4 endovascular intracranial procedures w CC. 27................ YES................. NO.................. 01 SURG................ Craniotomy &

2.0380

3.6

4.7 endovascular intracranial procedures w/o CC/MCC. 28................ NO.................. NO.................. 01 SURG................ Spinal procedures w

4.9251

10.9

14.7 MCC. 29................ NO.................. NO.................. 01 SURG................ Spinal procedures w CC 2.5965

5.7

7.7 30................ NO.................. NO.................. 01 SURG................ Spinal procedures w/o 1.5278

2.7

3.7 CC/MCC. 31................ NO.................. NO.................. 01 SURG................ Ventricular shunt

3.8505

9.2

13.2 procedures w MCC. 32................ NO.................. NO.................. 01 SURG................ Ventricular shunt

1.7502

3.9

5.8 procedures w CC. 33................ NO.................. NO.................. 01 SURG................ Ventricular shunt

1.2661

2.3

3.1 procedures w/o CC/MCC. 34................ NO.................. NO.................. 01 SURG................ Carotid artery stent

3.2158

4.8

7.3 procedure w MCC. 35................ NO.................. NO.................. 01 SURG................ Carotid artery stent

2.0186

2.0

3.0 procedure w CC. 36................ NO.................. NO.................. 01 SURG................ Carotid artery stent

1.5746

1.3

1.6 procedure w/o CC/MCC. 37................ NO.................. NO.................. 01 SURG................ Extracranial

3.0383

6.0

8.7 procedures w MCC. 38................ NO.................. NO.................. 01 SURG................ Extracranial

1.5518

2.6

3.8 procedures w CC. 39................ NO.................. NO.................. 01 SURG................ Extracranial

1.0172

1.5

1.9 procedures w/o CC/MCC. 40................ YES................. YES................. 01 SURG................ Periph & cranial nerve 3.8181

10.4

14.0 & other nerv syst proc w MCC. 41................ YES................. YES................. 01 SURG................ Periph & cranial nerve 2.1436

5.6

7.5 & other nerv syst proc w CC. 42................ YES................. YES................. 01 SURG................ Periph & cranial nerve 1.6878

2.5

3.7 & other nerv syst proc w/o CC/MCC. 52................ NO.................. NO.................. 01 MED................. Spinal disorders &

1.5118

4.9

6.8 injuries w CC/MCC. 53................ NO.................. NO.................. 01 MED................. Spinal disorders &

0.9105

3.2

4.0 injuries w/o CC/MCC. 54................ YES................. NO.................. 01 MED................. Nervous system

1.6182

5.5

7.4 neoplasms w MCC. 55................ YES................. NO.................. 01 MED................. Nervous system

1.0567

3.9

5.1 neoplasms w/o MCC. 56................ YES................. NO.................. 01 MED................. Degenerative nervous

1.6121

6.2

8.2 system disorders w MCC. 57................ YES................. NO.................. 01 MED................. Degenerative nervous

0.8403

4.0

5.0 system disorders w/o MCC. 58................ NO.................. NO.................. 01 MED................. Multiple sclerosis &

1.6022

5.8

8.0 cerebellar ataxia w MCC. 59................ NO.................. NO.................. 01 MED................. Multiple sclerosis &

0.9288

4.3

5.2 cerebellar ataxia w CC. 60................ NO.................. NO.................. 01 MED................. Multiple sclerosis &

0.7126

3.4

4.1 cerebellar ataxia w/o CC/MCC. 61................ NO.................. NO.................. 01 MED................. Acute ischemic stroke 2.9195

7.4

9.8 w use of thrombolytic agent w MCC. 62................ NO.................. NO.................. 01 MED................. Acute ischemic stroke 1.9977

5.4

6.4 w use of thrombolytic agent w CC. 63................ NO.................. NO.................. 01 MED................. Acute ischemic stroke 1.5581

4.0

4.6 w use of thrombolytic agent w/o CC/MCC. 64................ YES................. NO.................. 01 MED................. Intracranial

1.9072

5.9

7.9 hemorrhage or cerebral infarction w MCC. 65................ YES................. NO.................. 01 MED................. Intracranial

1.1841

4.5

5.4 hemorrhage or cerebral infarction w CC. 66................ YES................. NO.................. 01 MED................. Intracranial

0.8588

3.2

3.8 hemorrhage or cerebral infarction w/ o CC/MCC. 67................ NO.................. NO.................. 01 MED................. Nonspecific cva &

1.5069

4.8

6.2 precerebral occlusion w/o infarct w MCC. 68................ NO.................. NO.................. 01 MED................. Nonspecific cva &

0.8855

2.8

3.6 precerebral occlusion w/o infarct w/o MCC. 69................ NO.................. NO.................. 01 MED................. Transient ischemia.... 0.7372

2.5

3.1 70................ YES................. NO.................. 01 MED................. Nonspecific

1.8674

6.3

8.2 cerebrovascular disorders w MCC. 71................ YES................. NO.................. 01 MED................. Nonspecific

1.1698

4.6

5.8 cerebrovascular disorders w CC.

[[Page 24962]]

72................ YES................. NO.................. 01 MED................. Nonspecific

0.8275

3.0

3.8 cerebrovascular disorders w/o CC/MCC. 73................ NO.................. NO.................. 01 MED................. Cranial & peripheral

1.3298

4.8

6.4 nerve disorders w MCC. 74................ NO.................. NO.................. 01 MED................. Cranial & peripheral

0.8482

3.4

4.4 nerve disorders w/o MCC. 75................ NO.................. NO.................. 01 MED................. Viral meningitis w CC/ 1.7156

6.1

7.7 MCC. 76................ NO.................. NO.................. 01 MED................. Viral meningitis w/o

0.9367

3.5

4.2 CC/MCC. 77................ NO.................. NO.................. 01 MED................. Hypertensive

1.7374

5.6

7.2 encephalopathy w MCC. 78................ NO.................. NO.................. 01 MED................. Hypertensive

1.0221

3.8

4.6 encephalopathy w CC. 79................ NO.................. NO.................. 01 MED................. Hypertensive

0.8041

2.9

3.5 encephalopathy w/o CC/ MCC. 80................ NO.................. NO.................. 01 MED................. Nontraumatic stupor & 1.0699

3.6

4.9 coma w MCC. 81................ NO.................. NO.................. 01 MED................. Nontraumatic stupor & 0.6932

2.7

3.4 coma w/o MCC. 82................ NO.................. NO.................. 01 MED................. Traumatic stupor &

2.0060

3.9

6.4 coma, coma >1 hr w MCC. 83................ NO.................. NO.................. 01 MED................. Traumatic stupor &

1.3451

3.8

5.3 coma, coma >1 hr w CC. 84................ NO.................. NO.................. 01 MED................. Traumatic stupor &

0.8999

2.3

3.1 coma, coma >1 hr w/o CC/MCC. 85................ YES................. NO.................. 01 MED................. Traumatic stupor &

2.0578

6.0

8.2 coma, coma 1 hr w MCC. 83.................... Traumatic stupor &

12 0.6513

22.7

18.9 coma, coma >1 hr w CC2.

[[Page 25101]]

84.................... Traumatic stupor &

4 0.6513

22.7

18.9 coma, coma >1 hr w/o CC/MCC \2\. 85.................... Traumatic stupor &

102 0.9666

28.3

23.6 coma, coma 840. 841................... Lymphoma & non-acute

840

65 0.7405

20.1

16.8 leukemia w CC. 842................... Lymphoma & non-acute

840

11 0.6513

22.7

18.9 leukemia w/o CC/MCC \2\. 843................... Other myeloprolif dis

843

19 1.0950

30.3

25.3 or poorly diff neopl diag w MCC 4, 6. 844................... Other myeloprolif dis

843

13 1.0950

30.3

25.3 or poorly diff neopl diag w CC 4, 6. 845................... Other myeloprolif dis

843

3 1.0950

30.3

25.3 or poorly diff neopl diag w/o CC/MCC 4, 6. 846................... Chemotherapy w/o acute

846

31 1.8155

37.9

31.6 leukemia as secondary diagnosis w MCC. 847................... Chemotherapy w/o acute

846

61 1.3078

27.6

23.0 leukemia as secondary diagnosis w CC. 848................... Chemotherapy w/o acute

846

1 0.6513

22.7

18.9 leukemia as secondary diagnosis w/o CC/MCC \2\. 849................... Radiotherapy...........

849

141 0.8756

23.5

19.6 853................... Infectious & parasitic

853

698 1.7901

38.1

31.8 diseases w O.R. procedure w MCC. 854................... Infectious & parasitic

853

94 1.1472

31.0

25.8 diseases w O.R. procedure w CC. 855................... Infectious & parasitic

853

3 0.8072

24.6

20.5 diseases w O.R. procedure w/o CC/MCC \3\. 856................... Postoperative or post-

856

338 1.5473

36.2

30.2 traumatic infections w O.R. proc w MCC. 857................... Postoperative or post-

856

230 1.0438

31.6

26.3 traumatic infections w O.R. proc w CC. 858................... Postoperative or post-

856

30 0.8873

27.9

23.3 traumatic infections w O.R. proc w/o CC/MCC. 862................... Postoperative & post-

862

1,172 0.9120

25.1

20.9 traumatic infections w MCC. 863................... Postoperative & post-

862

1,298 0.6802

23.4

19.5 traumatic infections w/ o MCC. 864................... Fever of unknown origin

864

16 0.6513

22.7

18.9 \2\. 865................... Viral illness w MCC....

865

56 0.8213

21.8

18.2 866................... Viral illness w/o MCC..

865

33 0.5498

21.2

17.7 867................... Other infectious &

867

293 1.1329

23.6

19.7 parasitic diseases diagnoses w MCC. 868................... Other infectious &

867

80 0.7220

22.0

18.3 parasitic diseases diagnoses w CC. 869................... Other infectious &

867

11 0.4800

19.9

16.6 parasitic diseases diagnoses w/o CC/MCC \1\. 870................... Septicemia w MV 96+

870

585 1.9084

30.4

25.3 hours. 871................... Septicemia w/o MV 96+

871

3,871 0.8437

23.5

19.6 hours w MCC. 872................... Septicemia w/o MV 96+

871

1,532 0.6551

21.8

18.2 hours w/o MCC. 876................... O.R. procedure w

876

5 0.4800

19.9

16.6 principal diagnoses of mental illness \1\. 880................... Acute adjustment

880

21 1.0950

30.3

25.3 reaction & psychosocial dysfunction \4\. 881................... Depressive neuroses \1\

881

15 0.4800

19.9

16.6 882................... Neuroses except

882

16 0.4800

19.9

16.6 depressive \1\. 883................... Disorders of

883

15 0.4800

19.9

16.6 personality & impulse control \1\. 884................... Organic disturbances &

884

201 0.4785

23.2

19.3 mental retardation. 885................... Psychoses..............

885

1,386 0.4066

23.7

19.8 886................... Behavioral &

886

18 0.4800

19.9

16.6 developmental disorders \1\. 887................... Other mental disorder

887

0 0.4800

19.9

16.6 diagnoses \8\. 894................... Alcohol/drug abuse or

894

1 0.4800

19.9

16.6 dependence, left ama \1\. 895................... Alcohol/drug abuse or

895

1 0.4800

19.9

16.6 dependence w rehabilitation therapy \1\. 896................... Alcohol/drug abuse or

896

10 0.8072

24.6

20.5 dependence w/o rehabilitation therapy w MCC \3\. 897................... Alcohol/drug abuse or

896

24 0.6513

22.7

18.9 dependence w/o rehabilitation therapy w/o MCC \2\. 901................... Wound debridements for

901

222 1.4003

35.2

29.3 injuries w MCC. 902................... Wound debridements for

901

159 1.0434

33.4

27.8 injuries w CC. 903................... Wound debridements for

901

23 0.6513

22.7

18.9 injuries w/o CC/MCC \2\. 904................... Skin grafts for

904

87 1.3377

40.7

33.9 injuries w CC/MCC. 905................... Skin grafts for

904

8 0.6513

22.7

18.9 injuries w/o CC/MCC \2\.

[[Page 25113]]

906................... Hand procedures for

906

1 0.4800

19.9

16.6 injuries \1\. 907................... Other O.R. procedures

907

85 1.7294

36.8

30.7 for injuries w MCC. 908................... Other O.R. procedures

907

44 1.1963

34.2

28.5 for injuries w CC. 909................... Other O.R. procedures

907

7 1.0950

30.3

25.3 for injuries w/o CC/ MCC \4\. 913................... Traumatic injury w MCC.

913

50 0.9333

26.8

22.3 914................... Traumatic injury w/o

913

70 0.5330

21.3

17.8 MCC. 915................... Allergic reactions w

915

0 0.4800

19.9

16.6 MCC \9\. 916................... Allergic reactions w/o

915

1 0.4800

19.9

16.6 MCC \1\. 917................... Poisoning & toxic

917

7 0.6513

22.7

18.9 effects of drugs w MCC \2\. 918................... Poisoning & toxic

917

6 0.6513

22.7

18.9 effects of drugs w/o MCC \2\. 919................... Complications of

919

1,066 1.0291

26.2

21.8 treatment w MCC. 920................... Complications of

919

811 0.7703

24.6

20.5 treatment w CC. 921................... Complications of

919

113 0.6374

22.6

18.8 treatment w/o CC/MCC. 922................... Other injury, poisoning

922

5 0.4800

19.9

16.6 & toxic effect diag w MCC \1\. 923................... Other injury, poisoning

922

9 0.4800

19.9

16.6 & toxic effect diag w/ o MCC \1\. 927................... Extensive burns or full

927

0 1.0950

30.3

25.3 thickness burns w MV 96+ hrs w skin graft \8\. 928................... Full thickness burn w

928

10 1.0950

30.3

25.3 skin graft or inhal inj w CC/MCC \4\. 929................... Full thickness burn w

928

1 0.6513

22.7

18.9 skin graft or inhal inj w/o CC/MCC \2\. 933................... Extensive burns or full

933

7 1.0950

30.3

25.3 thickness burns w MV 96+ hrs w/o skin graft \4\. 934................... Full thickness burn w/o

934

48 0.6866

24.2

20.2 skin grft or inhal inj. 935................... Non-extensive burns....

935

40 0.7294

24.9

20.8 939................... O.R. proc w diagnoses

939

378 1.2925

33.8

28.2 of other contact w health services w MCC. 940................... O.R. proc w diagnoses

939

210 1.0280

33.9

28.3 of other contact w health services w CC. 941................... O.R. proc w diagnoses

939

38 0.7470

28.9

24.1 of other contact w health services w/o CC/ MCC. 945................... Rehabilitation w CC/MCC

945

2,173 0.5928

22.3

18.6 946................... Rehabilitation w/o CC/

945

527 0.4271

18.9

15.8 MCC. 947................... Signs & symptoms w MCC.

947

88 0.6459

22.8

19.0 948................... Signs & symptoms w/o

947

168 0.5300

23.5

19.6 MCC. 949................... Aftercare w CC/MCC.....

949

4,486 0.6728

22.1

18.4 950................... Aftercare w/o CC/MCC...

949

839 0.4847

18.5

15.4 951................... Other factors

951

38 1.2107

24.0

20.0 influencing health status. 955................... Craniotomy for multiple

955

0 1.6489

36.5

30.4 significant trauma \8\. 956................... Limb reattachment, hip

956

1 0.6513

22.7

18.9 & femur proc for multiple significant trauma \2\. 957................... Other O.R. procedures

957

3 1.6489

36.5

30.4 for multiple significant trauma w MCC \5\. 958................... Other O.R. procedures

957

1 1.0950

30.3

25.3 for multiple significant trauma w CC \4\. 959................... Other O.R. procedures

957

0 1.0950

30.3

25.3 for multiple significant trauma w/o CC/MCC \9\. 963................... Other multiple

963

12 0.8072

24.6

20.5 significant trauma w MCC \3\. 964................... Other multiple

963

9 0.6513

22.7

18.9 significant trauma w CC \2\. 965................... Other multiple

963

3 0.6513

22.7

18.9 significant trauma w/o CC/MCC \2\. 969................... HIV w extensive O.R.

969

7 1.6489

36.5

30.4 procedure w MCC \5\. 970................... HIV w extensive O.R.

969

3 1.6489

36.5

30.4 procedure w/o MCC \5\. 974................... HIV w major related

974

160 0.9279

21.8

18.2 condition w MCC. 975................... HIV w major related

974

70 0.6707

20.7

17.3 condition w CC. 976................... HIV w major related

974

43 0.6703

19.2

16.0 condition w/o CC/MCC. 977................... HIV w or w/o other

977

21 0.6513

22.7

18.9 related condition \2\. 981................... Extensive O.R.

981

1,065 2.2695

41.8

34.8 procedure unrelated to principal diagnosis w MCC. 982................... Extensive O.R.

981

279 1.4994

37.8

31.5 procedure unrelated to principal diagnosis w CC. 983................... Extensive O.R.

981

24 1.0950

30.3

25.3 procedure unrelated to principal diagnosis w/ o CC/MCC \4\. 984................... Prostatic O.R.

984

14 1.6489

36.5

30.4 procedure unrelated to principal diagnosis w MCC \5\. 985................... Prostatic O.R.

984

13 1.0950

30.3

25.3 procedure unrelated to principal diagnosis w CC \4\. 986................... Prostatic O.R.

984

1 1.0950

30.3

25.3 procedure unrelated to principal diagnosis w/ o CC/MCC \4\.

[[Page 25114]]

987................... Non-extensive O.R. proc

987

391 1.8112

37.9

31.6 unrelated to principal diagnosis w MCC. 988................... Non-extensive O.R. proc

987

182 1.0902

33.0

27.5 unrelated to principal diagnosis w CC. 989................... Non-extensive O.R. proc

987

21 0.8072

24.6

20.5 unrelated to principal diagnosis w/o CC/MCC \3\. 998................... Ungroupable \7\........

998

0 0.0000

0.0

0.0 999................... Principal diagnosis

999

0 0.0000

0.0

0.0 invalid as discharge diagnosis \7\.

\1\ Proposed relative weights for these proposed MS-LTC-DRGs were determined by assigning these cases to proposed low-volume quintile 1. \2\ Proposed relative weights for these proposed MS-LTC-DRGs were determined by assigning these cases to proposed low-volume quintile 2. \3\ Proposed relative weights for these proposed MS-LTC-DRGs were determined by assigning these cases to proposed low-volume quintile 3. \4\ Proposed relative weights for these proposed MS-LTC-DRGs were determined by assigning these cases to proposed low-volume quintile 4. \5\ Proposed relative weights for these proposed MS-LTC-DRGs were determined by assigning these cases to proposed low-volume quintile 5. \6\ Proposed relative weights for these proposed MS-LTC-DRGs were determined after adjusting to account for nonmonotonicity (see step 4 in section II.I.4. of the Addendum of this proposed rule). \7\ Proposed relative weights for these proposed MS-LTC-DRGs were assigned a proposed relative weight of 0.0000.

\8\ Proposed relative weights for these proposed MS-LTC-DRGs were determined by cross-walking these cases to the appropriate proposed MS-LTC-DRG and then assigning them to the appropriate proposed low volume quintile because they had no LTCH cases in the FY 2006 MedPAR file (see step 5 in section II.I.4 of the Addendum of this proposed rule). \9\ Proposed relative weights for these proposed MS-LTC-DRGs were determined by combining with its base MS-LTC- DRG because they had no LTCH cases in the FY 2006 MedPAR file (see step 5 in section II.I.4 of the Addendum of this proposed rule).

Appendix A--Regulatory Impact Analysis

I. Overall Impact

We have examined the impacts of this proposed rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review) and the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132.

Executive Order 12866 (as amended by Executive Order 13258, which merely reassigns responsibility of duties) directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year).

We have determined that this rule is a major rule as defined in 5 U.S.C. 804(2). We estimate that the proposed changes for FY 2008 operating and capital payments will redistribute in excess of $100 million among different types of inpatient cases. The market basket update to the IPPS rates required by the statute, in conjunction with other proposed payment changes in this proposed rule, would result in an approximate $3.3 billion increase in FY 2008 operating and capital payments. This amount does not reflect changes in hospital admissions or case-mix intensity in operating PPS payments, which would also affect overall payment changes.

The RFA requires agencies to analyze options for regulatory relief of small businesses. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and government agencies. Most hospitals and most other providers and suppliers are considered to be small entities, either by nonprofit status or by having revenues of $31 million in any 1 year. (For details on the latest standards for health care providers, we refer readers to the Small Business Administration Web site at: http://sba.gov/idc/groups/pubic/documents/sba_homepage/serv_sstd_tablepdf.pdf. ) For

purposes of the RFA, all hospitals and other providers and suppliers are considered to be small entities. Individuals and States are not included in the definition of a small entity. We believe that this proposed rule will have a significant impact on small entities as explained in this Appendix. Because we acknowledge that many of the affected entities are small entities, the analysis discussed throughout the preamble of this proposed rule constitutes our initial regulatory flexibility analysis. Therefore, we are soliciting comments on our estimates and analysis of the impact of the proposed rule on those small entities.

In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis for any proposed rule that may have a significant impact on the operations of a substantial number of small rural hospitals. This 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 previously defined 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). However, under the current labor market definitions, we no longer employ NECMAs to define urban areas in New England. Therefore, we now define a small rural hospital as a hospital that is located outside of an MSA and has fewer than 100 beds. Section 601(g) of the Social Security Amendments of 1983 (Pub. L. 98-21) designated hospitals in certain New England counties as belonging to the adjacent NECMA. Thus, for purposes of the IPPS, we continue to classify these hospitals as urban hospitals.

Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4) also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any 1 year of $100 million in 1995 dollars, updated annually for inflation. That threshold level is currently approximately $120 million. This proposed rule will not mandate any requirements for State, local, or tribal governments, nor will it affect private sector costs.

Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. As stated above, this proposed rule would not have a substantial effect on State and local governments.

The following analysis, in conjunction with the remainder of this document, demonstrates that this rule is consistent with the regulatory philosophy and principles identified in Executive Order 12866, the RFA, and section 1102(b) of the Act. The rule will affect payments to a substantial number of small rural hospitals, as well as other classes of hospitals, and the effects on some hospitals may be significant.

[[Page 25115]]

II. Objectives

The primary objective of the IPPS 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 preserving the Medicare Hospital Insurance Trust Fund.

We believe the proposed changes in this proposed rule would further each of these goals while maintaining the financial viability of the hospital industry and ensuring access to high quality health care for Medicare beneficiaries. We expect that these proposed changes would ensure that the outcomes of this payment system are reasonable and equitable while avoiding or minimizing unintended adverse consequences.

III. Limitations of Our Analysis

The following quantitative analysis presents the projected effects of our proposed policy changes, as well as statutory changes effective for FY 2008, on various hospital groups. We estimate the effects of individual proposed policy changes by estimating payments per case while holding all other payment policies constant. We use the best data available, but, generally, we do not attempt to predict behavioral responses to our proposed policy changes, and we do not make adjustments for future changes in such variables as admissions, lengths of stay, or case-mix. However, we believe that adoption of the MS-DRGs proposed in this proposed rule would create a risk of increased aggregate levels of payment as a result of more comprehensive documentation and coding. As explained earlier in this proposed rule, the Secretary has broad discretion under section 1886(d)(3)(A)(vi) of the Act to adjust the standardized amount so as to eliminate the effect of changes in coding or classification of discharges that do not reflect real changes in case-mix. Using this authority, the Medicare Actuary estimates that an adjustment of 4.8 percent over 2 years will be necessary to maintain budget neutrality for the transition to the MS-DRGs. We are proposing to reduce the IPPS standardized amounts by -2.4 percent each year for FY 2008 and FY 2009. The payment impacts shown below illustrate the impact of changes in hospital payment, including the proposed -2.4 percent adjustment to the IPPS standardized amounts both prior to and following the assumed growth in case-mix. As we have done in the previous rules, we are soliciting comments and information about the anticipated effects of these proposed changes on hospitals and our methodology for estimating them.

IV. Hospitals Included In and Excluded From the IPPS

The prospective payment systems for hospital inpatient operating and capital-related costs encompass nearly all general short-term, acute care hospitals that participate in the Medicare program. There were 35 Indian Health Service hospitals in our database, which we excluded from the analysis due to the special characteristics of the prospective payment methodology for these hospitals. Among other short-term, acute care hospitals, only the 45 such hospitals in Maryland remain excluded from the IPPS under the waiver at section 1814(b)(3) of the Act.

As of March 2007, there are 3,535 IPPS hospitals to be included in our analysis. This represents about 59 percent of all Medicare- participating hospitals. The majority of this impact analysis focuses on this set of hospitals. There are also approximately 1,283 CAHs. These small, limited service hospitals are paid on the basis of reasonable costs rather than under the IPPS. There are also 1,186 specialty hospitals and 2,315 specialty units that are excluded from the IPPS. These specialty hospitals include IPFs, IRFs, LTCHs, RNHCIs, children's hospitals, and cancer hospitals. Proposed changes in payments for IPFs and IRFs are made through other separate rulemaking. Payment impacts for these specialty hospitals and units, other than the reasonable cost updates for IPFs paid under a blend, are not included in this proposed rule. There is also a separate rule to update and propose changes to the LTCHs for its July 1 to June 30 rate year. However, we have traditionally used the IPPS rule to update the LTCH relative weights because the LTCH PPS uses the same DRGs as the IPPS, resulting in the LTCH relative weights being recalibrated according to the same schedule as the IPPS (that is, for each Federal fiscal year). The impacts of our proposed policy changes on LTCHs, where applicable, are discussed below.

V. Effects on Excluded Hospitals and Hospital Units

As of March 2007, there were 1,197 hospitals excluded from the IPPS. Of these 1,187 hospitals, 483 IPFs, 6 LTCHs, 81 children's hospitals, 11 cancer hospitals, and 16 RNHCIs are either being paid, on a reasonable cost basis or have a portion of the PPS payment based on a reasonable cost subject to the rate-of-increase ceiling under Sec. 413.40. The remaining providers, 216 IRFs and 371 LTCHs, are paid 100 percent of the Federal prospective rate under the IRF PPS and the LTCH PPS, respectively. As stated above, IRFs and IPFS are not affected by this proposed rule. The impacts of the changes to LTCHs are discussed separately below. In addition, there are 1,283 IPFs co-located in hospitals otherwise subject to IPPS, paid on a blend of the IPF PPS per diem payment and the reasonable cost- based payment and 996 IRFs (paid under the IRF PPS) co-located in hospitals otherwise subject to the IPPS. Under Sec. 413.40(a)(2)(i)(A), the rate-of-increase ceiling is not applicable to the 93 IPPS excluded hospitals and units in Maryland that are paid in accordance with the waiver at section 1814(b)(3) of the Act.

In the past, hospitals and units excluded from the IPPS have been paid based on their reasonable costs subject to limits as established by the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA). Hospitals that continue to be paid fully on a reasonable cost basis are subject to TEFRA limits for FY 2008. For these hospitals (cancer and children's hospitals), consistent with section 1886(b)(3)(B)(ii) of the Act, the proposed update will be the percentage increase in the FY 2008 IPPS operating market basket, currently estimated to be 3.3 percent. In addition, in accordance with Sec. 403.752(a) of the regulations, RNHCIs are paid under Sec. 413.40, which also uses section 1886(b)(3)(B)(ii) of the Act to update the percentage increase in the rate-of-increase limits. For RNHCIs, the update will be the percentage increase in the FY 2008 IPPS operating market basket increase, currently estimated to be 3.3 percent.

Effective for cost reporting periods beginning on or after October 1, 2002, LTCHs that elected to be paid based on 100 percent of the LTCH PPS rule are paid, based on a Federal prospective payment amount that is updated annually. Existing LTCHs would receive a PPS blended payment that consisted of the Federal prospective payment rate and a reasonable cost-based payment rate over a 5-year transition period, unless the LTCH elected to be paid at 100 percent of the Federal prospective rate at the beginning of any of its cost reporting periods during the 5-year transition period. In accordance with Sec. 412.533, for cost reporting periods beginning on or after October 1, 2006, the LTCH PPS transition blend percentages are 100 percent of the Federal prospective payment amount and zero percent of the PPS amount calculated under reasonable cost principles. FY 2007 was the fifth year of the 5-year transition period established under Sec. 412.533. Because the reasonable cost principles amount is zero percent for cost reporting periods beginning during FY 2008, LTCHs no longer receive a portion of their payment that is based in part on a reasonable cost subject to the rate-of-increase ceiling. Thus, there is no longer a need for an update factor for LTCHs' TEFRA target amount for FY 2008.

The final rule implementing the IPF PPS (69 FR 66922) established a 3-year transition to the IPF PPS during which some providers will receive a blend of the IPF PPS per diem payment and the TEFRA reasonable cost-based payment. For purposes of determining what the TEFRA payment to the IPF will be, we updated the IPF's TEFRA target amount by the excluded hospital market basket percentage increase of 3.4 percent.

The impact on excluded hospitals and hospital units of the proposed update in the rate-of-increase limit depends on the cumulative cost increases experienced by each excluded hospital or unit since its applicable base period. For excluded hospitals and units that have maintained their cost increases at a level below the rate-of-increase limits since their base period, the major effect is on the level of incentive payments these hospitals and hospital units receive. Conversely, for excluded hospitals and hospital units with per-case cost increases above the cumulative update in their rate-of-increase limits, the major effect is the amount of excess costs that will not be reimbursed.

We note that, under Sec. 413.40(d)(3), an excluded hospital or unit whose costs exceed 110 percent of its rate-of-increase limit receives its rate-of-increase limit plus 50 percent of the difference between its reasonable costs and 110 percent of the limit,

[[Page 25116]]

not to exceed 110 percent of its limit. In addition, under the various provisions set forth in Sec. 413.40, certain excluded hospitals and hospital units can obtain payment adjustments for justifiable increases in operating costs that exceed the limit.

VI. Quantitative Effects of the Proposed Policy Changes Under the IPPS for Operating Costs

A. Basis and Methodology of Estimates

In this proposed rule, we are announcing proposed policy changes and proposed payment rate updates for the IPPS for operating costs. Proposed changes to the capital payments are discussed in section VIII. of this Appendix.

Based on the overall percentage change in payments per case estimated using our payment simulation model, we estimate that proposed total FY 2008 operating payments would increase 3.3 percent compared to FY 2007 largely due to the statutorily mandated update to the IPPS rates. This amount reflects an adjustment of -2.4 percent to the IPPS standardized amounts to offset an anticipated increase in payments resulting from improved documentation and coding that does not represent real increases in underlying resource demands and patient acuity due to the proposed adoption of MS-DRGs. The impacts do not illustrate changes in hospital admissions or real case-mix intensity, which would also affect overall payment changes.

We have prepared separate impact analyses of the proposed changes to each system. This section deals with proposed changes to the operating prospective payment system. Our payment simulation model relies on the most recent available data to enable us to estimate the impacts on payments per case of certain changes in this proposed rule. However, there are other proposed changes for which we do not have data available that would allow us to estimate the payment impacts using this model. For those proposed changes, we have attempted to predict the payment impacts based upon our experience and other more limited data.

The data used in developing the quantitative analyses of proposed changes in payments per case presented below are taken from the FY 2006 MedPAR file and the most current Provider-Specific File that is used for payment purposes. Although the analyses of the changes to the operating PPS do not incorporate cost data, data from the most recently available hospital cost report were used to categorize hospitals. Our analysis has several qualifications. First, in this analysis, we do not make adjustments for future changes in such variables as admissions, lengths of stay, or underlying growth in real case-mix. Second, due to the interdependent nature of the IPPS payment components, it is very difficult to precisely quantify the impact associated with each proposed change. Third, we use 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. However, for individual hospitals, some miscategorizations are possible.

Using cases from the FY 2006 MedPAR file, we simulated payments under the operating IPPS given various combinations of payment parameters. Any short-term, acute care hospitals not paid under the IPPS (Indian Health Service hospitals and hospitals in Maryland) were excluded from the simulations. The impact of payments under the capital IPPS, or the impact of payments for costs other than inpatient operating costs, are not analyzed in this section. Estimated payment impacts of proposed FY 2008 changes to the capital IPPS are discussed in section VIII of this Appendix. The proposed changes discussed separately below are the following:

The effects of the proposed annual reclassification of diagnoses and procedures and the proposed recalibration of the DRG relative weights required by section 1886(d)(4)(C) of the Act.

The effects of the proposed changes in hospitals' wage index values reflecting wage data from hospitals' cost reporting periods beginning during FY 2004, compared to the FY 2003 wage data.

The effects of the proposed wage and recalibration budget neutrality factors.

The effects of the expiration of the labor market area transition for those hospitals that were urban under the old labor market area designations and are now considered rural hospitals.

The effects of the expiration of the 3-year provision for applying an imputed rural floor to States that have no rural areas and to States that have rural areas but no IPPS hospitals are located in those areas (69 FR 49109).

The effects of geographic reclassifications by the MGCRB that will be effective in FY 2008.

The effects of the proposed adjustment to the application of the rural floor budget neutrality provision on the wage index instead of on the standardized amount.

The effects of the September 30, 2007 expiration of section 508 of Pub. L. 108-173, which allowed qualifying hospitals to appeal the wage index classification otherwise and apply for reclassification to another area of the State in which the hospital is located (or, at the discretion of the Secretary, to an area within a contiguous State).

The effects of section 505 of Pub. L. 108-173, which provides for an increase in a hospital's wage index if the hospital qualifies by meeting a threshold percentage of residents of the county where the hospital is located who commute to work at hospitals in counties with higher wage indexes.

The effect of the budget neutrality adjustment being made for the adoption of the proposed MS-DRGs under section 1886(d)(3)(A)(iv) of the Act for the change in aggregate payments that is a result of changes in the coding or classification of discharges that do not reflect real changes in case-mix.

The total estimated change in payments based on proposed FY 2008 policies relative to payments based on FY 2007 policies.

To illustrate the impacts of the proposed FY 2008 changes, our analysis begins with a FY 2007 baseline simulation model using: the proposed FY 2008 update of 3.3 percent; the FY 2007 DRG GROUPER (Version 24.0); the most current CBSA designations for hospitals based on OMB's MSA definitions; the FY 2007 wage index; and no MGCRB reclassifications. Outlier payments are set at 5.1 percent of total operating DRG and outlier payments.

Section 1886(b)(3)(B)(viii) of the Act, as added by section 5001(a) of Pub. L. 109-171, provides that for FY 2007 and subsequent years, the update factor will be reduced by 2.0 percentage points for any hospital that does not submit quality data in a form and manner and at a time specified by the Secretary. At the time this impact was prepared, 147 providers did not receive the full market basket rate-of-increase for FY 2007 because they failed the quality data submission process. For purposes of the simulations shown below, we modeled the proposed payment changes for FY 2008 using a reduced update for these 147 hospitals. However, we do not have enough information to determine which hospitals will not receive the full market basket rate-of-increase for FY 2008 at this time.

Each proposed and statutory policy change is then added incrementally to this baseline, finally arriving at an FY 2008 model incorporating all of the proposed changes. This simulation allows us to isolate the effects of each proposed change.

Our final comparison illustrates the proposed percent change in payments per case from FY 2007 to FY 2008. Three factors not discussed separately have significant impacts here. The first is the update to the standardized amount. In accordance with section 1886(b)(3)(B)(i) of the Act, we are updating the standardized amounts for FY 2008 using the most recently forecasted hospital market basket increase for FY 2008 of 3.3 percent. (Hospitals that fail to comply with the quality data submission requirement to receive the full update will receive an update reduced by 2.0 percentage points to 1.3 percent.) Under section 1886(b)(3)(B)(iv) of the Act, the updates to the hospital-specific amounts for SCHs and for MDHs are also equal to the market basket increase, or 3.3 percent.

A second significant factor that affects the proposed changes in hospitals' payments per case from FY 2007 to FY 2008 is the change in a hospital's geographic reclassification status from one year to the next. That is, payments may be reduced for hospitals reclassified in FY 2007 that are no longer reclassified in FY 2008. Conversely, payments may increase for hospitals not reclassified in FY 2007 that are reclassified in FY 2008. Particularly with the expiration of section 508 of Pub. L. 108-173, the reclassification provision, these impacts can be quite substantial, so if a relatively small number of hospitals in a particular category lose their reclassification status, the percentage change 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 2007 will be 4.9 percent of total DRG payments. When the FY 2007 final rule was published, we projected FY 2007 outlier payments would be 5.1 percent

[[Page 25117]]

of total DRG plus outlier payments; the average standardized amounts were offset correspondingly. The effects of the lower than expected outlier payments during FY 2008 (as discussed in the Addendum to this proposed rule) are reflected in the analyses below comparing our current estimates of FY 2007 payments per case to estimated FY 2008 payments per case (with outlier payments projected to equal 5.1 percent of total DRG payments).

B. Analysis of Table I

Table I displays the results of our analysis of the proposed changes for FY 2008. 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 3,535 hospitals included in the analysis.

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; and rural. There are 2,540 hospitals located in urban areas included in our analysis. Among these, there are 1,409 hospitals located in large urban areas (populations over 1 million), and 1,131 hospitals in other urban areas (populations of 1 million or fewer). In addition, there are 995 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 2008 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 that the number of hospitals paid based on these categorizations after consideration of geographic reclassifications (including reclassifications under section 1886(d)(8)(B) and section 1886(d)(8)(E) of the Act that have implications for capital payments) are 2,619, 1,436, 1,183 and 916, respectively.

The next three groupings examine the impacts of the proposed changes on hospitals grouped by whether or not they have GME residency programs (teaching hospitals that receive an IME adjustment) or receive DSH payments, or some combination of these two adjustments. There are 2,479 nonteaching hospitals in our analysis, 816 teaching hospitals with fewer than 100 residents, and 240 teaching hospitals with 100 or more residents.

In the DSH categories, hospitals are grouped according to their DSH payment status, and whether they are considered urban or rural for DSH purposes. The next category groups together hospitals considered urban after geographic reclassification, in terms of whether they receive the IME adjustment, the DSH adjustment, both, or neither.

The next five rows examine the impacts of the proposed changes on rural hospitals by special payment groups (SCHs, RRCs, and MDHs), as well as rural hospitals not receiving a special payment designation. There were 59 RRCs, 45 SCHs, 21 MDHs, 17 hospitals that are both SCHs and RRCs, and 1 hospital that is both MDH and RRC.

The next series of groupings concern the geographic reclassification status of hospitals. The first grouping displays all urban hospitals that were reclassified by the MGCRB for FY 2008. The second grouping shows the MGCRB rural reclassifications.

The final two groupings are based on the type of ownership and the hospital's Medicare utilization expressed as a percent of total patient days. These data were taken from the FY 2004 Medicare cost reports. BILLING CODE 4120-01-P

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BILLING CODE 4120-01-C

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C. Effects of the Proposed Changes to the DRG Reclassifications and Relative Cost-Based Weights (Column 2)

In Column 2 of Table I, we present the combined effects of the proposed 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 annually to make appropriate classification changes in order to reflect changes in treatment patterns, technology, and any other factors that may change the relative use of hospital resources.

As discussed in the preamble of this proposed rule, we are proposing to continue the 3-year transition from charge-based to cost-based relative weights. The proposed relative weights for FY 2008 will be \2/3\ cost-based and \1/3\ charge-based. Further, we are proposing to adopt MS-DRGs that would increase the number of DRGs from 538 to 745. In column 2, we compare aggregate payments using the proposed FY 2008 MS-DRGS (GROUPER Version 25.0) and blended relative weights to the FY 2007 CMS DRG blended relative weights (GROUPER Version 24.0). The proposed methods of calculating the relative weights and the reclassification changes to the GROUPER are described in more detail in section II.H. of the preamble to this proposed rule. We note that, consistent with section 1886(d)(4)(C)(iii) of the Act, we are proposing to apply a budget neutrality factor to ensure that the overall payment impact of the proposed DRG changes (combined with the proposed wage index changes) is budget neutral. This proposed budget neutrality factor of 0.999317 is applied to payments in Column 4 and not Column 2 because it is a combined DRG reclassification and recalibration and wage index budget neutrality factor.

We estimate that proposed changes to the relative weights and DRGs will increase payments to hospitals located in large urban areas (populations over 1 million) by approximately 0.9 percent. These changes generally increase payments to hospitals in all urban areas (0.4 percent) and large teaching hospitals (0.7 percent). Rural hospitals will generally experience a decrease in payments from these changes (-1.8 percent). However, it is important to evaluate these changes together with the cost weights that we adopted in the FY 2007 IPPS final rule. We are adopting cost weights over a transition period from FY 2007 to FY 2009. The cost weights generally increased payments to rural hospitals. Column 2 shows the changes for the proposed rule only and therefore reflects the full payment impact of the MS-DRGs while showing only the FY 2008 portion of the transition to cost weights finalized in last year's rule. In FY 2007, we are paying hospitals using a blend of \1/3\ cost and \2/ 3\ charge relative weights. In FY 2008, we will pay hospitals using a blend of \2/3\ cost and \1/3\ charge relative weights. In FY 2009, we will pay hospitals using 100 percent cost relative weights. Therefore, there will likely be some additional increases in payments to rural hospitals from the final year of the transition to fully implemented cost weights that are not illustrated in the above table. Cardiac specialty hospitals would experience the greatest decline in payments (4.0 percent) from the proposed changes to adopt MS-DRGs and the blended relative cost weights.

D. Effects of Proposed Wage Index Changes (Column 3)

Section 1886(d)(3)(E) of the Act requires that, beginning October 1, 1993, we annually update the wage data used to calculate the wage index. In accordance with this requirement, the proposed wage index for FY 2008 is based on data submitted for hospital cost reporting periods beginning on or after October 1, 2003 and before October 1, 2004.

The estimated impact of the proposed wage data on hospital payments is isolated in Column 3 by holding the other payment parameters constant in this simulation. That is, Column 3 shows the percentage changes in payments when going from a model using the FY 2007 wage index, based on FY 2003 wage data and having a 100-percent occupational mix adjustment applied, to a model using the FY 2008 pre-reclassification wage index, adjusted for occupational mix, based on FY 2004 wage data. The wage data collected on the FY 2004 cost report include overhead costs for contract labor that were not collected on FY 2003 and earlier cost reports. The impacts below incorporate the effects of the FY 2004 wage data collected on hospital cost reports, including additional overhead costs for contract labor compared to the wage data from FY 2003 cost reports that were used to calculate the FY 2007 wage index.

Column 3 shows the impacts of updating the wage data using FY 2004 cost reports. Overall, the new wage data will lead to a -0.1 percent change for all hospitals. This decrease could be attributed to fluctuations in the wage data. Among the regions, the largest increase is in the rural Pacific region, which experiences a 0.5 percent increase. The largest decline from updating the wage data is seen in the Puerto Rico region (a 0.5 percent decrease).

In looking at the wage data itself, the national average hourly wage increased 4.3 percent compared to FY 2007. Therefore, the only manner in which to maintain or exceed the previous year's wage index was to match or exceed the national 4.3 percent increase in average hourly wage. Of the 3,486 hospitals with wage data for both FYs 2007 and 2008, 1,709, or 49.0 percent, experienced an average hourly wage increase of 4.3 percent or more.

The following chart compares the shifts in wage index values for hospitals for FY 2008 relative to FY 2007. Among urban hospitals, 52 will experience an increase of more than 5 percent and less than 10 percent and 6 will experience an increase of more than 10 percent. Among rural hospitals, 21 will experience an increase of more than 5 percent and less than 10 percent, and 4 will experience an increase of more than 10 percent. However, 965 rural hospitals will experience increases or decreases of less than 5 percent, while 2,384 urban hospitals will experience increases or decreases of less than 5 percent. Thirty-three urban hospitals will experience decreases in their wage index values of more than 5 percent and less than 10 percent. Twenty-one urban hospitals will experience decreases in their wage index values of greater than 10 percent. No rural hospitals will experience decreases of more than 5 percent.

The following chart shows the projected impact for urban and rural hospitals.

Number of hospitals

Percentage change in area wage index values

Urban Rural

Increase more than 10 percent.....................

4 Increase more than 5 percent and less than 10

21 percent.......................................... Increase or decrease less than 5 percent.......... 2,384

965 Decrease more than 5 percent and less than 10

0 percent.......................................... Decrease more than 10 percent.....................

E. Combined Effects of Proposed DRG and Wage Index Changes (Column 4)

Section 1886(d)(4)(C)(iii) of the Act requires that changes to DRG reclassifications and the relative weights cannot increase or decrease aggregate payments. In addition, section 1886(d)(3)(E) of the Act specifies that any updates or adjustments to the wage index are to be budget neutral. As noted in the Addendum to this proposed rule, in determining the budget neutrality factor, we equated simulated aggregate payments for FY 2007 and FY 2008 using the FY 2006 Medicare utilization data after applying the proposed changes to the DRG relative weights and the wage index.

We computed a wage and DRG recalibration budget neutrality factor of 0.999317. The 0.0 percent impact for all hospitals demonstrates that these proposed changes, in combination with the proposed budget neutrality factor, are budget neutral. In Table I, the combined overall impacts of the effects of both the proposed DRG reclassifications and the updated wage index are shown in Column 4. The estimated changes shown in this column reflect the combined effects of the proposed changes in Columns 2 and 3 and the budget neutrality factor for the revised FY 2008 wage index.

[[Page 25125]]

Due to the proposed changes to the application of the rural floor budget neutrality, this column does not include the wage index floor for urban areas as required by section 4410 of Pub. L. 105-33. The effects of that provision are included in Column 7. There also may be some variation of plus or minus 0.1 percentage point due to rounding.

F. Effects of the Expiration of the 3-Year Provision Allowing Urban Hospitals That Were Converted to Rural as a Result of the FY 2005 Labor Market Area Changes To Maintain the Wage Index of the Urban Labor Market Area in Which They Were Formerly Located (Column 5)

The policy adopted in FY 2005 for urban hospitals that became rural under the new labor market area definitions is to expire in FY 2008. In FY 2005, we adopted a policy that allowed urban hospitals that became rural under the new labor market area regions to maintain the wage index assignment of the MSA where they were located for the 3-year period FY 2005, FY 2006, and FY 2007. Beginning in FY 2008, these hospitals will receive their statewide rural wage index or their FY 2008 MGCRB reclassified wage index. Column 5 shows the impact of the expiration of the labor market area transition for those hospitals that were urban under the old labor market area designations and are now considered rural hospitals. Currently, the rural hospital row shows a 0.2 percent decrease from the end of the provision as these hold harmless hospitals are now considered geographically rural and are now receiving the wage index of the MSA where they are currently located.

G. Effects of MGCRB Reclassifications (Column 6)

Our impact analysis to this point has assumed hospitals are paid on the basis of their actual geographic location (with the exception of ongoing policies that provide that certain hospitals receive payments on other bases than where they are geographically located). The proposed changes in Column 6 reflect the per case payment impact of moving from this baseline to a simulation incorporating the MGCRB decisions for FY 2008 which affect hospitals' wage index area assignments.

By February 28 of each year, the MGCRB makes reclassification determinations that will be effective for the next fiscal year, which begins on October 1. The MGCRB may approve a hospital's reclassification request for the purpose of using another area's wage index value. The proposed FY 2008 wage index values incorporate all of the MGCRB's reclassification decisions for FY 2008. The wage index values also reflect any decisions made by the CMS Administrator through the appeals and review process through February 28, 2007.

The overall effect of geographic reclassification is required by section 1886(d)(8)(D) of the Act to be budget neutral. Therefore, we are proposing to apply an adjustment of 0.991938 to ensure that the effects of the section 1886(d)(10) reclassifications are budget neutral. (See section II.A. of the Addendum to this proposed rule.) Geographic reclassification generally benefits hospitals in rural areas. We estimate that geographic reclassification will increase payments to rural hospitals by an average of 1.7 percent.

H. Effects of the Adjustment to the Application of the Rural Floor (Column 7)

As discussed in section III.G. of the preamble of this proposed rule, section 4410 of Pub. L. 105-33 established the rural floor by requiring that the wage index for a hospital in any urban area cannot be less than the area wage index determined for the state's rural area. Since FY 1998, we have implemented this provision by adjusting the standardized amounts. In this proposed rule, we are proposing to change how we apply budget neutrality to the rural floor beginning in FY 2008. Rather than applying a budget neutrality adjustment to the standardized amount, a uniform budget neutrality adjustment would be applied to the wage index. Therefore, we are proposing to apply an adjustment to the wage index of 0.997084 (- 0.29 percent) to ensure that the rural floor adjustments are budget neutral as indicated by the zero effect on payments to hospitals overall.

Column 7 shows the projected impact of change in the application of the rural floor. The column compares the post-reclassification FY 2008 wage index of providers before the rural floor adjustment and the post-reclassification FY 2008 wage index of providers with the rural floor adjustment. Only urban hospitals can benefit from the rural floor provision. Because the provision is budget neutral, all other hospitals (that is, all rural hospitals and those urban hospitals to which the adjustment is not made) will experience a decrease in payments due to the budget neutrality adjustment. We project rural hospitals will experience a 0.1 percent decrease in payments. We project hospitals located in other urban areas (populations of 1 million or fewer) will experience a 0.1 percent increase in payments. The rural floor will benefit 77 percent of the hospitals in New Hampshire (10) and 45 percent of the hospitals in Connecticut (15), explaining the average increase of 1 percent shown in the table for hospitals located in New England. The average increase among hospitals in the Pacific region is estimated at 0.4 percent and is explained by application of the rural floor to 34 percent of the hospitals in California (114) and 18 percent of the hospitals in Washington (9).

I. Effects of the Expiration of the Imputed Rural Floor (Column 8)

The FY 2005 IPPS final rule (69 FR 49109) established a temporary imputed rural floor for all urban States from FY 2005 to FY 2007. The rural floor requires that an urban wage index cannot be lower than the wage index for any rural hospital in that State. Therefore, an imputed rural floor was established for States that do not have rural areas or rural IPPS hospitals. The provision will expire at the end of FY 2007 unless we were to adopt a change to the regulation to continue it for FY 2008.

Column 8 shows the effects of the expiration of the imputed rural floor. Only hospitals located in Massachusetts and New Jersey were affected by the provision. However, as explained in section III.G. of the preamble of this proposed rule, the imputed rural floor will no longer apply in Massachusetts even if it were to be continued because one hospital acquired rural status under Sec. 412.103 of the regulations. Urban providers in New England (MA) and the Mid-Atlantic region (NJ) will experience a decrease by 0.1 percent and by 0.2 percent respectively from the imputed rural floor no longer being applied in those States.

J. Effects of the Expiration of Section 508 of Pub. L. 108-173 (Column 9)

Section 508 of Pub. L. 108-173 will expire on September 30, 2007. As stated in the FY 2007 IPPS final rule (71 FR 48333), we established procedural rules under section 1886(d)(10)(D)(v) of the Act to address specific circumstances where individual and group reclassifications involve a section 508 hospital. In the final rule, the rules were designed to recognize the special circumstances of section 508 hospital reclassifications ending mid-year during FY 2007 and were intended to allow previously approved reclassifications to continue through March 31, 2007, and new section 1886(d)(10) reclassifications to begin April 1, 2007, upon the conclusion of the section 508 reclassifications. Under these procedural rules, some section 1886(d)(10) hospital reclassifications are only in effect for the second half of the fiscal year. However, Division B, Title I, section 106(a) of the MIEA-TRHCA (Pub. L. 109-432) extended any geographic reclassifications of hospitals that would expire on March 31, 2007, by 6 months until September 30, 2007. For FY 2008, the providers that had been reclassified under section 508 in FY 2007 will receive payment using the wage index for the area where they are currently located. The impact of the expiration of the policy is modeled in Column 9 of Table I. Section 508 of Pub. L. 108-173 was not a budget neutral provision of statute. Its enactment increased total payments for Medicare inpatient hospital services. Therefore, relative to FY 2007, the expiration of section 508 of Pub. L. 108-173 will reduce Medicare inpatient hospital payments by an estimated 0.1 percent.

K. Effects of the Proposed Wage Index Adjustment for Out-Migration (Column 10)

Section 1886(d)(13) of the Act, as added by section 505 of Pub. L. 108-173, provides for an increase in the wage index for hospitals located in certain counties that have a relatively high percentage of hospital employees who reside in the county, but work in a different area with a higher wage index. Hospitals located in counties that qualify for the payment adjustment are to receive an increase in the wage index that is equal to a weighted average of the difference between the wage index of the resident county, post- reclassification and the higher wage index work area(s), weighted by the overall percentage of workers who are employed in an area with a higher wage index. With the out-migration adjustment, rural providers will experience a 0.1 percent increase in payments in FY 2008 relative to

[[Page 25126]]

no adjustment at all. We included these additional payments to providers in the impact table shown above, and we estimate the impact of these providers receiving the out-migration increase to be approximately $15 million.

L. Effects of All Proposed Changes With CMI Adjustment Prior to Assumed Growth (Column 11)

Column 11 compares our estimate of payments per case between FY 2007 and FY 2008 with all proposed changes reflected in this proposed rule for FY 2008 including a 0.976 adjustment to the payment rates to account for anticipated improvements in documentation and coding that is expected to increase case-mix. We generally apply an adjustment to the DRGs to ensure budget neutrality assuming constant utilization. However, with the proposed adoption of the MS-DRGs, the number of DRGs will expand from 538 to 745. Therefore, we expect an increase in the CMI due to improved coding and have applied an additional adjustment to achieve budget neutrality. However, because we modeled the impact, including the adjustment for anticipated case-mix increase but not the actual case-mix increase itself in column 11, this column illustrates a total payment changes that is less than what is anticipated to occur.

M. Effects of All Proposed Changes With CMI Adjustment and Assumed Growth (Column 12)

Column 12 compares our estimate of payments per case between FY 2007 and FY 2008, incorporating all proposed changes reflected in this proposed rule for FY 2008 (including statutory changes). This column includes all of the proposed policy changes and assumes the 2.4 percent increase in case-mix from improved documentation and coding will occur equally across all hospitals.

Column 12 reflects the impact of all proposed FY 2008 changes relative to FY 2007, including those shown in Columns 2 through 10. The average increase for all hospitals is approximately 3.3 percent. This increase includes the effects of the proposed 3.3 percent market basket update. It also reflects the 0.2 percentage point difference between the projected outlier payments in FY 2008 (5.1 percent of total DRG payments) and the current estimate of the percentage of actual outlier payments in FY 2007 (4.9 percent), as described in the introduction to this Appendix and the Addendum to this proposed rule. As a result, payments are projected to be 0.2 percentage points lower in FY 2007 than originally estimated, resulting in a 0.2 percentage point greater increase for FY 2008 than would otherwise occur. In addition, the impact of expiration of section 508 of Pub. L. 108-173 reclassification accounts for a 0.1 percent decrease in estimated payments. As stated earlier, section 1886(d)(13) of the Act provides for an increase in the wage index for hospitals located in certain counties that have a relatively high percentage of hospital employees who reside in the county, but work in a different area with a higher wage index. This provision of the statute is not budget neutral. Although the out-migration adjustment will increase payments to some hospitals in FY 2008 relative to not having an adjustment at all, the total number of hospitals receiving the adjustment will be less in FY 2008 than FY 2007, resulting in a 0.1 percent reduction in total IPPS payments. There might also be interactive effects among the various factors comprising the payment system that we are not able to isolate. For these reasons, the values in Column 10 may not equal the product of the percentage changes described above.

The proposed overall change in payments per case for hospitals in FY 2008 is estimated to increase by 3.3 percent. Hospitals in urban areas would experience an estimated 3.6 percent increase in payments per case compared to FY 2007. Hospitals in large urban areas would experience an estimated 4.2 percent increase and hospitals in other urban areas would experience an estimated 2.8 percent increase in payments per case in FY 2008. Hospitals' payments per case in rural areas are estimated to increase 0.9 percent.

Among urban census divisions, the largest estimated payment increases would be 4.7 percent in the Pacific region and 4.2 percent in the South Atlantic region. The smallest urban increase is estimated at 2.6 percent in the New England region.

Among rural regions in Column 12, the providers in the West South Central region experience an estimated decrease in payments by 0.7 percent. The Pacific and South Atlantic regions would benefit the most, with 2.0 and 1.8 percent estimated increases, respectively.

Among special categories of rural hospitals in Column 12, the one MDH/RRC provider would experience an estimated decrease in payments of 0.8 percent and MDH providers would receive an estimated increase of 0.3 percent. RRCs would experience an estimated increase in payments by 2.5 percent.

Urban hospitals reclassified for FY 2008 are anticipated to receive an increase of 3.3 percent, while urban hospitals that not reclassified for FY 2008 are expected to receive an increase of 3.6 percent. Rural hospitals reclassifying for FY 2008 are anticipated to receive a 1.5 percent payment increase.

N. Effects of Proposed Policy on Payment Adjustments for Low-Volume Hospitals

For FY 2008, we are proposing to continue to apply the volume adjustment criteria we specified in the FY 2005 IPPS final rule (69 FR 49099). We expect that three providers would receive the low- volume adjustment for FY 2008. We included these additional payments to providers in the impact table shown above and we estimate the impact of these providers receiving the additional 25-percent payment increase to be approximately $50,000.

O. Impact Analysis of Table II

Table II presents the projected impact of the proposed changes for FY 2008 for urban and rural hospitals and for the different categories of hospitals shown in Table I. It compares the estimated payments per case for FY 2007 with the proposed average estimated per case payments for FY 2008, as calculated under our models. Thus, this table presents, in terms of the average dollar amounts paid per discharge, the combined effects of the proposed changes presented in Table I. The proposed percentage changes shown in the last column of Table II equal the percentage changes in average payments from Column 12 of Table I.

Table II.--Impact Analysis of Proposed Changes for FY 2008 Operating Prospective Payment System [Payments per case]

Average Average FY proposed FY All proposed Number of 2007 payment 2008 payment FY 2008 hospitals (1) per case \1\ per case \1\ changes (4) (2)

(3)

All hospitals...................................

3535

9004

9299

3.3 By Geographic Location:

Urban hospitals.............................

2540

9343

9678

3.6

Large urban areas (populations over 1

1409

9750

10156

4.2 million)...................................

Other urban areas (populations of 1 million

1131

8854

9103

2.8 or fewer)..................................

Rural hospitals.............................

995

7060

7123

0.9 Bed Size (Urban):

0-99 beds...................................

632

7236

7263

0.4

100-199 beds................................

849

7904

8170

3.4

200-299 beds................................

480

8815

9120

3.5

300-499 beds................................

412

9749

10136

4.0

500 or more beds............................

167

11762

12234

4.0

[[Continued on page 25129]]

From the Federal Register Online via GPO Access [wais.access.gpo.gov] ]

[[pp. 25129-25135]] Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates

[[Continued from page 25128]]

[[Page 25127]]

Bed Size (Rural):

0-49 beds...................................

342

6161

6065

-1.6

50-99 beds..................................

369

6558

6588

0.5

100-149 beds................................

172

6867

6960

1.3

150-199 beds................................

7626

7735

1.4

200 or more beds............................

8759

8938

2.0 Urban by Region:

New England.................................

126

9748

10001

2.6

Middle Atlantic.............................

350

10243

10529

2.8

South Atlantic..............................

388

8801

9175

4.2

East North Central..........................

395

8890

9197

3.4

East South Central..........................

166

8512

8784

3.2

West North Central..........................

156

9064

9321

2.8

West South Central..........................

358

8819

9174

4.0

Mountain....................................

153

9507

9826

3.3

Pacific.....................................

395

11136

11657

4.7

Puerto Rico.................................

4368

4525

3.6 Rural by Region:

New England.................................

9675

9714

0.4

Middle Atlantic.............................

7466

7525

0.8

South Atlantic..............................

173

6579

6700

1.8

East North Central..........................

124

7521

7574

0.7

East South Central..........................

177

6400

6479

1.2

West North Central..........................

115

7743

7792

0.6

West South Central..........................

194

6381

6339

-0.7

Mountain....................................

7766

7834

0.9

Pacific.....................................

8725

8896

2.0 By Payment Classification:

Urban hospitals.............................

2619

9298

9629

3.6

Large urban areas (populations over 1

1436

9725

10127

4.1 million)...................................

Other urban areas (populations of 1 million

1183

8789

9034

2.8 or fewer)..................................

Rural areas.................................

916

7175

7242

0.9 Teaching Status:

Non-teaching................................

2479

7648

7851

2.7

Fewer than 100 Residents....................

816

9067

9384

3.5

100 or more Residents.......................

240

13006

13533

4.1 Urban DSH:

Non-DSH.....................................

879

8146

8307

2.0

100 or more beds............................

1527

9792

10182

4.0

Less than 100 beds..........................

359

6574

6697

1.9 Rural DSH:

SCH.........................................

391

6992

7013

0.3

RRC.........................................

189

7686

7818

1.7

100 or more beds............................

5902

6028

2.1

Less than 100 beds..........................

154

5333

5353

0.4 Urban teaching and DSH:

Both teaching and DSH.......................

805

10750

11185

4.0

Teaching and no DSH.........................

192

8861

9078

2.5

No teaching and DSH.........................

1081

7990

8283

3.7

No teaching and no DSH......................

541

7664

7812

1.9 Rural Hospital Types:

RRC.........................................

8155

8358

2.5

SCH.........................................

9225

9301

0.8

MDH.........................................

6321

6339

0.3

SCH and RRC.................................

9968

10239

2.7

MDH and RRC.................................

9755

9674

-0.8 Type of Ownership:

Voluntary...................................

2069

9136

9424

3.2

Proprietary.................................

823

8173

8478

3.7

Government..................................

598

9270

9593

3.5 Medicare Utilization as a Percent of Inpatient Days:

0-25........................................

230

12731

13443

5.6

25-50.......................................

1292

10160

10570

4.0

50-65.......................................

1453

7913

8116

2.6

Over 65.....................................

441

7240

7331

1.2

[[Page 25128]]

Hospitals Reclassified by the Medicare Geographic Classification Review Board: FY 2008 Reclassifications:

All Reclassified Hospitals FY 2008..........

801

8695

8938

2.8

All Non-Reclassified Hospitals FY 2008......

2734

9106

9417

3.4

Urban Reclassified Hospitals FY 2008........

434

9273

9581

3.3

Urban Non-reclassified Hospitals FY 2008....

2105

9359

9701

3.6

Rural Reclassified Hospitals FY 2008........

367

7555

7669

1.5

Rural Nonreclassified Hospitals FY 2008.....

568

6411

6392

-0.3

All Section 401 Reclassified Hospitals......

8647

8799

1.8

Other Reclassified Hospitals (Section

6635

6729

1.4 1886(d)(8)(B)).............................

Former Section 508 Hospitals................

107

9766

9814

0.5 Specialty Hospitals:

Cardiac Specialty Hospitals.................

10736

10676

-0.6

\1\ These payment amounts per case do not reflect any estimates of annual case-mix increase.

VII. Effects of Other Proposed Policy Changes

In addition to those proposed policy changes discussed above that we are able to model using our IPPS payment simulation model, we are proposing to make various other changes in this proposed rule. Generally, we have limited or no specific data available with which to estimate the impacts of these proposed changes. Our estimates of the likely impacts associated with these other proposed changes are discussed below.

A. Effects of Proposed Policy on Hospital-Acquired Conditions, Including Infections

In section II.F. of the preamble of this proposed rule, we discuss our proposal to implement section 5001(c) of Pub. L. 109- 171, which requires the Secretary to identify, by October 1, 2007, at least two conditions that are (a) high cost or high volume or both, (2) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through application of evidence-based guidelines. For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case will be paid as though the secondary diagnosis was not present. However, the statute also requires the Secretary to continue counting the condition as a secondary diagnosis that results in a higher IPPS payment when doing the budget neutrality calculations for DRG reclassifications and recalibration. Therefore, we do our budget neutrality calculations as though the payment provision did not apply but Medicare will make a lower payment to the hospital for the specific case that includes the secondary diagnosis. Thus, the provision will result in cost savings to the Medicare program.

Although we believe there will be modest savings to the Medicare program from implementation of this provision, we cannot estimate them at this time. To estimate savings associated with this provision, we would need to know the frequency that the selected conditions are not present on admission in the Medicare population. Medicare will not begin collecting this information from hospitals until October 1, 2007. Therefore, there is currently no data upon which to estimate the savings of this provision. The provision does not go into effect until October 1, 2008. For this reason, there will be no savings for FY 2008. Any savings associated with this provision will not be realized until FY 2009. Based on the data available to us for next year's IPPS rule, we will estimate the savings associated with the conditions we selected under this provision for FY 2009 and subsequent years.

We further note that the provision will only apply when the selected conditions are the only secondary diagnosis present on the claim that will lead to higher payment. Therefore, if a nonselected secondary diagnosis that leads to the same higher payment is on the claim, the case will continue to be assigned to the higher paying DRG and there will be no savings to Medicare from the case. Our analysis of the Medicare claims suggests that patients will generally have multiple secondary diagnoses during a hospital stay. Patients having one MCC or CC will frequently have additional conditions that also lead to higher payment. In only a small percentage of the cases did we find that a patient had only one secondary diagnosis that would lead to higher payment, and in these cases, we have no information to suggest whether the condition was acquired after admission. Therefore, we believe the savings associated with this provision are likely to be very modest. Again, once we have data on the frequency of occurrence of the selected conditions after admission, we will refine our analysis.

B. Effects of Proposed MS-LTC-DRG Reclassifications and Relative Weights for LTCHs

In section II.I. of the preamble to this final rule, we discuss the proposed changes to adopt MS-LTC-DRG relative weights for FY 2008, which are based on the Version 25.0 of the CMS GROUPER (including the changes in the classifications, relative weights, and geometric mean length of stay for each proposed MS-LTC-DRG). We noted in the same section that, in the FY 2008 LTCH PPS proposed rule (72 FR 4784 through 4786), we proposed that, beginning with the MS-LTC-DRG update for FY 2008, the annual update to the proposed MS- LTC-DRG classifications and relative weights would be done in a budget neutral manner, such that estimated aggregate LTCH PPS payments would be unaffected; that is, they would be neither greater than nor less than the estimated aggregate LTCH PPS payments that would have been made without the proposed MS-LTC-DRG classification and relative weight changes. However, if the budget neutrality policy had not been proposed, we are estimating that, under the current payment policies (RY 2007), using the most recent available claims data (FY 2006 MedPAR files) for the 376 LTCHs in our database, the proposed changes to the MS-LTC-DRG classifications and relative weights for FY 2008 would have resulted in an aggregate decrease in LTCH PPS payments of approximately 1.6 percent. In applying the budget neutrality adjustment described above, we assumed constant utilization. However, with the proposed adoption of the MS-LTC-DRGs, we expect an increase in coding or classification of discharges that do not reflect real change in case-mix due to the adoption of the new patient classification system. Therefore, we have applied an additional adjustment of 0.976 to the proposed MS- LTC-DRG relative weights for the anticipated increase in case-mix due to improved documentation and coding.

[[Page 25129]]

C. Effects of Proposed New Technology Add-On Payments

In section II.I. of the preamble to this proposed rule, we discuss proposed add-on payments for new medical services and technologies. As explained in that section, we are not required to ensure that any add-on payments for new technology under section 1886(d)(5)(K) of the Act are budget neutral. As discussed earlier in this proposed rule, we have yet to determine whether Wingspan[supreg] meets the criteria for new technology add-on payments for FY 2008. Therefore, it is premature to estimate the potential payment impact in FY 2008 of any potential decision to make new technology add-on payments for Wingspan[supreg]. In addition, for FY 2008, we have proposed to discontinue new technology add-on payments for GORE TAG, Restore[supreg], and X STOP. In the FY 2007 IPPS final rule (71 FR 48344), we estimated that FY 2007 IPPS new technology add-on payments would be $16.61 million, $6.01 million, and $9.35 million, respectively, for these technologies. We have no additional information to further refine these estimates. Therefore, we estimate that Medicare's new technology add-on payments will decline by approximately $32 million (the sum of our estimates for FY 2007) in FY 2008 compared to FY 2007.

D. Effects of Requirements for Hospital Reporting of Quality Data for Annual Hospital Payment Update

In section IV.A. of the preamble of this proposed rule, we discuss the requirements for hospitals to report quality data in order for hospitals to receive the full annual hospital payment update for FY 2008 and FY 2009. We also note that, for the FY 2008 payment update, hospitals must pass our validation requirement of a minimum of 80 percent reliability, based upon our chart-audit validation process, for the first three quarters of data from CY 2006. These data were due to the QIO Clinical Warehouse by August 15, 2006 (first quarter CY 2006 discharges), November 15, 2006 (second quarter CY 2006 discharges), and February 15, 2007 (third quarter CY 2006 discharges). We have continued our efforts to ensure that QIOs provide assistance to all hospitals that wish to submit data. In the preamble of this proposed rule, we are providing additional validation criteria to ensure that the quality data being sent to CMS are accurate. The requirement of 5 charts per hospital will result in approximately 21,500 charts per quarter total submitted to the agency. We reimburse hospitals for the cost of sending charts to the Clinical Data Abstraction Center (CDAC) at the rate of 12 cents per page for copying and approximately $4.00 per chart for postage. Our experience shows that the average chart received at the CDAC is approximately 150 pages. Thus, the agency will have expenditures of approximately $473,200 per quarter to collect the charts. Given that we reimburse for the data collection effort, we believe that a requirement for five charts per hospital per quarter represents a minimal burden to the participating hospital.

E. Effects of Proposed Policy on Cancellation of Classification of Acquired Rural Status and Rural Referral Centers

In section IV.C.2. of the preamble of this proposed rule, we are proposing to revise our regulations to change the effective date of cancellation of acquired rural status for rural referral centers from ``the hospital's next full cost reporting period following the date of its request for cancellation'' to the next cost reporting period for hospitals paid on the basis of reasonable costs (such as CAHs) and for hospitals under the IPPS, after at least one 12-month cost reporting period as rural and not until the beginning of the Federal fiscal year following the date of its request for cancellation. Currently, there are about 100 IPPS hospitals that have acquired rural status. During this fiscal year (FY 2007), we have only received requests for cancellations from five hospitals. However, this number may increase if the current policy is not changed. We anticipate that the proposed policy change would, at a minimum, affect these five hospitals. However, we estimate that the proposed policy change would not have a significant impact on IPPS hospitals.

F. Effects of Proposed Policy on Payment for IME and Direct GME

In section IV.D.3. of the preamble of this proposed rule, we discuss our proposed changes related to whether vacation and sick leave as well as orientation should be included in the FTE count for IME and direct GME payment purposes. We are proposing, for cost reporting periods beginning on or after October, 1, 2007, for direct GME and IME, that time spent by residents on vacation or sick leave be removed from the total time considered to constitute an FTE resident. In addition, we are proposing to continue our existing policy to count time spent by residents in orientation activities for both IME and direct GME payment purposes. Because we are proposing to remove vacation and sick leave from the total time considered to constitute an FTE resident, we believe the impact of this change would be negligible. In addition, there is no impact from the clarification of the policy for orientation time since it is not a change in policy.

G. Effects of Proposed Policy Changes Relating to Emergency Services Under EMTALA During an Emergency Period

In section IV.F. of the preamble of this proposed rule, we are proposing to amend the EMTALA regulations regarding EMTALA implementation in emergency areas during an emergency period. Section 1135 of the Act authorizes the Secretary to temporarily waive or modify the application of several requirements and their implementing regulations as they relate to actions taken in an emergency area during an emergency period. The EMTALA regulations (Sec. 489.24(a)(2)) now specify that sanctions for inappropriate transfer during a national emergency do not apply to a hospital with a dedicated emergency department located in an emergency area.

To make our regulations better reflect the scope of the authority under section 1135 of the Act, we are proposing to revise them to clarify that such waivers also may apply to sanctions for the redirection or relocation of an individual to an alternate location to receive a medical screening examination where that direction or relocation occurs pursuant to a State emergency preparedness plan. We also are proposing to revise the regulations to incorporate changes made by the Pandemic and All-Hazards Preparedness Act. That legislation amended section 1135 of the Act to state that, in the case of a public health emergency that involves a pandemic infectious disease, sanctions for the direction or relocation of an individual to an alternative location for screening may be waived based on either a State emergency preparedness plan or a State pandemic preparedness plan, whichever applies in the State. In addition, section 1135 of the Act was amended to create an exception to the otherwise applicable 72-hour limitation on the duration of waivers or modifications of sanctions for EMTALA violations in cases where a public health emergency involves a pandemic infectious disease (such as pandemic influenza).

As described more fully earlier in this preamble, these changes are not discretionary and do not impose any substantive new requirements. On the contrary, they merely update our regulations to make them consistent with current statutory requirements. Because of this, we are estimating no impact on Medicare expenditures and no significant impact on hospitals with emergency departments.

H. Effects of Proposed Policy on Disclosure of Physician Ownership in Hospitals and Patient Safety Measures

In section IV.G. of the preamble of this proposed rule, we discuss our proposals to adopt a requirement relating to disclosure of physician ownership in hospitals and to increase patient safety measures. In the strategic and implementing plan included in our ``Final Report to the Congress and Strategic and Implementing Plan'' required under section 5006 of the Deficit Reduction Act of 2005, we stated that we would adopt a disclosure requirement that would require hospitals to disclose to patients whether they are physician-owned and, if so, the names of the physician-owners. In addition, we recognize that patients should be made aware of whether or not a physician is present in the hospital at all times, and the hospital's plans to address patients' emergency medical conditions when a physician is not present.

We believe this proposed rule would impose minimal additional costs on hospitals. We believe the cost of implementing these provisions borne by hospitals would be limited to a one-time cost associated with completing minor revisions to portions of the medical staff bylaws and policies and procedures related to patient admission and registration, as well as providing written notification to patients and affected staff. In addition, the proposed changes concerning disclosure of physician ownership in hospitals are consistent with current practices of members of the physician-owned specialty hospital associations. Therefore, we do not believe that these proposed changes will have any significant economic impact on hospitals.

[[Page 25130]]

I. Effects of Implementation of Rural Community Hospital Demonstration Program

In section IV.H. of the preamble to this proposed rule, we discuss our implementation of section 410A of Pub. L. 108-173 that required the Secretary to establish a demonstration that will modify reimbursement for inpatient services for up to 15 small rural hospitals. Section 410A(c)(2) requires that ``in conducting the demonstration program under this section, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration program under this section was not implemented.'' As discussed in section IV.H. of the preamble to this proposed rule, we are satisfying this requirement by adjusting national IPPS rates by a factor that is sufficient to account for the added costs of this demonstration. We estimate that the average additional annual payment for FY 2008 that would be made to each participating hospital under the demonstration would be approximately $1,075,765. We based this estimate on the recent historical experience of the difference between inpatient cost and payment for hospitals that are participating in the demonstration. For the 9 participating hospitals, the total annual impact of the demonstration program is estimated to be $9,681,893. The proposed adjustment factor to the Federal rate used in calculating Medicare inpatient prospective payments as a result of the demonstration is 0.999899.

J. Effects of Proposed Policy on Services Furnished to Beneficiaries in Custody of Penal Authorities

In section VII. of the preamble of this proposed rule, we discuss our proposal to revise our regulations relating to the special conditions under which Medicare payment may be made for services furnished to individuals in custody of penal authorities. We are proposing to indicate that, for purposes of Medicare payment, individuals who are in custody include, but are not limited to, individuals who are under arrest, incarcerated, imprisoned, escaped from confinement, under supervised release, required to reside in mental health facilities, required to reside in halfway houses, required to live under home detention, or confined completely or partially in any way under a penal statute or rule. This proposed definition is in accordance with how custody has been defined by Federal courts for purposes of the habeas corpus protections of the Constitution and is consistent with current CMS policy. We anticipate that this proposed change would have no measurable impact on Medicare expenditures.

VIII. Impact of Proposed Changes in the Capital IPPS

A. General Considerations

Fiscal year (FY) 2001 was the last year of the 10-year transition period established to phase in the PPS for hospital capital-related costs. During the transition period, hospitals were paid under one of two payment methodologies: fully prospective or hold harmless. Under the fully prospective methodology, hospitals were paid a blend of the capital Federal rate and their hospital- specific rate (see Sec. 412.340). Under the hold-harmless methodology, unless a hospital elected payment based on 100 percent of the capital Federal rate, hospitals were paid 85 percent of reasonable costs for old capital costs (100 percent for SCHs) plus an amount for new capital costs based on a proportion of the capital Federal rate (see Sec. 412.344). As we state in section V. of the preamble of this proposed rule, with the 10-year transition period ending with hospital cost reporting periods beginning on or after October 1, 2001 (FY 2002), beginning in FY 2002 capital prospective payment system payments for most hospitals are based solely on the capital Federal rate. Therefore, we no longer include information on obligated capital costs or projections of old capital costs and new capital costs, which were factors needed to calculate payments during the transition period, for our impact analysis.

In accordance with Sec. 412.312, the basic methodology for determining a capital PPS payment includes a large urban add-on adjustment. However, as discussed above and in section V. of the preamble of this proposed rule, we are proposing to eliminate the large urban add-on adjustment to capital IPPS payments in FY 2008. The proposed basic methodology for calculating capital IPPS payments in FY 2008 would be: (Standard Federal Rate) x (DRG weight) x (GAF) x (COLA for hospitals located in Alaska and Hawaii) x (1 + Disproportionate Share Adjustment Factor + IME Adjustment Factor, if applicable).

In addition, hospitals may also receive outlier payments for those cases that qualify under the threshold established for each fiscal year.

The data used in developing the impact analysis presented below are taken from the December 2006 update of the FY 2006 MedPAR file and the December 2006 update of the Provider-Specific File that is used for payment purposes. Although the analyses of the proposed changes to the capital prospective payment system do not incorporate cost data, we used the December 2006 update of the most recently available hospital cost report data (FYs 2004 and 2005) to categorize hospitals. Our analysis has several qualifications. In general, we do not make adjustments for behavioral changes that hospitals may adopt in response to proposed policy changes. However, as discussed in section III. of the Addendum to this proposed rule, we proposed that the capital rates would be adjusted to account for upcoding under the proposed MS-DRGs. Furthermore, due to the interdependent nature of the IPPS, it is very difficult to precisely quantify the impact associated with each proposed change. In addition, we draw upon various sources for the data used to categorize hospitals in the tables. In some cases (for instance, 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 sources overall. However, for individual hospitals, some miscategorizations are possible.

Using cases from the December 2006 update of the FY 2006 MedPAR file, we simulated payments under the capital PPS for FY 2007 and FY 2008 for a comparison of total payments per case. Any short-term, acute care hospitals not paid under the general IPPS (Indian Health Service hospitals and hospitals in Maryland) are excluded from the simulations.

As we explain in section III.A. of the Addendum to this proposed rule, payments are no longer made under the regular exceptions provision under Sec. Sec. 412.348(b) through (e). Therefore, we no longer use the actuarial capital cost model (described in Appendix B of the August 1, 2001 proposed rule (66 FR 40099)). We modeled payments for each hospital by multiplying the capital Federal rate by the GAF and the hospital's case-mix. We then added estimated payments for indirect medical education, disproportionate share, large urban add-on, and outliers, if applicable. (We note that, consistent with our proposal to eliminate the large urban add-on beginning in FY 2008, such estimated payments under this policy are only reflected in the payments we modeled for FY 2007 and were not included in the payments we modeled for FY 2008.) For purposes of this impact analysis, the model includes the following assumptions:

We estimate that the Medicare case-mix index will increase by 1.0 percent in both FYs 2007 and 2008. (We note that this does not reflect the proposed adjustment to the capital rates to account for assumed growth in case mix due to improvement in documentation and coding (upcoding) under the proposed MS-DRGs, as discussed in section III. of the Addendum of this proposed rule.)

We estimate that the Medicare discharges will be 12.925 million in FY 2007 and 12.995 million in FY 2008 for an estimated 0.54 percent increase from FY 2007 to FY 2008.

The capital Federal rate was updated beginning 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. As discussed in section V. of the preamble and section III.A. of the Addendum to this proposed rule, the proposed FY 2008 update for rural hospitals is 0.8 percent. We are proposing a 0.0 percent update for urban hospitals in FY 2008.

In addition to the proposed FY 2008 update factors, the proposed FY 2008 capital Federal rate for both urban and rural hospitals was calculated based on a proposed GAF/DRG budget neutrality factor of 1.0018, a proposed outlier adjustment factor of 0.9484, and a proposed exceptions adjustment factor of 0.9997.

For FY 2008, as discussed in section V. of the preamble and section III.A. of the Addendum to this proposed rule, the proposed FY 2008 capital rates for all hospitals was further adjusted by a factor of 0.976 (or -2.4 percent) to maintain budget neutrality if the proposed MS-DRGs are implemented by eliminating the effect of changes in coding or classification of discharges that do not reflect real case mix changes.

[[Page 25131]]

B. Results

We used the actuarial model described above to estimate the potential impact of our proposed changes for FY 2008 on total capital payments per case, using a universe of 3,535 hospitals. As described above, the individual hospital payment parameters are taken from the best available data, including the December 2006 update of the FY 2006 MedPAR file, the December 2006 update to the Provider-Specific File, and the most recent cost report data from the December 2006 update of HCRIS. In Table III, we present a comparison of total payments per case for FY 2007 compared to proposed FY 2008 based on the proposed FY 2008 payment policies. Column 2 shows estimates of payments per case under our model for FY 2007. Column 3 shows estimates of payments per case under our model for FY 2008. Column 4 shows the total percentage change in payments from FY 2007 to FY 2008. The change represented in Column 4 includes the proposed 0.8 percent update to the capital Federal rate for rural hospitals and a 0.0 percent update for urban hospitals, a 1.0 percent increase in case-mix, changes in the adjustments to the capital Federal rate (for example, the effect of the hospital wage index on the GAF), reclassifications by the MGCRB, and the proposed additional 2.4 percent reduction to all of the rates to account for upcoding or changes in coding that do not reflect real changes in case-mix if the proposed MS-DRGs are implemented. The comparisons are provided by: (1) geographic location; (2) region; and (3) payment classification.

The simulation results show that, on average, capital payments per case can be expected to decrease 0.7 percent in FY 2008. In addition to the proposed 0.0 percent update for urban hospitals, this projected decrease in capital payments per case can be attributed to the proposed -2.4 percent adjustment to all hospitals to account for assumed growth in case mix due to improvements in documentation and coding prior to the assumed growth occurring if the proposed MS-DRGs are implemented. Although the proposed GAF/DRG factor is expected to increase payments slightly (0.18 percent) in FY 2008 as compared to FY 2007, the proposed outlier factor is expected to contribute to the estimated decrease in capital payments from FY 2007 to FY 2008 by 0.88 percent.

The results of our comparisons by geographic location and by region are consistent with the results we expected after proposing to eliminate the large urban add-on adjustment, and the proposed 0.0 percent update for urban hospitals. The geographic comparison shows that urban hospitals are expected to experience a 0.6 percent decrease in IPPS capital payments per case, while rural hospitals are expected to experience a 0.9 percent decrease in capital payments per case. This difference is mostly due to the proposed MS- DRGs. Specifically, based on existing hospital claims data, under the proposed MS-DRGs, the better recognition of severity of illness is expected to increase payments to urban hospitals that treat a more acutely ill mix of patients and improvement in the DRG system will increase their payments. Similarly, however, the improved recognition of severity of illness will decrease payments to rural hospitals because they are treating less severely ill patients. Therefore we project a lower increase in estimated payments for rural hospitals due to the proposed DRG changes as compared to urban hospitals. In addition to the effect of the proposed DRG changes, the capital impact is also somewhat affected by the proposed wage- index changes because the GAF values are derived from the proposed wage index. Another factor contributing to the decrease in payments for rural hospitals is the expiration of the 3-year hold harmless provision for urban hospitals that were converted to rural under the new CBSAs in FY 2005. The policy allowed urban hospitals under the old labor market area designations that became rural under the CBSAs to receive payment using the wage index of the MSA where they were previously classified as urban for 3 years: FY 2005 through FY 2007. Beginning in FY 2008, these rural hospitals will receive the wage index for the area that they are currently located in. As a result, rural hospitals will experience a decrease in payments because of the addition of these formerly urban hospitals.

More than half of all regions are estimated to experience a decrease in total capital payments per case from FY 2007 to FY 2008. These decreases vary by region and range from a -2.3 percent in the Middle Atlantic urban region to a -0.7 in the East South Central urban region. For most of the regions projected to experience a larger than average decrease in capital payments, the difference is mostly due to changes in the proposed GAF and the elimination of the large urban add-on adjustment. In the regions experiencing an increase in total capital payments per case, the range is from 0.7 in the Pacific rural region to a 0.1 percent increase in the South Atlantic rural region. For most of the regions projected to experience an increase in capital payments, it is mostly due to changes to adopt the proposed MS-DRGs. The change in payments per case for all hospitals is -0.7 percent.

By type of ownership, voluntary hospitals are estimated to experience a decrease of -1.0 percent in capital payments per case, while proprietary and government hospitals are estimated to experience 0.1 percent and 0.2 percent increases in payments, respectively. Government hospitals and proprietary hospitals are projected to have slight increases in capital payments mostly due to a smaller than average estimated decrease in payments due to proposed changes in the GAF and a slightly larger than average estimated increase in payments due to proposed changes to adopt MS- DRGs.

Section 1886(d)(10) of the Act established the MGCRB. Before FY 2005, hospitals could apply to the MGCRB for reclassification for purposes of the standardized amount, wage index, or both. Section 401(c) of Pub. L. 108-173 equalized the standardized amounts under the operating IPPS. Therefore, beginning in FY 2005, there is no longer reclassification for the purposes of the standardized amounts; however, hospitals still may apply for reclassification for purposes of the wage index for FY 2008. Reclassification for wage index purposes also affects the GAF because that factor is constructed from the hospital wage index.

To present the effects of the hospitals being reclassified for FY 2008, we show the average payments per case for reclassified hospitals for FY 2007. Rural nonreclassified hospitals are expected to have the largest decrease in payments (-2.0 percent), as compared to the -0.3 percent for rural reclassified hospitals for FY 2008. This difference is mostly due to proposed changes in the GAF and proposed changes to adopt MS-DRGs. Urban hospitals are expected to experience a decrease in payments of 0.9 percent and 0.6 percent, respectively, for reclassified and nonreclassified hospitals. This difference is mostly due to the proposed elimination of the large urban add-on.

Table III.--Comparison of Total Payments Per Case [FY 2007 payments compared to FY 2008 payments]

Average FY Average FY Number of 2007 payments/ 2008 payments/ Change hospitals

case

By Geographic Location:

All hospitals...............................

3,535

758

753

-0.7

Large urban areas (populations over 1

1,409

842

833

-1.1 million)...................................

Other urban areas (populations of 1 million

1,131

747

0.0 or fewer)..................................

Rural areas.................................

995

524

519

-0.9

Urban hospitals.............................

2,540

799

794

-0.6

0-99 beds...................................

632

628

618

-1.7

100-199 beds................................

849

683

677

-0.8

200-299 beds................................

480

754

748

-0.8

300-499 beds................................

412

828

824

-0.5

[[Page 25132]]

500 or more beds............................

167

1,002

999

-0.3

Rural hospitals.............................

995

524

519

-0.9

0-49 beds...................................

342

430

418

-2.8

50-99 beds..................................

369

480

473

-1.5

100-149 beds................................

172

523

521

-0.3

150-199 beds................................

576

573

-0.5

200 or more beds............................

657

656

-0.1 By Region:

Urban by Region.............................

2,540

799

794

-0.6

New England.................................

126

847

830

-2.1

Middle Atlantic.............................

350

875

855

-2.3

South Atlantic..............................

388

756

759

0.3

East North Central..........................

395

783

777

-0.8

East South Central..........................

166

723

718

-0.7

West North Central..........................

156

780

772

-1.0

West South Central..........................

358

749

750

0.2

Mountain....................................

153

797

799

0.2

Pacific.....................................

395

914

918

0.5

Puerto Rico.................................

348

344

-1.2

Rural by Region.............................

995

524

519

-0.9

New England.................................

694

683

-1.5

Middle Atlantic.............................

536

531

-0.8

South Atlantic..............................

173

508

0.1

East North Central..........................

124

557

548

-1.6

East South Central..........................

177

487

481

-1.2

West North Central..........................

115

556

550

-1.1

West South Central..........................

194

478

469

-2.0

Mountain....................................

522

524

0.4

Pacific.....................................

634

639

0.7 By Payment Classification:

All hospitals...............................

3,535

758

753

-0.7

Large urban areas (populations over 1

1,436

840

831

-1.1 million)...................................

Other urban areas (populations of 1 million

1,183

742

0.1 or fewer)..................................

Rural areas.................................

916

527

522

-1.0 Teaching Status:

Non-teaching................................

2,479

640

636

-0.6

Fewer than 100 Residents....................

816

770

764

-0.8

100 or more Residents.......................

240

1,096

1,090

-0.5 Urban DSH:

100 or more beds............................

1,527

823

820

-0.2

Less than 100 beds..........................

359

551

542

-1.7 Rural DSH:

Sole Community (SCH/EACH)...................

391

469

463

-1.3

Referral Center (RRC/EACH)..................

189

584

583

-0.2 Other Rural:

100 or more beds............................

479

478

-0.2

Less than 100 beds..........................

154

433

425

-1.8 Urban teaching and DSH:

Both teaching and DSH.......................

805

902

899

-0.4

Teaching and no DSH.........................

192

807

788

-2.3

No teaching and DSH.........................

1,081

672

-0.1

No teaching and no DSH......................

541

704

694

-1.4 Rural Hospital Types:

Non special status hospitals................

2,477

801

796

-0.6

RRC/EACH....................................

693

692

-0.2

SCH/EACH....................................

633

623

-1.5

Medicare-dependent hospitals (MDH)..........

450

433

-3.7

SCH, RRC and EACH...........................

741

740

0.0 Hospitals Reclassified by the Medicare Geographic Classification Review Board: FY2008 Reclassifications:

All Urban Reclassified......................

434

793

786

-0.9

All Urban Non-Reclassified..................

2,105

800

796

-0.6

All Rural Reclassified......................

367

570

568

-0.3

All Rural Non-Reclassified..................

568

459

450

-2.0

Other Reclassified Hospitals (Section

511

501

-2.1 1886(d)(8)(B))............................. Type of Ownership:

Voluntary...................................

2,069

776

768

-1.0

Proprietary.................................

823

689

690

0.1

[[Page 25133]]

Government..................................

598

745

746

0.2 Medicare Utilization as a Percent of Inpatient Days:

0-25........................................

230

1,001

1,006

0.5

25-50.......................................

1,292

857

854

-0.4

50-65.......................................

1,453

672

666

-1.0

Over 65.....................................

441

605

594

-1.8

IX. Alternatives Considered

This proposed rule contains a range of proposed policies. The preamble of this proposed rule provides descriptions of the statutory provisions that are addressed, identifies those proposed policies when discretion has been exercised, presents rationale for our decisions and, where relevant, alternatives that were considered.

X. Overall Conclusion

The changes we are proposing in this proposed rule would affect all classes of hospitals. Some hospitals are expected to experience significant gains and others less significant gains, but overall hospitals are projected to experience positive updates in IPPS payments in FY 2008. Table I of section VI of this Appendix demonstrates the estimated distributional impact of the IPPS budget neutrality requirements for proposed DRG and wage index changes, and for the wage index reclassifications under the MGCRB. Table I also shows an overall increase of 3.3 percent in operating payments, an estimated increase of $3.28 billion, which includes hospital reporting of quality data program costs ($1.89 million) and all operating payment policies as described in section VI. of this Appendix. Capital payments are estimated to decrease by 0.7 percent per case, as shown in Table III of section VIII. of this Appendix. Therefore, we project that capital payments will decline by $13 million in FY 2008 compared to FY 2007. The operating and capital payments should result in a net increase of $3.269 billion to IPPS providers. The discussions presented in the previous pages, in combination with the rest of this proposed rule, constitute a regulatory impact analysis.

XI. Accounting Statement

As required by OMB Circular A-4 (available at http://www.whitehousegov/omb/circulars/a004/a-4.pdf ), in Table IV below, we

have prepared an accounting statement showing the classification of the expenditures associated with the provisions of this proposed rule. This table provides our best estimate of the increase in Medicare payments on providers as a result of the proposed changes to the IPPS presented in this rule. All expenditures are classified as transfers to Medicare providers.

Table IV.--Accounting Statement: Classification of Estimated Expenditures From FY 2007 to FY 2008

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Advanced A.I. technology developed exclusively by vLex editorially enriches legal information to make it accessible, with instant translation into 14 languages for enhanced discoverability and comparative research.
Over 2 million registered users

Founded over 20 years ago, vLex provides a first-class and comprehensive service for lawyers, law firms, government departments, and law schools around the world.

Subscribers are able to see any amendments made to the case.

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Why Sign-up to vLex?

Over 100 Countries

Search over 120 million documents from over 100 countries including primary and secondary collections of legislation, case law, regulations, practical law, news, forms and contracts, books, journals, and more.
Thousands of Data Sources

Updated daily, vLex brings together legal information from over 750 publishing partners, providing access to over 2,500 legal and news sources from the world’s leading publishers.
Find What You Need, Quickly

Advanced A.I. technology developed exclusively by vLex editorially enriches legal information to make it accessible, with instant translation into 14 languages for enhanced discoverability and comparative research.
Over 2 million registered users

Founded over 20 years ago, vLex provides a first-class and comprehensive service for lawyers, law firms, government departments, and law schools around the world.

Subscribers are able to see a visualisation of a case and its relationships to other cases. An alternative to lists of cases, the Precedent Map makes it easier to establish which ones may be of most relevance to your research and prioritise further reading. You also get a useful overview of how the case was received.

Request your trial

Why Sign-up to vLex?

Over 100 Countries

Search over 120 million documents from over 100 countries including primary and secondary collections of legislation, case law, regulations, practical law, news, forms and contracts, books, journals, and more.
Thousands of Data Sources

Updated daily, vLex brings together legal information from over 750 publishing partners, providing access to over 2,500 legal and news sources from the world’s leading publishers.
Find What You Need, Quickly

Advanced A.I. technology developed exclusively by vLex editorially enriches legal information to make it accessible, with instant translation into 14 languages for enhanced discoverability and comparative research.
Over 2 million registered users

Founded over 20 years ago, vLex provides a first-class and comprehensive service for lawyers, law firms, government departments, and law schools around the world.

Subscribers are able to see the list of results connected to your document through the topics and citations Vincent found.

You can sign up for a trial and make the most of our service including these benefits.

Request your trial

Why Sign-up to vLex?

Over 100 Countries

Search over 120 million documents from over 100 countries including primary and secondary collections of legislation, case law, regulations, practical law, news, forms and contracts, books, journals, and more.
Thousands of Data Sources

Updated daily, vLex brings together legal information from over 750 publishing partners, providing access to over 2,500 legal and news sources from the world’s leading publishers.
Find What You Need, Quickly

Advanced A.I. technology developed exclusively by vLex editorially enriches legal information to make it accessible, with instant translation into 14 languages for enhanced discoverability and comparative research.
Over 2 million registered users

Founded over 20 years ago, vLex provides a first-class and comprehensive service for lawyers, law firms, government departments, and law schools around the world.

Part II

You can sign up for a trial and make the most of our service including these benefits.

Why Sign-up to vLex?

Over 100 Countries

Thousands of Data Sources

Find What You Need, Quickly

Over 2 million registered users

You can sign up for a trial and make the most of our service including these benefits.

Why Sign-up to vLex?

Over 100 Countries

Thousands of Data Sources

Find What You Need, Quickly

Over 2 million registered users

You can sign up for a trial and make the most of our service including these benefits.

Why Sign-up to vLex?

Over 100 Countries

Thousands of Data Sources

Find What You Need, Quickly

Over 2 million registered users

You can sign up for a trial and make the most of our service including these benefits.

Why Sign-up to vLex?

Over 100 Countries

Thousands of Data Sources

Find What You Need, Quickly

Over 2 million registered users

You can sign up for a trial and make the most of our service including these benefits.

Why Sign-up to vLex?

Over 100 Countries

Thousands of Data Sources

Find What You Need, Quickly

Over 2 million registered users

Why Sign-up to vLex?

Over 100 Countries

Thousands of Data Sources

Find What You Need, Quickly

Over 2 million registered users

You can sign up for a trial and make the most of our service including these benefits.

Why Sign-up to vLex?

Over 100 Countries

Thousands of Data Sources

Find What You Need, Quickly

Over 2 million registered users